10-Q: Quarterly report pursuant to Section 13 or 15(d)

Published on July 26, 2004

OHIO DEPARTMENT OF JOB AND FAMILY SERVICES

 

OHIO MEDICAL ASSISTANCE PROVIDER AGREEMENT

FOR MANAGED CARE PLAN

 

This provider agreement is entered into this first day of July, 2004, at Columbus, Franklin County, Ohio, between the State of Ohio, Department of Job and Family Services, (hereinafter referred to as ODJFS) whose principal offices are located in the City of Columbus, County of Franklin, State of Ohio, and Buckeye Community Health Plan, Inc., Managed Care Plan (hereinafter referred to as MCP), an Ohio for-profit corporation, whose principal office is located in the city of Columbus, County of Franklin, State of Ohio.

 

MCP is an entity eligible to enter into a provider agreement in accordance with 42 CFR 438.6 and is engaged in the business of providing prepaid comprehensive health care services as defined in 42 CFR 438.2. MCP is licensed as a Health Insuring Corporation by the State of Ohio, Department of Insurance (hereinafter referred to as ODI), pursuant to Chapter 1751. of the Ohio Revised Code and is organized and agrees to operate as prescribed by Chapter 5101:3-26 of the Ohio Administrative Code (hereinafter referred to as OAC), and other applicable portions of the OAC as amended from time to time.

 

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

 


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

 

ARTICLE I - GENERAL

 

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

 

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

 

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

 

ARTICLE II - TIME OF PERFORMANCE

 

A. Upon approval by the Director of ODJFS this provider agreement shall be in effect from the date entered through June 30, 2005, unless this provider agreement is suspended or terminated pursuant to Article VIII prior to the termination date, or otherwise amended pursuant to Article IX.

 

ARTICLE III - REIMBURSEMENT

 

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

 

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ARTICLE IV - MCP INDEPENDENCE

 

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

 

ARTICLE V - CONFLICT OF INTEREST; ETHICS LAWS

 

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

 

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

 

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

 

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

 

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

 

ARTICLE VI - EQUAL EMPLOYMENT OPPORTUNITY

 

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

 

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

 

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

 

ARTICLE VII - RECORDS, DOCUMENTS AND INFORMATION

 

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

 

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

 

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

 

ARTICLE VIII - SUSPENSION AND TERMINATION

 

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

 

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

 

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

 

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

 

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

 

ARTICLE IX - AMENDMENT AND RENEWAL

 

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

 

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

 

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

 

ARTICLE X - LIMITATION OF LIABILITY

 

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

 

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

 

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

 

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ARTICLE XI - ASSIGNMENT

 

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

 

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

 

ARTICLE XII - CERTIFICATION MADE BY MCP

 

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

 

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

 

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

 

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If it is ever determined that MCP knowingly executed this certification erroneously, then in addition to any other remedies, this provider agreement shall be terminated pursuant to Article VII, and ODJFS must advise the Secretary of the appropriate Federal agency of the knowingly erroneous certification.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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ARTICLE XIII - CONSTRUCTION

 

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

 

ARTICLE XIV - INCORPORATION BY REFERENCE

 

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

 

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

 

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

 

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

 

BUCKEYE COMMUNITY HEALTH PLAN, INC.:

       
BY:   /S/    MICHAEL F. NEIDORFF              

DATE: 6/16/04

    MICHAEL F. NEIDORFF, PRESIDENT            

 

OHIO DEPARTMENT OF JOB AND FAMILY SERVICES:

       
BY:   /s/    THOMAS J. HAYES              

DATE: 6/30/04

    THOMAS J. HAYES, DIRECTOR            

 

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Bob Taft

Governor

   [GRAPHIC]   

Tom Hayes

Director

    

30 East Broad Street $ Columbus, Ohio 43215-3414

http://jfs.ohio.gov

    

 

To Medicaid-Contracting Managed Care Plans

 

TO:

 

MCP Medicaid Coordinators

        

FROM:    / S /

 

Deborah MacDonald, Acting Chief

Bureau of Managed Health Care

        

SUBJECT:

 

SFY05 MCP Provider Agreement

        

DATE:

 

June 14, 2004

        

 

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

 

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

 

Based on omissions that we discovered, comments we received from the MCPs, and our follow-up discussions, several notable changes were made to the provider agreement as originally proposed:

 

Appendix C - Primary Language Information

 

The section regarding advance directives was deleted in error and has been re-inserted; gifts of nominal value are now defined as items worth no more than $15.00; and language has been added to further clarify that the submission of delivery payments that are over one year old may require the use of a manual process to pay such claims.

 

An Equal Opportunity Employer

 


SFY 2005 MCP Provider Agreement

Page 2

June 14, 2004

 

As discussed in the June 2, 2004, the word “system” has been changed to “database” to more clearly convey the ODJFS’ expectation regarding the MCP’s data management of their listing of members identified with limited English proficiency.

 

Additionally, in our first draft we neglected to add language to explain that major holiday closures could also be specified in the MCP’s member newsletter or other such general issuances to the MCP’s members and this oversight has now been corrected.

 

Appendix G - Coverage and Services

 

The due date for submission of the MCP’s Emergency Department Diversion (EDD) program has been deleted and that section was revised to state that MCPs must have approved EDD programs which, if changed, require ODJFS approval. This correction was erroneously omitted from the draft document you originally received. As a result of the June 2, 2004, conference call, we have accentuated the need for MCPs to refer to the provider e-manuals on the ODJFS website as the definitive information source for the Medicaid covered-services specifications. The BMHC will also arrange for an upcoming technical assistance session on how to access and utilize the electronic provider manuals.

 

Appendix H - Provider Panel Specifications

 

In response to the comments we received, the language in the hospital section of the Non-PCP Minimum Provider Network section has been revised to further clarify that MCPs must ensure that Medicaid-covered “hospital” services are available to their members from another hospital when the MCP’s contracted hospital elects not to provide a particular Medicaid-covered hospital service due to a moral or religious objection.

 

Also, in reviewing the comments we received on the “full-time practice” revision we realized that the OB/GYN and vision provider sections of this appendix were not as clear as they should have been and we have further revised these sections to improve their clarity.

 

Appendix K - Quality Assessment and Performance Improvement Program

 

As a result of the comments received and the discussion in our June 2, 2004, conference call, further clarification was added regarding exemptions from the non-duplication of mandatory activities as part of the administrative review portion of the external quality review activities.

 


SFY 2005 MCP Provider Agreement

Page 3

June 14, 2004

 

Appendix L - Data Quality

 

The language in the paragraph describing ODJFS’ discretion to apply the most appropriate penalty has been clarified to clearly indicate that the $300,000 monetary cap applies to all data quality penalties.

 

Appendix M - Performance Evaluation

 

The penalty for noncompliance with EDD performance was modified so as to not unduly penalize high-performing MCPs that experience a slight decrease in their performance level. Additionally, for consistency purposes, the language “17 years of age and under” has been corrected to “children 17 and under.”

 

Appendix O - Performance Incentives

 

The minimum performance standard for the Emergency Department Diversion (EDD) performance measure was modified. With the added language, the minimum level of performance needed to qualify MCPs for the SFY 2005 performance incentive is either the standard level of improvement or the breakpoint established in appendix M. Additionally, for SFY 2005, the ODJFS will be using the updated HEDIS 2004 methods for the “Use of Appropriate Medication for People with Asthma” measure. NCQA is including fewer drugs in the HEDIS 2004 methods than in the HEDIS 2003 methods and we expect this to slightly lower results. To account for this change in methodology, the ODJFS has reduced the excellent standard from 54% to 53% and the superior standard from 62% to 61% for the SFY 2005 incentive system. The term “national” benchmarks has also been changed to “Medicaid” benchmarks.

 

Future Provider Agreement Revisions

 

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

 


SFY 2005 MCP Provider Agreement

Page 4

June 14, 2004

 

We do recognize that it would also be beneficial for the BMHC to routinely plan in advance for either an in-person meeting or telephone conference for the discussion of issues which are identified as significant concerns by a substantial number of the MCPs and this will be added to our future timelines. Also, we remind the MCPs that when draft revisions are distributed for their review and comment, the accompanying cover letter always encourages the MCPs to contact the BMHC for immediate clarification on any proposed revision at any time during the comment period. Often, what is an issue for one MCP, is not of similar concern to another, and our experience has been that these issues are most productively addressed in direct discussions between the BMHC and that MCP where plan-specific information can be more openly shared.

 

In response to the request for more detailed written explanations of the proposed changes, the BMHC does recognize that when revisions are so pervasive that it is not possible to use the strike-out/bold typeface approach, it is certainly more challenging to determine what specific changes have been made. This was the case with the 1997 Balance Budget Act revisions that were incorporated into the provider agreement for SFY 2004. Fortunately, the SFY 2005 revisions were primarily time period adjustments and clarifications of existing program requirements rather than substantive changes to the Medicaid managed care program and we were therefore able to easily identify all proposed changes through the strike-out/bold typeface approach. The comments we received, and the June 2, 2004, conference call, however, did help us appreciate the value in providing specific examples with technical revisions such as the calculation for a specific performance standard (i.e., the new EDD target measure), and we will try and include such examples in the future.

 

Please ensure that the appropriate party at your MCP signs the provider agreement signature page (the last page of the baseline section of the document) and returns it to the attention of Kimberly Blaz by no later than 3 PM on June 18, 2004. We must receive an original copy of the signed agreement as we are unable to accept a facsimile or photocopy of the signature page for the execution of this agreement. Please be sure to use the correct address for the Bureau of Managed Health Care.

 

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

 

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

 


SFY 2005 MCP Provider Agreement

Page 5

June 14, 2004

 

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

 

Thank you.

 

c: BMHC Chiefs
     CAs and Supervisors
     Suzie Garcia, HMA
     Kelly McGivern, OAHP
     Matthew Moore, Three Rivers Health Plan
     Kelly Johnson, Molina Health Plan
     Tom Samol, The Health Plan
     Debbie Bahnsen, AmeriGroup

 


RESPONSES TO MCP COMMENTS

ON 07/01/04 PROVIDER AGREEMENT

 

Appendix A

 

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

 

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

 

Appendix B

 

Appendix B, Page 4 - MCP Provider Agreement Amendments

 

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

 

To appropriately consider future expansion possibilities, what counties does ODJFS consider clusters? Or service areas? Does ODJFS have a proposed expansion timeline?

 

Outlining the steps necessary for service area expansion filing, separate from the initial procurement process, makes very good sense. While we understand the Bureau’s desire to save cost and not prepare appendices E & H for the entire state, we would appreciate a definition of the expected timeline for the ODJFS to develop those requirements for counties not currently defined.

 

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In addition, for planning purposes, it would be extremely helpful for MCPs to know which counties will only be considered as part of a larger group or cluster of counties. The “regional” approach might lend itself nicely to future expansions by building upon already established access patterns into more major urban areas.

 

Response: The development of minimum provider panel requirements for each county is a considerably complex and time-consuming process. The county-specific requirements are developed using a provider to resident ratio which is applied to the number of Medicaid managed care eligibles in each county for each provider type. In order to determine if an alternate provider area is indicated for a county, ODJFS must consider the out-of-county utilization patterns depicted in both fee-for-service (FFS) and MCP encounter data claims. In instances where out-of-county utilization for a specific neighboring county is significant, a minimum provider requirement may be established for the neighboring county. In Ohio’s more rural counties, this out-of-county utilization may include any number of counties. ODJFS may determine that if a MCP wishes to provide Medicaid managed care services in a county that has high out-of-county utilization in more than one neighboring county, then the MCP must first establish adequate provider panels for the out-of-county areas most utilized by the Medicaid population. In some cases, ODJFS may determine that the MCP must serve a “region” or “cluster” of counties in light of utilization patterns and/or provider availability. ODJFS is unable to specify which counties might be required to be served as “regions” or “clusters” until we perform our complete analysis of these counties. Due to the extensive work this involves, we will not begin this process until an MCP has indicated a serious interest in serving this county(ies). Depending on other priorities, ODJFS anticipates that it will take at least four to six weeks after an MCP has submitted a letter of intent to provide Medicaid managed care services in a new county, to develop provider panel requirements for any county currently not included in appendix H.

 

In terms of rate development, on March 5, 2004, the ODJFS requested that MCPs and all currently-identified prospective MCPs identify any new counties they might wish to serve in 2005-2006. Our actuary, Mercer Government Human Services Consulting Firm (Mercer), is preparing rates for all the new counties submitted. If additional expansion counties are submitted in the future, we will ask Mercer to prepare these rates as soon as possible but the exact time frame will be dependent on the other work priorities they have at that time.

 

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Appendix C

 

Appendix C, Page 2, Section 11 – MCP Responsibilities

 

Although no changes is yet proposed, MCPs would like to request that a qualifier be added to the item stating, “ . . .ODJFS retains the right to make the final determination on medical necessity in specific member situations, unless the benefit is specifically excluded from coverage.” This will help clarify that services like adult chiropractic, although potentially “medically necessary,” will not be arbitrarily added to a plan’s financial responsibility.

 

Response: The purpose of this provision is to clarify that the MCP, and not its providers, are ultimately responsible for determining the medical necessity for services and supplies requested for their members. In the past we have had state hearing disputes where the provider has asserted that if they prescribe a service or supply, then that service or supply is inherently medically necessary or it would not have been prescribed. ODJFS, however, must retain the right, however, to make final determinations on medical necessity in member-specific situations. We do not believe that it is necessary to add the proposed qualifier to this section as MCPs are not required to cover excluded benefits (see appendix G.2.a.).

 

Appendix C, Page 3, Section 19, subsection b – Primary Language

 

MCPs agree that an MCP member primary language information (PLI) system is advantageous to the MCP and the member. MCPs agree this system should be readily available to MCP staff. However, it is impossible to guarantee MCP staff fluent in every language globally, when there may exist only one MCP member using this as their primary language, speaking fluently in a secondary language designation of a more common language. Additionally, MCPs question the need to share all PLI with providers, except on an “as requested” basis. Sharing PLI information with PCPs, PBMs, and TPAs would required expensive system enhancements across all of their systems, with very little return for their investment. Members will self-select those providers who are accommodating to their respective culture. As such, MCPs recommend deleting the last two sentences on the paragraph at the top of page 4.

 

The last two sentences should be removed. An extensive data sharing process with PBMs, TPAs, providers, etc, would be unreasonably expensive. No requirement beyond verbal communication when requested, of the Primary Language Indicator (PLI), should be mandated. To be competitive, an MCP will naturally work toward contracting with providers who are capable of communicating effectively with significant subpopulations. However, placing the requirement globally for any language, and the loose requirement as it now stands that a provider’s system must accommodate a data feed from us, creates a whole new process and provider systems enhancement that is cost prohibitive.

 

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Response: As we indicated during our conference call on June 2, 2004, we understand that the use of the term “system” was confusing and are therefore revising this provision to instead specify that the MCPs are to utilize a centralized “database.” This clarification makes the language consistent with the interpreter services discussions we had with the MCPs last fall and with Julie Davis’ memo of December 5, 2003. We also clarified during our conference call that if an MCP has identified one of their members as requiring interpreter services, we expect the MCP to notify the member’s primary care physician (PCP) (or use this information in assigning the member to the most appropriate PCP) and the MCP’s pharmacy benefit manger (PBM) so that these providers can take whatever steps may be needed to address the member’s language needs (e.g., having an interpreter available for that member’s appointments or adding an edit to the pharmacy system to alert the pharmacist to this situation). This information exchange can take whatever form the MCP deems most appropriate.

 

We are confused by the assertions that this provision would require all MCP staff to be fluent in all languages. MCPs are required to provide interpreter services to members who require such assistance and this requirement applies to the MCP’s providers and the MCP’s staff members that interact with the MCP’s members. As in the past, we expect the MCPs to use services such as the Language Line or locally-available interpreters when these services are needed. There is no requirement or expectation that all MCP staff must be fluent in all languages.

 

Appendix C, Page 4-5, Section 21 – Advance Directives

 

MCPs would like to know the reason for deletion of the Advance Directives language and verification that it is not necessary for inclusion in the Medicaid member kits.

 

Why was the reference to Advance Directives was removed from the Provider Agreement when Ohio Administrative Code (OAC) still has requirements?

 

Response: This section was deleted in error during the renumbering within this appendix. This section has been reinserted into the provider agreement as #22 and the wording is the same as it was when it appeared in the SFY 2003 provider agreement. The ODJFS apologizes for any confusion this inadvertent deletion may have caused.

 

Appendix C, Page 4, Section 22 – Call Center Standards

 

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

 

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Response: Because the MCP member services staff perform such a critical function in assisting MCP members in receiving their health care benefit, ODJFS expects the member services staff to be available when members would reasonably expect them to be available. For that reason we do not permit the MCP member services toll-free hotline to be closed during business hours for any reason other than major holidays. Since there are some regional differences in terms of the “importance” of how certain holidays/events are recognized, we have not developed a definitive list of acceptable holiday closures but believe the criteria we have stipulated should guide the MCPs in determining what holiday closures will be acceptable to ODJFS. In that ODJFS must prior approve all MCP member materials, including the MCP member handbook, ODJFS would determine if the holiday closures proposed by the MCP were appropriate as part of that member material review process. (Note: During our final review of the revised provider agreement we identified an omission in this section. We neglected to add that major holiday closures could also be specified in the MCP’s member newsletter or other such general issuances to the MCP’s members. This omission has now been corrected.)

 

Appendix C, Page 5, Section 21, subsection a – Marketing Materials

 

This section defines marketing materials, including gifts of nominal value (i.e., items worth no more than $10.00). We suggest the amount be updated to $15.00, the amount currently cited by CMS.

 

Response: The ODJFS wants to thank the Ohio Association of Health Plans (OAHP) for providing the Center for Medicare and Medicaid Services (CMS) citation referenced in this comment. Although this is a Medicare provision, there is comparability on this specific issue and after further internal review and discussion, ODJFS has revised the provider agreement to state that gifts of nominal value are items worth no more than $15.00.

 

Appendix C, Page 15, Section 26 – Timing of Delivery Payments

 

New language in this section outlining delivery payments states that the delivery payment will not cover encounters that occurred over one year ago. MCPs suggest exception language be added to this section for those cases where the HMO is the secondary payor. This is a current requirement in the Ohio Revised Code 3901.384 for the commercial market.

 

Considering the time involved in coordination of benefits (COB) cases, we requests that ODJFS consider removing the proposed limitation for timing of delivery payments in cases where COB efforts can be documented. Briefly, a delivery can be considered an emergency service requiring MCPs to work with non-contracting providers. Some MCPs allow non-contracting providers 365 days for billing. When considering COB activities this limitation appears disadvantageous.

 

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Response: Language was added to this section to clarify that delivery payments that were over one year old may require payment through a manual process as described in the June 2002 memo which notified the MCPs of this process. In some cases, MCPs have submitted delivery encounters more than two years after the delivery occurred. ODJFS implemented this change to assure that ODJFS does not make duplicate payments for the same delivery. The June 2002 memo explained that, if an MCP is denied payment through the department’s automated payment system because the delivery encounter was not submitted within a year of the delivery date, then it will be necessary for the MCP to contact the ODJFS to receive payment. Payment will be made for the delivery if a payment had not previously been made for the same delivery. The language in this section of the provider agreement has been modified to reflect this policy for delivery encounters submitted more than one year after the delivery occurred.

 

Appendix G

 

Appendix G, Page 1, Section 1 – Coverage and Services

 

MCPs request an explanation for changes to the list of coverage items including the deletion of certain services and language changes in others. MCPs feel an overall understanding of changes from the SFY 2004 agreement would be helpful. Although the ODJFS website is cited, for contract purposes a clear explanation is needed.

 

A full definition of subsection f., family planning services and supplies, is requested. MCPs are uncertain whether this new language is a change in what must be covered under family planning services. If new services are provided, MCPs would anticipate a corresponding change in rates.

 

MCPs would like clarification on the need for changing the word prescribed to prescription. Does this change the services that are already being provided and if so the MCPs would anticipate a corresponding change in rates.

 

We request an explanation on why some of the changes were made; for example why was “obstetrical services” lined out? Why were the references to FQHC and RHC lined out? How does ODJFS define short term in regards to rehabilitative care?

 

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

 

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Could this list become more static? As changes occur year after year, the MCPs try to determine whether the benefits are really changing. An example is adding “and supplies” to Family Planning Services. Is that change just a clarification, or are other “supplies” now being covered that weren’t historically. The ODJFS should indicate such on each change within Appendix G, as well as indicate the actuarial impact if benefits are changing.

 

We assume the change “Prescription drugs” is simply a clarification, but please confirm.

 

There are concerns about appendix G. Obstetrical services, Clinical services (including federal health centers and rural health clinics), Emergency services and speech and hearing services, among others, have been crossed out. This is a bit confusing. Why are they crossed out? Are they now considered to be lumped under “physician services”? Speech and hearing services (formerly O) is now J and grouped with physical therapy. Is this the same situation for the others? Please verify.

 

We would like clarification of the following points in Appendix G:

 

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

 

* 1m—Emergency Services

 

* 2 a Education testing and diagnosis

 

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

 

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Appendix G, Page 1 – Coverage and Services

 

As rates move to a calendar year basis while the contract stays on a fiscal year, there should be a provision for rate adjustments in the event the contract changes benefits off-cycle from the rate setting process. The change protects both sides; ODJFS when benefits are re moved from coverage, as well as MCPs when benefits are added.

 

Response: The rate schedule was moved to a calendar year to make provisions for rate adjustments for potential program changes that might be approved by the legislature as part of the department’s budget for that year. This budget approval information is not available until July which is the beginning of a fiscal year. If we go by SFY rate schedule to match the MCP contract year we have to revise the rates after the budget is finalized. We have done that in the past and it proved to be burdensome for the MCPs and the ODJFS.

 

Appendix G, Page 6 – Emergency Department Diversion

 

Regarding EDD, page seven, please explain why the reference to the EDD program still says it must be submitted by a date in the past when other date references have been dealt with by saying “must have approved”.....program.

 

Response: The deletion of the previous due date for the MCP’s Emergency Department Diversion (EDD) program was inadvertently overlooked by the ODJFS during the revision process. Please note that this section has been revised to read as follows:

 

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

 

Appendix H

 

Appendix H, Page 5, Section 1 b – Minimum Non-PCP Network

 

This section requires non-PCP provider types maintain a fulltime practice, defined as being available to patients at a “practice site” for at least 25 hours a week. Several questions have been raised. First, does this apply to all non-PCP provider types? Next, Does the term “practice site” include office, surgical and clinical sites? For instance, surgeons and orthopedists may have some office hours but many more surgical hours that are divided between one or more facilities. It would be unrealistic to require the 25 hours be spent in only on site for certain providers. Finally, this requirement could incite another reason for providers to refuse to contract with an MCP.

 

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Regarding the requirement to have non-PCP type physician’s full time practice defined as 25 hours per week at a practice location, we do not think this is a realistic requirement specifically for general surgeons and orthopedists. These two specialty types are in surgery and making hospital rounds a significant portion of every day.

 

We do not feel that 25 hours is appropriate for all specialties. For example, a general surgeon may have a practice site but spend most of his or her time performing surgeries at the hospital. Under the guidelines would the surgeon need to have 25 hours a week at the office site?

 

Response: As discussed in our June 2, 2004, conference call, the ODJFS does accept the inclusion of inpatient/outpatient surgical hours for general surgeons, otolaryngologists, and orthopedists, and hospital delivery hours for obstetricians/gynecologists in addition to regular office hours to fulfill the fulltime practice requirement. The “full-time” practice requirement (without a specific definition in terms of “hours”) was first added to the provider agreement in July 2002. After the ODJFS determined that there appeared to be some confusion in terms of how the MCPs were supposed to submit the practice designations and, at the request of the MCPs to establish a specific definition of the “full-time” term, clarification was provided through Appendix L of the ODJFS’s October 15, 2003, Medicaid Managed Care Plan Provider Verification System Instructional Manual and the BMHC’s October 17, 2003, memorandum to MCP Coordinators. Both of these earlier issuances specifically stipulated that in order for certain specialty providers to be counted toward the minimum provider panel requirements, they must routinely be available to patients at their practice site(s) in that county at least 25 hours per week which includes the clarifications explained earlier in this response.

 

Appendix H, Page 5, Section 1 b. – Non-PCP Minimum Provider Network – Hospitals

 

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

 

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Response: When a hospital elects to contract with an MCP, that hospital (or the larger entity representing that hospital) must complete the ODJFS- specified model contract addendum which includes a Hospital Services Form. Hospitals use this form to specify what types of hospital services they are agreeing to provide for the MCP, as well as to indicate if there are certain services they will not provide due to an objection on moral or religious grounds. While some hospital services might also be provided by a non-hospital provider, the appropriate setting would be driven by the specific case in question. Obviously, in the vast majority of situations, hospital services need to be provided by a hospital. In order to better clarify this requirement we will revise this language to indicate that this is only applicable if the hospital elects not to provide specific Medicaid-covered “hospital” services.

 

Appendix H, Page 8 – Provider Panel Exceptions

 

Regarding the proposed language for Provider Panel Exceptions, while understanding the intent of the language, we find the language broad with no defined terms. For example what is “sufficient documentation”? This questions the fairness of the language and leaves us wondering how ODJFS would administer in a way that would not be arbitrary. Perhaps adding more definition around the terms would be helpful. The most notable issue however is how this language erodes one of the most important managed care concepts, that being contracted access to care.

 

Response: This provision has been part of the MCP provider agreement since 1999. It was added when we identified the need to be able to deviate from the specified minimum provider panel requirements in situations where the MCP has made all reasonable efforts to obtain a critical provider contract and the provider has refused. Since the time that this provision went into effect we have approved only one provider panel exception and that approval was rendered moot when the originally-required provider soon thereafter signed a contract with the MCP. ODJFS of course believes that contractual provider relationships are critical to assuring a member’s access to care but we are also cognizant that some services are only available from a minimal number of providers which may place them in an unfair bargaining position. ODJFS would prefer to never exercise the option of approving a provider panel exception request but we believe this provision is essential to ensure the current stability and future expansion of the Medicaid managed care program. Since these requests are so infrequent and situation-specific, ODJFS believes it is sufficient to stress the general principles that we will use in making such determinations.

 

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Appendix H, Page 11-28 – Minimum Provider Panel Charts

 

We are concerned that minimum requirements have increased in some counties. ODJFS does publish methodology for how PCP requirements are determined. Methodology is not known for non-PCP providers and as such we is concerned that requirements for dental providers have increased. Difficulties regarding dental providers for Medicaid recipients for both FFS and MCP are known.

 

Will ODJFS share the calculations and methodology for minimum standards?

 

Response: Minimum provider requirements for non-PCPs are calculated on a county-by-county basis and are based on a ratio of the number of providers (by type) per the number of residents. Ratios are calculated for the following provider types: dentists, pediatricians, OB/GYNs, general surgeons, otolaryngologosts, allergists / immunologists, orthopedists, opthalmologists / optometrists, and pharmacies. This ratio is applied to the number of Medicaid managed care eligibles in each county for each provider type. The pediatrician and OB/GYN provider ratios are applied only to children and women of child-bearing age, respectively, and therefore, the number of children and women are calculated for each county based on statewide percentages of managed care eligibles in each category. The total managed care eligibles in each county is adjusted based on the number of eligibles and their enrollment status. For mandatory and voluntary counties, if the total number of eligibles is greater than 100,000, the MCP’s provider panel must include enough providers to cover at least 40% of the total eligibles. If the total number of eligibles is less than or equal to 100,000, the MCP’s provider panel must cover at least 50% of the total eligibles. In order to ensure that MCPs in preferred option counties can provide access to an adequate number of non-PCP specialists that takes into account the “default” assignment of additional Medicaid eligibles, a 1.5 multiplier is applied to the calculation to determine the minimum specialist provider requirement. A change (increase or decrease) in the population of either providers, residents, or eligibles in the state directly affects the calculation of the provider to resident ratio. This change, in turn, is reflected by an increase or decrease in the number of required providers for a county when the ratio is applied to the county-specific Medicaid managed care eligibles.

 

The 2004 dental provider numbers increased because the number of dental providers in the state increased. This increase in the actual number of statewide dental providers affected the provider to resident ratio described above and therefore, led to an increase in the recommended number of dental providers for each county. If the MCP is able to adequately provide their members with access to all Medicaid-covered dental services, then ODJFS will not consider the MCP to be out of compliance with the dental panel requirement even if the MCP’s dental provider panel does not meet the recommendations as specified in Appendix H.

 

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Appendix I

 

Appendix I – Program Integrity

 

Although there are no proposed changes to this appendix we would like to offer some comments. Considering PCP turnover rate has such significant incentive outcomes, we request that providers who are termed from the MCP for fraud and abuse issues, including those providers terminated after receiving notification from ODJFS, be excluded from the PCP turnover rate calculation.

 

Response: The PCP turnover rate is based on the HEDIS practitioner turnover measure which specifies that there are no exclusions from the denominator. All providers are to be included regardless of whether they died, retired, relocated, or were terminated. The HEDIS methodology does not define ‘terminated’ providers. Therefore, all terminated providers are to be included in the measure regardless of the reason for their termination.

 

Appendix K

 

Appendix K, Page 1, Section 1 – Performance Improvement Projects

 

There is no further discussion of the requirements for PIPs. Was this an oversight?

 

Response: Additional discussion on the requirements for Performance Improvements Projects (PIPs) was not included in the SFY 2005 provider agreement because the SFY 2004 PIP process, as currently described in the provider agreement, will continue through SFY 2005. The protocols for the PIPs were developed by the ODJFS in accordance with guidelines established by the CMS. The PIP process includes 10 steps to design and implement the quality improvement studies. For SFY 2004, ODJFS selected one clinical and non-clinical study and defined the study topic questions (Steps 1-2). The MCPs were required to develop the study topic indicators, identify the study population, and define the sampling methods and the data collection procedures (Steps 3-6). Upon ODJFS approval of the MCPs’ PIP submission, the MCPs were expected to implement their PIPs in SFY 2004.

 

The remaining steps (7-10) in the PIP process will be completed during SFY 2005. MCPs will submit PIP findings for ODJFS to review the data, analyze the results, and assess any progress made due to the implementation of the PIP. Additionally, the external quality review (EQR) vendor will review each MCP’s PIP submissions and submit recommendations to ODJFS about the extent to which the findings of the MCPs’ PIPs are valid and reliable. A detailed letter instructing the MCPs of the requirements for the final phase and timeline of the PIP process will be distributed in the near future.

 

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Appendix K, Page 3, Section 5 – Non-Duplication Exemptions

 

MCPs believe the language contained in this section is overly restrictive. Non-duplication exemptions could include use of HEDIS data in lieu of duplicating efforts in compiling clinical data. This exemption can also be used as an exemption for administrative reviews. MCPs oppose language that would prohibit either option from going forward in SFY ’05. We strongly encourage the state to go forward in accepting HEDIS data for the next round of EQR clinical studies in SFY ’05 and, where possible, exempt eligible plans from portions of the administrative review.

 

It was also our understanding that some of these revised requirements were still under negotiation between the MCPs and the Bureau, such as issues in the Quality Assessment and Performance Improvement Program, Appendix K. MCPs and BMHC held a conference call meeting on this issue as late as Monday, May 24, 1:00 - 3:00 PM, for further discussion. With submission of comments on the provider agreement due Tuesday, May 25, including comments on Appendix K, it is extremely disappointing to see the SFY 05 Proposed Provider Agreement reflect an ODJFS position without the results and discussion of the May 24 conference call.

 

Response: The language in the provider agreement was revised to reflect the revisions to 42 CFR 438.360 and 438.362 that became effective in October 2003. In reviewing the MCP and OAHP comments, it appears as though there was confusion around the interpretation of the terms “exemption from the non-duplication of mandatory activities” and/or “deeming.” We believed that this distinction had been fully addressed during the March 24, 2004, monthly MCP meeting (followed by the clarifying question and answer document) and the subsequent May 24, 2004, conference call. As discussed in our June 2, 2004, conference call and as outlined in the above-referenced CFR citations, MCPs that meet the specified eligibility requirement(s) may be able to apply for an exemption only from portions of the administrative review conducted during the EQR. An exemption from the non-duplication of mandatory activities would not include the acceptance of HEDIS data in lieu of the clinical quality of care studies. Additional language will be incorporated into Appendix K to clearly state that the exemption from the non-duplication of mandatory activities is only applicable to the administrative review.

 

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

 

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Upon approval from CMS, the MCPs may be eligible to apply for exemption from portions of the administrative review during SFY 2006. ODJFS recognizes that MCPs are concerned with the timeframe for this activity, however, it is anticipated that the planning and approval process for this written plan will take at least six to 12 months. Given this, the language in the provider agreement identifying this timeframe must remain as originally proposed so as not to raise false expectations about the possibility of exemptions being awarded prior to SFY 2006 although we have attempted to further clarify the limitation of what activities may be exempted.

 

ODJFS staff are committed to participating in an on-going dialogue with the MCPs to explore proposed recommendations to the EQR process.

 

Appendix L

 

Appendix L, Page 1, Section 1 – Encounter Data

 

Encounter data volume minimums have increased in most categories. We request the volumes be measured six (6) months after the report period to allow for adequate claims lag.

 

Response: The claims lag was shortened in SFY 2004 to give the MCPs feedback in a more timely manner after analysis showed that the data needed to set the standard was significantly complete (i.e. the data had a high completion factor) after four months. ODJFS believes that more timely feedback will aid the MCPs in more quickly addressing poor quality encounter data submissions. The claims lag used to set the standard and the claims lag used to calculate the results for the encounter data volume measure must match. If a longer claims lag is used in calculating the results than was used in setting the standard, then a completion factor would have to be incorporated into the methods and the feedback would be delayed. The ODJFS believes it is more appropriate to use a calculation method that is more direct and timely than what was proposed.

 

Appendix L, Page 15, Section 6a – Penalties for Noncompliance

 

MCPs are concerned with language that provides ODJFS with unlimited discretion to apply unconstrained penalties to an area of deficiency identified when an MCP is determined to be noncompliant with a standard. Caps on penalties are the norm in both the Ohio Revised Code and Administrative rules and serve as a protection and assurance of a limit on consequences. This language should be removed and the cap of $300,000 should remain as written.

 

Encounter data volume minimums have increased in most categories. We request that the volumes be measured six (6) months after the report period to allow for adequate claims lag.

 

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

 

Response: The importance of accurate encounter data submitted by MCPs is emphasized by ODJFS’ policy of conducting standard compliance evaluations on a quarterly basis. Encounter data is increasingly being used by ODJFS for a variety of reasons and accurate data is important to both ODJFS and the MCPs. Quarterly evaluations are beneficial to the MCPs because it allows them to more easily and quickly correct errors that may arise which would be more difficult to accomplish if evaluations were only conducted annually.

 

The intent of the encounter data volume measure is to periodically assess the data quality of encounter data submissions and provide an incentive for MCPs to evaluate and resolve instances where a particular measure indicates poor quality data. The expectation is that a particular deficiency will be resolved and therefore, subsequent compliance for the deficient quarter and service category will not be an issue. In order to ensure the maintenance of accurate and complete historical data, encounter data volume will be monitored over time. A single year’s worth of data is not considered sufficient for historical purposes. Considering that program evaluations and rate setting both require trending over a minimum of three years of encounter data and MCPs have the ability to add or delete encounters over any time period, measuring the volume on a one year rolling basis would not be sufficient to ensure the data used meets minimum data quality standards.

 

ODJFS considers the penalty system in place to be a graduated system and not duplicative. Instead of starting with a new member selection freeze, MCPs who are noncompliant with this measure for the first time are issued a sanction advisory. If noncompliance continues for the next quarter, a refundable financial penalty is imposed. The financial penalty is not repeated for consecutive quarters of noncompliance. If noncompliance continues for three consecutive quarters, then a selection freeze is imposed. This system gives the MCP three quarters to resolve a data quality problem before enrollment is frozen. Penalties remain in place until compliance with the standard(s) is achieved. Notwithstanding other provisions of this appendix and once an MCP comes into compliance with the standard(s), any financial penalties assessed against the MCP are returned and the MCP’s enrollment is unfrozen. We believe that this graduated penalty system gives MCPs sufficient time to address and resolve data quality problems and underscores the importance ODJFS places on the submission of high quality encounter data.

 

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Table 1 Standards. MCPs need to understand the basis for changes in the expectations. Please share the calculations and methodology.

 

Response:

 

Calculating the Standards

 

Changes in the methods for calculating the standards reflect changes due to HIPAA and two new considerations: county variances and seasonality (i.e., fluctuations in utilization from quarter to quarter). HIPAA required the elimination of local codes. The primary effect on this measures was the grouping of encounters in the ancillary and primary/specialists categories of service. With the updated methods, all antepartum and postpartum visits are reported in one category of service (i.e., primary/specialist) versus a split across these two categories of service. To account for county variances, results were calculated for each MCP by county (MCP/county) by quarter. An MCP/county average (across all MCPs) was then calculated for each quarter. The high outlier MCP/counties (e.g., counties with a significantly high result primarily due to low enrollment) was excluded from the calculation of the average. In order to allow for seasonality in the data, the quarter with the lowest average was used to establish the standard. As in previous years, once the average for a category of service was established the standard was set at 1.5 standard deviations below the average.

 

Changes in Methodology

 

It should be noted that the SFY 2005 methods were calculated using CY 2003 encounter data. The SFY 2004 methods used CY 2002 data.

 

Inpatient: There were no changes in methodology for this service category. The change in the standard (from 5.4 to 5.0) reflects the seasonality effect described above.

 

Emergency Department: The methodology was revised to exclude any ED encounters with a behavioral health diagnosis or procedure code in order to be more consistent with HEDIS methodology. However, the actual standard increased because the encounter data for CY 2003 reflects a higher number of ED encounters submitted per member per month.

 

Dental: There was no change to the dental methodology. The increase in the standard reflects improvements in data quality.

 

Vision: The vision methodology was changed to exclude the “supply of materials” current procedural terminology (CPT) codes 93290-92396. These codes represented a small number of encounters and did not significantly affect the calculation of the standard. This measure is not intended to include frames and lenses and therefore should not include the “supply of materials” codes. In addition, the county variance added to the drop in the standard for this measure.

 

Primary and Specialist Care: This measure was revised to include all antepartum and postpartum visits reported with CPT codes 59420, 59425, 59426, 59430 (which were previously included in the ancillary category).

 

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Ancillary Services: This measure was revised to exclude the antepartum and postpartum visits referred to above under primary and specialist care.

 

Behavioral Health: There was no change to the methodology for this service category.

 

Pharmacy: There was no change to the methodology for this service category. However, pharmacy encounters for one MCP were under-reported in the past. The issue was resolved, the MCP’s pharmacy encounter data has been corrected, and the SFY 2005 standard reflects this correction.

 

Appendix L, Page 15, section 6.a. – Penalties, Including Monetary Sanctions, for Noncompliance

 

Regarding the language added on page 15, 6.a., we request that the following statement be added “The appropriate penalty would not exceed the penalty described in each section and sub-section”.

 

The quarterly evaluation table has the propensity to penalize an MCP quarter after quarter if they have one bad quarter. The table instead should be based upon a rolling annual basis, evaluating no more than 1 year at a time. A bad quarter in 2003 continues to affect reporting through May of 2006!

 

Please specify “.....ODJFS reserves the right to apply the most appropriate penalty.....” This would seem to have the potential to for a MCP to be subject to a more severe penalty than what is stated in the appendix.

 

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

 

Appendix M

 

Appendix M, Page 15, Section 4.b – Emergency Department Diversion

 

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

 

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Impacting EDD requires extensive resources and interventions on behalf of MCP staff. The lack of necessary incentives such as co-payments and the existence of prudent layperson requirements leave little room in trying to successfully impact the use of emergency rooms to the level being proposed. To demonstrate the impact, the OAHP commercial plans reported a 45% increase in ER utilization since the passage of prudent layperson into Ohio law.

 

This appendix establishes a target of 0.7% for the Emergency Department Diversion measure. This contradicts the SFY 2004 provider agreement that states “for report period of contract period SFY 2005 (July-December, 2004) the minimum performance standard is 1.0%.” Is there a national benchmark to indicate this is an achievable target?

 

While we understand the minimum standard includes a 10% gap decrease, not requiring us to achieve the 0.7% rate, our concerns remain; the continuing decrease in the performance standard of a measure with such significant financial implications and a measure in which MCPs are limited by legislation to impose known utilization reducing processes.

 

4.b. Changing a target from 1% to 0.7% of the eligible population having four or more ED visits during the reporting period is unrealistic in a one-year period of time. While we fully support improving quality results year over year, a target of 30% improvement from a program already experiencing good results isn’t appropriate. Even the minimum performance standard of a 10% improvement in the difference between the target and baseline results is unrealistic for a State program already performing strongly. Incremental change at that high level of performance can become cost prohibitive, particularly in a program where there’s no opportunity to help drive compliance levels by member cost sharing techniques. ODJFS should set targets upon a more realistic basis.

 

We would like clarification of the following points in Appendix M: The reduction of the ED Diversion Target to 0.7%.

 

Response: The change in methods reduces the expected level of improvement for all MCPs performing at a rate above 1.0%. For an MCP with a rate of 1.5%, the existing standard expects a reduction of 0.5% or 33%. By changing the standard to account for the expectation that the difference between last year’s result and 0.70% would be reduced by 10%, the same MCP would be expected to reduce their result by 0.08% or 5.3%.

 

For MCPs that are already performing at or below the previously established 1.0% standard, the change in method required them to maintain their performance versus allowing the level of their performance to drop below the 1.0% standard. In recognition of the increase in the expected level of performance, a change was made to the proposed standard to lower the expected level of performance for MCPs in the above situation.

 

18


Similar to what was done regarding the clinical performance measures, a breakpoint was established where MCPs that are performing better than average (i.e., at or below 1.1%) but do not meet the standard level of performance will be issued a quality improvement directive. 1.1% was chosen because it is the current program average.

 

MCPs not meeting the standard level of improvement and are above the average, must develop a corrective action plan and ODJFS may direct the MCP to develop the components of their EDD program as specified by ODJFS.

 

ODJFS recognizes that this measure is integral to the incentive system. As you know, ODJFS’ actuary calculates actuarially sound capitation rates and ODJFS adds 1% as an incentive to improve performance in specific areas important to the Medicaid MCPs’ members. MCPs receive the extra 1% with their monthly premium payments. To retain the extra amount, MCPs must achieve a minimum level of performance on selected measures and improve performance by meeting higher standard levels for three selected measures. MCPs that do not qualify for or meet the higher performance standards must return the extra 1% because the MCP did not complete this deliverable as specified in the provider agreement.

 

With the changes to the standard in appendix M for the EDD measure, accompanying changes were made to the EDD minimum performance expectation in the incentive system in appendix O. As with the clinical performance measures, MCPs that meet the breakpoint established in appendix M are considered to have met the minimum performance level needed to qualify for the retention of incentive payments made in accordance with the incentive system.

 

Appendix M – Case Management of ODJFS-Mandated Conditions

 

Regarding Measure 2, Case Management of ODJFS-Mandated Conditions, please clarify the correct verbiage. In the methodology documents the verbiage is “17 years of age and under” while the verbiage in the Provider Agreement, SFY2004 and SFY2005, states “under 17 years of age”. We believe the verbiage should be identical in the two documents.

 

Response: The correct language is, ‘children 17 and under’ and the provider agreement has been corrected to reflect this.

 

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Appendix O

 

Appendix O – Performance Incentives

 

This section indicates that the methodologies for 2005 measures can be found on the website listed. However, this information is not updated for 2005 as noted. The MCPS request a hard copy or electronic version of the 2005 methodologies be sent before final acceptance of the SFY ‘05 provider agreement.

 

The website listing the “detailed description of the methodologies of each measure” www.jfs.ohio.gov/ohp/ODJFS/managed.stm contains information from SFY 2004. We would like a chance to review the draft methodologies. When can we expect updated information to appear?

 

Response: The updated methods were finalized and sent to all MCPs during the second week of June.

 

Additionally, this section makes reference to “national benchmarks”. MCPs request a citation on the source of the national benchmarks used for these measures.

 

The ODJFS should share the methodology used to calculate the standards, and define where the National Benchmarks are obtained.

 

Response: The figures were established based upon national Medicaid results, as obtained from NCQA at:

 

http://www.ncqa.org/Programs/HEDIS/02medicaid.htm

 

National results were available for all of the measures except for the lead screening measure. To avoid confusion, the term “National Benchmark” will be changed to “Medicaid Benchmark.”

 

Although not specifically addressed in the proposed revisions to the Provider Agreement, we would like to take this opportunity to request ODJFS allow all claims be submitted through the encounter data process. ODJFS and HSAG cite HEDIS as benchmarks, however, MCPs are allowed to submit denied claims only for immunizations. As you know HEDIS accepts all submitted claims regardless of final adjudication status. We believe ODJFS should adopt the same practice and allow MCPs to submit all claims, regardless of final status.

 

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

 

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APPENDIX A

 

OAC RULES 5101:3-26

 

The managed care program rules can be accessed electronically through the following website:

 

http://emanuals.odjfs.state.oh.us/emanuals/medicaid/MHC/@Generic_BookView;cs=default;ts=default

 


APPENDIX B

 

MCP PROCUREMENT AND PRE-CONTRACTING REQUIREMENTS

 

The Ohio Department of Job and Family Services (ODJFS) has an open procurement process (pursuant to 45 CFR 92.36 whereby any qualifying entity may request consideration to receive a Managed Care Plan (MCP) provider agreement from ODJFS. Prospective MCPs interested in participating in Ohio’s Medicaid managed care program must submit a formal letter of intent to the Chief of the Bureau of Managed Health Care (BMHC) which specifically states that the prospective MCP wishes to actively pursue a provider agreement with ODJFS. Upon receipt of this letter, BMHC staff will schedule a meeting with the prospective MCP, following which ODJFS will provide the prospective MCP with a follow-up letter further outlining the pre-contracting requirements specified in this Appendix and the projected timetable required for the MCP to receive a provider agreement. The projected timetable to receive a provider agreement to serve Medicaid eligibles in counties currently not included in Appendix E (Rate Methodology) and/or Appendix H (Provider Panel Specifications) may need to incorporate sufficient time for ODJFS to determine the appropriate capitation rates and/or provider panel requirements for these service areas. ODJFS may require that some counties may only be included in a provider agreement if they are part of a larger group or cluster of counties which would constitute one combined service area.

 

ODJFS may at its discretion allow a prospective MCP to begin the pre-contracting process prior to the receipt of their certificate of authority (COA) from the Ohio Department of Insurance. However, the MCP must have a valid COA prior to entering into a provider agreement with ODJFS. A prospective MCP that previously had a provider agreement with ODJFS must comply with all procurement and pre-contracting requirements prior to receiving a new provider agreement. If the prior provider agreement terminated more than two years prior to the effective date of any new provider agreement, such MCP will be considered a plan new to Ohio Medicaid Managed Care and in its first year of operation.

 

Prior to ODJFS’ issuance of a provider agreement, a prospective MCP must demonstrate the capability to meet all applicable program requirements specified in Chapter 5101:3-26 of the Ohio Administrative Code (OAC) and the ODJFS - MCP Provider Agreement. This demonstration will include a review of documentation and data submitted by the prospective MCP, and may also include an on-site review of the prospective MCP’s administrative operations. The ODJFS’ review and approval of submissions from the prospective MCP includes, but is not limited to the following:

 

1. Administrative submissions:

 

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

 

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

 


Appendix B

Page 2

 

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

 

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

 

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

 

  f. a table of organization;

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 


Appendix B

Page 3

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 


Appendix B

Page 4

 

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

 

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

 

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

 

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

 

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

 

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

 

  d. Capability to reconcile membership data with remittance advice;

 

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

 

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

 

MCP Provider Agreement Amendments

 

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

 


Appendix B

Page 5

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 


APPENDIX C

 

MCP RESPONSIBILITIES

 

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

 

General Provisions

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 


Appendix C

Page 2

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 


Appendix C

Page 3

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 


Appendix C

Page 4

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

  i. Provides written information to all adult members concerning:

 

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

 


Appendix C

Page 5

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

23. Call Center Standards

 

The MCP must provide assistance to enrollees through a member services toll-free call-in system pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services staff must be available at all times to provide assistance to members through the toll-free call-in system every Monday through Friday, 8:30 a.m. to 4:30 p.m., except for major holidays as specified in the MCP’s member handbook, member newsletter, or other general issuance to the MCP’s members. ODJFS defines a major holiday as a day when much of the workforce is exempt from work to commemorate an event (i.e., holiday closure days normally observed by banks, government offices, or many businesses).

 

The MCP must also provide access to medical advice and direction through a centralized twenty-four-hour toll-free call-in system pursuant to OAC rule 5101:3-26-03.1(A)(6).

 


Appendix C

Page 6

 

The twenty-four hour call-in system must be staffed by appropriately trained medical personnel. For the purposes of meeting this requirement, trained medical professionals are defined as physicians, physician assistants, licensed practical nurses, and registered nurses.

 

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

 

24. HIPAA Privacy Compliance Requirements

 

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

 

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

 

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

 

  c. MCPs shall report to ODJFS any unauthorized use or disclosure of PHI of which it becomes aware.

 

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

 

 

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

 

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

 

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

 


Appendix C

Page 7

 

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

 

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

 

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

 

25. MCP Membership acceptance, documentation and reconciliation

 

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

 

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

 

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

 

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

 


Appendix C

Page 8

 

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

 

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

 

  f. Newborn Notifications: Effective December 1, 2003, the MCP is required to submit newborn notifications to ODJFS in accordance with the ODJFS Newborn Notification File and Submissions Specifications.

 

  g. Pending Member

 

  (i) If a pending member (i.e., an eligible individual subsequent to plan selection but prior to their membership effective date) contacts the selected MCP, the MCP must provide any membership information requested and ensure that any care coordination (e.g., PCP selection, continuity of care) information provided by the member is forwarded to the appropriate MCP staff for processing. Such communication does not constitute confirmation of membership.

 

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

 


Appendix C

Page 9

 

26. Health Information System Requirements

 

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

 

  a. Health Information System

 

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

 

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

 

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

 

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

 

  b. Electronic Data Interchange and Claims Adjudication Requirements

 

Claims Adjudication

 

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

 

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

 


Appendix C

Page 10

 

Electronic Data Interchange

 

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

 

Health care claims;

 

Health care claim status request and response;

 

Health care payment and remittance status; and

 

Standard code sets.

 

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

 

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

 

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

 

ASC X12 834 - Benefit Enrollment and Maintenance.

 

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

 

Documentation of Compliance with Mandated EDI Standards

 

The capacity of the MCP and/or applicable trading partners and business associates to electronically conduct claims processing and related transactions in compliance with standards and effective dates mandated by HIPAA must be demonstrated as outlined below.

 


Appendix C

Page 11

 

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

 

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

 

  1. Trading Partner Agreements

 

  2. Code Sets

 

  3. Transactions

 

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

 

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

 

  c. Referral Certification and Authorization (ASC X12N 278)

 

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

 

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

 

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

 

  g. Health Plan Premium Payments (ASC X12N 820)

 

  h. Coordination of Benefits

 

Trading Partner Agreement with ODJFS

 

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

 

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

 


Appendix C

Page 12

 

  c. Encounter Data Submission Requirements

 

General Requirements

 

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

 

  • Institutional Claims - UB92 flat file

 

  • Noninstitutional Claims - National standard format

 

  • Prescription Drug Claims - NCPDP

 

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

 

An encounter represents all of the services, including medical supplies and medications, provided to a member of the MCP by a particular provider, regardless of the payment arrangement between the MCP and the provider. For example, if a member had an emergency department visit and was examined by a physician, this would constitute two encounters, one related to the hospital provider and one related to the physician provider. However, for the purposes of calculating a utilization measure, this would be counted as a single emergency department visit. If a member visits their PCP and the PCP examines the member and has laboratory procedures done within the office, then this is one encounter between the member and their PCP. If the PCP sends the member to a lab to have procedures performed, then this is two encounters; one with the PCP and another with the lab. For pharmacy encounters, each prescription filled is a separate encounter.

 

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

 


Appendix C

Page 13

 

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

 

Acceptance Testing

 

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

 

Acceptance testing of encounter data is required:

 

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

 

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

 

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

 

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

 

Encounter Data Tape Submission Procedures

 

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

 


Appendix C

Page 14

 

No more than two production tapes per format (e.g., NSF) should be submitted each month. If it is necessary for an MCP to submit more than two production tapes for a particular format in a month, they must request permission to do so through their Contract Administrator.

 

Timing of Encounter Data Submissions

 

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

 

  d. Information Systems Review

 

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

 

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

 

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

 

  (ii) Review the completed ISCA and accompanying documents;

 

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

 

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

 

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

 

  (vi) Examine MCP processes for data transfers;

 


Appendix C

Page 15

 

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

 

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

 

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

 

As noted above, the information system review may be performed every two years. However, if ODJFS or its designee identifies significant information system problems, then ODJFS or its designee may conduct, and the MCP must participate in, a review the following year.

 

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

 

27. Delivery Payments

 

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

 

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

 


Appendix C

Page 16

 

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

 

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

 

If a physician and a hospital encounter is found for the same delivery, only one payment will be made. The same is true for multiple births; if multiple delivery encounters are submitted, only one payment will be made. The method for reimbursing for deliveries includes the delivery of stillborns where the MCP incurred costs related to the delivery.

 

Rejections

 

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

 

Timing of Delivery Payments

 

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

 

Updating and Deleting Delivery Encounters

 

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

 

The process for deleting delivery encounters can be found on page 35 of the UB-92 technical specifications (record/field 20-7)

and page III-47 of the NSF technical specifications (record/field CA0-31.0a).

 


Appendix C

Page 17

 

Auditing of Delivery Payments

 

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

 

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

 

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

 

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

 

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

 


APPENDIX D

 

ODJFS RESPONSIBILITIES

 

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

 

General Provisions

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 


Appendix D

Page 2

 

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

 

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

 

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

 

12. Consumer information

 

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

 

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

 

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

 

13. Membership Selection and Premium Payment

 

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

 


Appendix D

Page 3

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 


APPENDIX E

 

RATE METHODOLOGY

 


MERCER

Government Human Services Consulting

 

800 LaSalle Avenue, Suite 2100

Minneapolis, MN 55402-2012

612 642 8892 Fax 612 642 8911

angela.wasdyke@mercer.com

www.mercerHR.com

 

November 11, 2003

 

Ms. Mitali Ghatak

Office of Health Plan Policy

Ohio Department of Job and Family Services

30 East Broad Street, 27th Floor

Columbus, Ohio 43215-3414

 

Subject:

 

July 1, 2003 - December 31, 2004 Capitation Rate Final Certification

 

Dear Mitali:

 

The Ohio Department of Job and Family Services (State) contracted with Mercer Government Human Services Consulting (Mercer) to develop actuarially sound capitation rates for use during July 1, 2003 through December 31, 2004. Six (6)-month rates were developed for the period July 1, 2003 through December 31, 2003 and twelve (12) - month rates were developed for the period January 1, 2004 through December 31, 2004. As part of the rate-setting process, Mercer developed a Data Book summarizing Ohio’s historical Medicaid fee-for-service (FFS) cost and utilization experience. This letter, together with the Data Book, details the methodology used to determine the fee-for-service equivalents (FFSEs) and capitation rates for the Healthy Families (HF) and Healthy Start (HST) populations.

 

Overview

 

I. Data Book

 

II. Develop FFSEs

 

III. Develop Capitation Rates

 

IV. Certification of Final Rates

 

I. Data Book

 

The rate-setting process began with summarizing the FFS data from calendar years (CY) 1998-2000, which is contained in the Data Book dated March 29, 2002. This data was validated by the State as outlined in the Centers for Medicare and Medicaid Services’ (CMS) Rate Checklist.

 

During the time period of this base data, three significant expansions took place in Ohio that have an effect upon the 6-month and 12-month rates. These expansions increased eligibility

 

[GRAPHIC] Marsh & McLennan Companies


MERCER

Government Human Services Consulting

 

Page 2

November 11, 2003

Ms. Mitali Ghatak

Ohio Department of Job and Family Services

 

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

 

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

 

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

 

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

 

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

 

For July 1, 2003 through December 31, 2004 rate-setting purposes, historical experience was available in sufficient quantity only for the first expansion occurring in January 1998. Although the experience for the January and July 2000 expansions was reviewed, it was not used in rate setting since it was determined insufficiently credible. Instead, non-expansion and credible expansion data were blended together to account for the new populations.

 

The FFS data are categorized by rate cohort. The basis of these rate cohorts is the demographics of the population and the treatment patterns and risks associated with each group. For this reason, newborns are isolated, males and females are separated where differences exist, maternity is separated from non-maternity, and ages are split into groupings based on levels of expenses. More detail regarding these breakdowns, services covered, and any adjustments made to this data are outlined in the Data Book. Some of the adjustments applied to the FFS data are:

 

  • Incurred claims completion factors,

 

  • Gross adjustments for payments not processed through MMIS,

 

  • Third party liability,

 

  • Hospital settlements,

 

  • Pharmacy rebates,

 

  • Third trimester enrollment,

 

  • Retrospective eligibility costs, and

 

  • Fraud and abuse.

 

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

 


MERCER

Government Human Services Consulting

 

Page 3

November 11, 2003

Ms. Mitali Ghatak

Ohio Department of Job and Family Services

 

II. Develop FFSEs

 

The FFSEs represent the corresponding claims experience expressed on a per member per month (PMPM) basis for a population that is actuarially equivalent to the population that will be enrolled in the managed care program during the 6-month and 12-month periods.

 

The FFSEs are derived from further adjusting the data contained in the Data Book. These further adjustments are described in the following sections:

 

A. Historical Trend

 

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

 

B. Data Credibility

 

Since the FFS data has eroded due to the increase in managed care membership, some of the remaining FFS data may not be meaningful, and should not be used to set capitation rates. The increase in managed care enrollment is due to the Preferred Option program and higher enrollment in some voluntary counties. Mercer did not rely on historical data for time periods with managed care penetration in excess of 60%. As a result, area factors were used in several counties1. Data was used in two counties2 with managed care penetration exceeding 60% in one of the three base years; however, less credibility was given to the year in question. All remaining counties received equal credibility between the three trended base years.

 

Area factors were developed for most counties using a blend of historical FFS data from state fiscal year (SFY) 1995 and SFY 1996. Because managed care penetration was below 60% in all but Hamilton and Montgomery counties, the data from SFY 1995-SFY 1996 was deemed credible. Historical FFS data from these years was summarized for each area factor county and the Base Region3. Each area factor county’s FFS cost and utilization data was compared with the


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

 

2 Stark and Wood counties

 

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

 


MERCER

Government Human Services Consulting

 

Page 4

November 11, 2003

Ms. Mitali Ghatak

Ohio Department of Job and Family Services

 

Base Region FFS data from the same time period. This was done on a COS and rate cohort level of detail. Developing the area factors by rate cohort removes the impact of shifting demographics from year to year.

 

Since the managed care penetration level for Hamilton and Montgomery counties was greater than 60% in SFY 1995 and SFY 1996, the FFS data for these counties and this time period were deemed not credible. Therefore, the area factor approach as outlined above could not be used. The rates for these counties were developed based on Cuyahoga county data and adjusted for inpatient services reflective of each county. This is the same approach used in the CY 2002 rate-setting process.

 

Furthermore, adequate membership size was necessary to develop individual county capitation rates. The FFS data from a number of smaller, more rural counties expected to enter managed care during the 12-month rating period were combined to develop the capitation rates. These counties included Belmont/Monroe, Clark/Madison, Defiance/Fulton/Henry, and Ottawa/Sandusky.

 

C. Blending with CY 2002 FFSEs

 

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

 

III. Develop Capitation Rates

 

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

 


MERCER

Government Human Services Consulting

 

Page 5

November 11, 2003

Ms. Mitali Ghatak

Ohio Department of Job and Family Services

 

A. Prospective Trend

 

Trend is an estimate of the change in the overall cost of providing a specific benefit service over a finite period of time. A trend factor is necessary to estimate the expenses of providing health care services in some future year, based in whole or in part upon expenses incurred in prior years. CMS requires the FFSEs be trended forward from the base period to the contract period, and actual trend experience is used to the fullest extent possible.

 

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

 

B. Programmatic Changes

 

CMS requires the rate-setting methodology used to determine capitation rates incorporate the impact of any programmatic changes that have taken place or are anticipated to take place between the base period and the contract period.

 

The State provided Mercer with a detailed list of program changes that will have a material impact upon the cost, utilization, or demographic structure of the program prior to or within the contract period, and whose impact was not included within the base period data. For those adjustments not incorporated through trend, Mercer adjusted the FFS experience for the following changes:

 

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

 

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

 


MERCER

Government Human Services Consulting

 

Page 6

November 11, 2003

Ms. Mitali Ghatak

Ohio Department of Job and Family Services

 

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

 

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

 

C. Voluntary Selection

 

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

 

D. Clinical Measures

 

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

 

E. Managed Care Savings

 

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


4 Please see revised penetration chart shown in Exhibit A.

 


MERCER

Government Human Services Consulting

 

Page 7

November 11, 2003

Ms. Mitali Ghatak

Ohio Department of Job and Family Services

 

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

 

F. MCP Administrative Load

 

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

 

  • First Plan Year

 

  • Administration of 13% of premium

 

  • 0% at risk

 

  • Second Plan Year

 

  • Administration of 12% of premium

 

  • 0% percent at risk

 

  • Third Plan Year

 

  • Administration of 12% of premium

 

  • 1% at risk

 

IV. Certification of Final Rates

 

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

 

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

 

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

 

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

 

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

 

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

 


MERCER

Government Human Services Consulting

 

Page 8

November 11, 2003

Ms. Mitali Ghatak

Ohio Department of Job and Family Services

 

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

 

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

 

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

 

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

 

  • Delivery Payment.

 

Summaries of the 6-month and 12-month rates by county and by rate cohort may be found in Exhibit B.

 

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

 

Sincerely,

 

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

 

AW/SJ/KC/kb

 

Copy:

Stephanie Davis, Shereen Jensen, Kristin Coyle

 


State of Ohio

   Exhibit A    Final
     Penetration Chart     

 

County


  

Projected

7/03-12/03


   

Projected

CY04


 
    

Allen

         15 %

Belmont/Monroe

         5 %

Butler

   65 %   75 %

Clark

   40 %      

Clark/Madison

         60 %

Clermont

   5 %   5 %

Columbiana

         15 %

Crawford

         5 %

Cuyahoga

   90 %   90 %

Defiance/Fulton/Henry

         5 %

Delaware

         5 %

Fairfield

         5 %

Franklin

   65 %   75 %

Greene

   40 %   45 %

Hamilton

   65 %   70 %

Huron

         5 %

Jefferson

         5 %

Licking

         15 %

Lorain

   60 %   65 %

Lucas

   90 %   90 %

Mahoning

   5 %   40 %

Montgomery

   60 %   75 %

Muskingum

         5 %

Ottawa/Sandusky

         5 %

Pickaway

   5 %   5 %

Portage

         15 %

Richland

         5 %

Stark

   75 %   90 %

Summit

   90 %   90 %

Trumbull

   5 %   40 %

Warren

   5 %   5 %

Washington

         5 %

Wood

   15 %   15 %

 

Mercer Government Human Services Consulting

         


State of Ohio

   Exhibit B    Final
     Six Month Rates     
     2nd Half 2003     

 

County


  

Rate Cohort


  

Annualized

Dec 2002

Managed Care

MM/Delv


   % of MM

   

CY 2002

Rate w/

Admin


  

7/1/2003 -

12/31/2003

Guaranteed

Rate


  

7/1/2003 -
12/31/2003

Rate At Risk


  

7/1/2003 -

12/31/2003

Rate w/

Admin


  

Percent

Increase


 

Butler

   HF/HST, Age 0, M & F    7,908    6.1 %   $ 527.77    $ 428.03    $ 4.32    $ 432.36    -18.1 %

Butler

   HF/HST, Age 1, M & F    7,752    6.0 %   $ 110.32    $ 119.95    $ 1.21    $ 121.16    9.8 %

Butler

   HF/HST, Age 2-13, M & F    66,072    50.7 %   $ 70.25    $ 78.13    $ 0.79    $ 78.92    12.3 %

Butler

   HF/HST, Age 14-18, M    7,452    5.7 %   $ 94.50    $ 101.30    $ 1.02    $ 102.32    8.3 %

Butler

   HF/HST, Age 14-18, F    8,184    6.3 %   $ 123.11    $ 137.87    $ 1.39    $ 139.27    13.1 %

Butler

   HF, Age 19-44, M    6,564    5.0 %   $ 221.82    $ 220.97    $ 2.23    $ 223.20    0.6 %

Butler

   HF, Age 19-44, F    23,040    17.7 %   $ 187.85    $ 211.60    $ 2.14    $ 213.74    13.8 %

Butler

   HF, Age 45+, M & F    1,608    1.2 %   $ 490.36    $ 488.26    $ 4.93    $ 493.19    0.6 %

Butler

   HST, Age 19-64, F    1,668    1.3 %   $ 304.21    $ 341.42    $ 3.45    $ 344.87    13.4 %
         
  

 

  

  

  

  

Butler

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

 

  

  

  

  

Butler

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

 

  

  

  

  

Butler

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

 

  

  

  

  

Clark

   HF/HST, Age 0, M & F    1,116    6.0 %   $ 578.29    $ 444.83    $ 4.49    $ 449.32    -22.3 %

Clark

   HF/HST, Age 1, M & F    1,044    5.6 %   $ 116.69    $ 122.08    $ 1.23    $ 123.31    5.7 %

Clark

   HF/HST, Age 2-13, M & F    9,036    48.8 %   $ 70.44    $ 76.92    $ 0.78    $ 77.70    10.3 %

Clark

   HF/HST, Age 14-18, M    924    5.0 %   $ 88.36    $ 93.27    $ 0.94    $ 94.21    6.6 %

Clark

   HF/HST, Age 14-18, F    924    5.0 %   $ 126.73    $ 139.13    $ 1.41    $ 140.53    10.9 %

Clark

   HF, Age 19-44, M    1,188    6.4 %   $ 192.54    $ 190.61    $ 1.93    $ 192.53    0.0 %

Clark

   HF, Age 19-44, F    3,936    21.3 %   $ 200.69    $ 224.96    $ 2.27    $ 227.24    13.2 %

Clark

   HF, Age 45+, M & F    252    1.4 %   $ 383.27    $ 408.24    $ 4.12    $ 412.36    7.6 %

Clark

   HST, Age 19-64, F    96    0.5 %   $ 281.21    $ 308.43    $ 3.12    $ 311.55    10.8 %
         
  

 

  

  

  

  

Clark

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

 

  

  

  

  

Clark

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

 

  

  

  

  

Clark

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

 

  

  

  

  

Clermont

   HF/HST, Age 0, M & F    427    5.5 %   $ 546.23    $ 417.91    $ 4.22    $ 422.14    -22.7 %

Clermont

   HF/HST, Age 1, M & F    430    5.5 %   $ 141.76    $ 140.79    $ 1.42    $ 142.21    0.3 %

Clermont

   HF/HST, Age 2-13, M & F    3,975    51.2 %   $ 73.20    $ 82.80    $ 0.84    $ 83.64    14.3 %

Clermont

   HF/HST, Age 14-18, M    456    5.9 %   $ 81.01    $ 90.95    $ 0.92    $ 91.87    13.4 %

Clermont

   HF/HST, Age 14-18, F    522    6.7 %   $ 139.84    $ 156.97    $ 1.59    $ 158.56    13.4 %

Clermont

   HF, Age 19-44, M    268    3.5 %   $ 197.25    $ 193.51    $ 1.95    $ 195.47    -0.9 %

Clermont

   HF, Age 19-44, F    1,513    19.5 %   $ 212.15    $ 238.48    $ 2.41    $ 240.89    13.5 %

Clermont

   HF, Age 45+, M & F    96    1.2 %   $ 472.01    $ 497.78    $ 5.03    $ 502.81    6.5 %

Clermont

   HST, Age 19-64, F    79    1.0 %   $ 362.51    $ 371.10    $ 3.75    $ 374.85    3.4 %
         
  

 

  

  

  

  

Clermont

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

 

  

  

  

  

Clermont

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

 

  

  

  

  

Clermont

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

 

  

  

  

  

Cuyahoga

   HF/HST, Age 0, M & F    80,520    4.5 %   $ 584.96    $ 475.39    $ 4.80    $ 480.19    -17.9 %

Cuyahoga

   HF/HST, Age 1, M & F    86,280    4.8 %   $ 124.16    $ 135.90    $ 1.37    $ 137.28    10.6 %

Cuyahoga

   HF/HST, Age 2-13, M & F    891,084    50.0 %   $ 65.37    $ 73.31    $ 0.74    $ 74.05    13.3 %

Cuyahoga

   HF/HST, Age 14-18, M    119,844    6.7 %   $ 73.86    $ 79.26    $ 0.80    $ 80.06    8.4 %

Cuyahoga

   HF/HST, Age 14-18, F    127,620    7.2 %   $ 113.20    $ 128.73    $ 1.30    $ 130.03    14.9 %

Cuyahoga

   HF, Age 19-44, M    61,008    3.4 %   $ 174.98    $ 170.34    $ 1.72    $ 172.06    -1.7 %

Cuyahoga

   HF, Age 19-44, F    360,012    20.2 %   $ 196.51    $ 223.69    $ 2.26    $ 225.94    15.0 %

Cuyahoga

   HF, Age 45+, M & F    36,600    2.1 %   $ 386.19    $ 380.57    $ 3.84    $ 384.42    -0.5 %

Cuyahoga

   HST, Age 19-64, F    17,808    1.0 %   $ 343.12    $ 388.93    $ 3.93    $ 392.86    14.5 %
         
  

 

  

  

  

  

Cuyahoga

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

 

  

  

  

  

Cuyahoga

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

 

  

  

  

  

Cuyahoga

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

 

  

  

  

  

Franklin

   HF/HST, Age 0, M & F    41,412    4.9 %   $ 503.34    $ 408.34    $ 4.12    $ 412.47    -18.1 %

Franklin

   HF/HST, Age 1, M & F    45,912    5.5 %   $ 107.80    $ 116.70    $ 1.18    $ 117.88    9.3 %

Franklin

   HF/HST, Age 2-13, M & F    432,048    51.6 %   $ 63.12    $ 70.60    $ 0.71    $ 71.32    13.0 %

Franklin

   HF/HST, Age 14-18, M    47,880    5.7 %   $ 75.42    $ 80.51    $ 0.81    $ 81.33    7.8 %

Franklin

   HF/HST, Age 14-18, F    54,540    6.5 %   $ 112.59    $ 127.29    $ 1.29    $ 128.57    14.2 %

Franklin

   HF, Age 19-44, M    29,256    3.5 %   $ 195.37    $ 193.10    $ 1.95    $ 195.05    -0.2 %

Franklin

   HF, Age 19-44, F    168,024    20.1 %   $ 217.48    $ 247.09    $ 2.50    $ 249.58    14.8 %

Franklin

   HF, Age 45+, M & F    10,668    1.3 %   $ 413.63    $ 412.66    $ 4.17    $ 416.83    0.8 %

Franklin

   HST, Age 19-64, F    7,488    0.9 %   $ 264.53    $ 300.16    $ 3.03    $ 303.19    14.6 %
         
  

 

  

  

  

  

Franklin

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

 

  

  

  

  

Franklin

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

 

  

  

  

  

Franklin

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

 

  

  

  

  

 

Mercer Government Human Services Consulting

  

Page 1 of 4

    


State of Ohio

   Exhibit B    Final
     Six Month Rates     
     2nd Half 2003     

 

County


  

Rate Cohort


  

Annualized

Dec 2002

Managed Care

MM/Delv


   % of MM

   

CY 2002

Rate w/

Admin


  

7/1/2003 -
12/31/2003

Guaranteed

Rate


  

7/1/2003 -
12/31/2003

Rate At Risk


  

7/1/2003 -
12/31/2003

Rate w/
Admin


  

Percent

Increase


 

Greene

   HF/HST, Age 0, M & F    2,543    5.5 %   $ 578.29    $ 452.62    $ 4.57    $ 457.20    -20.9 %

Greene

   HF/HST, Age 1, M & F    2,561    5.5 %   $ 116.69    $ 124.30    $ 1.26    $ 125.56    7.6 %

Greene

   HF/HST, Age 2-13, M & F    23,654    51.2 %   $ 70.44    $ 82.15    $ 0.83    $ 82.98    17.8 %

Greene

   HF/HST, Age 14-18, M    2,716    5.9 %   $ 88.36    $ 96.89    $ 0.98    $ 97.87    10.8 %

Greene

   HF/HST, Age 14-18, F    3,108    6.7 %   $ 126.73    $ 142.41    $ 1.44    $ 143.84    13.5 %

Greene

   HF, Age 19-44, M    1,596    3.5 %   $ 192.54    $ 191.25    $ 1.93    $ 193.18    0.3 %

Greene

   HF, Age 19-44, F    9,006    19.5 %   $ 200.69    $ 228.01    $ 2.30    $ 230.32    14.8 %

Greene

   HF, Age 45+, M & F    570    1.2 %   $ 383.27    $ 381.51    $ 3.85    $ 385.37    0.5 %

Greene

   HST, Age 19-64, F    470    1.0 %   $ 281.21    $ 321.33    $ 3.25    $ 324.57    15.4 %
         
  

 

  

  

  

  

Greene

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

 

  

  

  

  

Greene

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

 

  

  

  

  

Greene

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

 

  

  

  

  

Hamilton

   HF/HST, Age 0, M & F    24,540    5.9 %   $ 629.79    $ 510.07    $ 5 .15    $ 515.22    -18.2 %

Hamilton

   HF/HST, Age 1, M & F    22,860    5.5 %   $ 125.83    $ 137.00    $ 1.38    $ 138.39    10.0 %

Hamilton

   HF/HST, Age 2-13, M & F    213,888    51.8 %   $ 65.52    $ 72.73    $ 0.73    $ 73.47    12.1 %

Hamilton

   HF/HST, Age 14-18, M    26,520    6.4 %   $ 75.82    $ 80.75    $ 0.82    $ 81.56    7.6 %

Hamilton

   HF/HST, Age 14-18, F    31,944    7.7 %   $ 112.60    $ 127.50    $ 1.29    $ 128.79    14.4 %

Hamilton

   HF, Age 19-44, M    8,688    2.1 %   $ 180.67    $ 175.04    $ 1.77    $ 176.81    -2.1 %

Hamilton

   HF, Age 19-44, F    74,136    18.0 %   $ 197.19    $ 222.26    $ 2.25    $ 224.50    13.9 %

Hamilton

   HF, Age 45+, M & F    4,752    1.2 %   $ 392.89    $ 382.85    $ 3.87    $ 386.72    -1.6 %

Hamilton

   HST, Age 19-64, F    5,316    1.3 %   $ 344.27    $ 386.60    $ 3.91    $ 390.50    13.4 %
         
  

 

  

  

  

  

Hamilton

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

 

  

  

  

  

Hamilton

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

 

  

  

  

  

Hamilton

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

 

  

  

  

  

Lorain

   HF/HST, Age 0, M & F    7,236    5.0 %   $ 422.96    $ 345.40    $ 3.49    $ 348.89    -17.5 %

Lorain

   HF/HST, Age 1, M & F    8,100    5.6 %   $ 88.61    $ 92.40    $ 0.93    $ 93.33    5.3 %

Lorain

   HF/HST, Age 2-13, M & F    72,528    49.9 %   $ 57.69    $ 62.36    $ 0.63    $ 62.99    9.2 %

Lorain

   HF/HST, Age 14-18, M    8,496    5.8 %   $ 57.46    $ 61.51    $ 0.62    $ 62.13    8.1 %

Lorain

   HF/HST, Age 14-18, F    8,844    6.1 %   $ 108.81    $ 122.36    $ 1.24    $ 123.59    13.6 %

Lorain

   HF, Age 19-44, M    7,428    5.1 %   $ 160.70    $ 162.14    $ 1.64    $ 163.78    1.9 %

Lorain

   HF, Age 19-44, F    29,268    20.1 %   $ 179.46    $ 199.03    $ 2.01    $ 201.04    12.0 %

Lorain

   HF, Age 45+, M & F    2,040    1.4 %   $ 299.67    $ 299.69    $ 3.03    $ 302.72    1.0 %

Lorain

   HST, Age 19-64, F    1,416    1.0 %   $ 309.72    $ 343.68    $ 3.47    $ 347.16    12.1 %
         
  

 

  

  

  

  

Lorain

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

 

  

  

  

  

Lorain

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

 

  

  

  

  

Lorain

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

 

  

  

  

  

Lucas

   HF/HST, Age 0, M & F    32,076    5.4 %   $ 647.45    $ 533.45    $ 5.39    $ 538.84    -16.8 %

Lucas

   HF/HST, Age 1, M & F    33,228    5.6 %   $ 100.36    $ 109.64    $ 1.11    $ 110.75    10.4 %

Lucas

   HF/HST, Age 2-13, M & F    294,060    49.3 %   $ 62.88    $ 70.64    $ 0.71    $ 71.35    13.5 %

Lucas

   HF/HST, Age 14-18, M    37,416    6.3 %   $ 71.47    $ 78.97    $ 0.80    $ 79.77    11.6 %

Lucas

   HF/HST, Age 14-18, F    40,872    6.9 %   $ 116.85    $ 131.41    $ 1.33    $ 132.74    13.6 %

Lucas

   HF, Age 19-44, M    24,528    4.1 %   $ 187.36    $ 183.95    $ 1.86    $ 185.81    -0.8 %

Lucas

   HF, Age 19-44, F    115,356    19.4 %   $ 199.19    $ 224.58    $ 2.27    $ 226.85    13.9 %

Lucas

   HF, Age 45+, M & F    9,048    1.5 %   $ 415.02    $ 407.68    $ 4.12    $ 411.80    -0.8 %

Lucas

   HST, Age 19-64, F    9,516    1.6 %   $ 340.77    $ 385.01    $ 3.89    $ 388.90    14.1 %
         
  

 

  

  

  

  

Lucas

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

 

  

  

  

  

Lucas

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

 

  

  

  

  

Lucas

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

 

  

  

  

  

Mahoning

   HF/HST, Age 0, M & F    953    5.5 %   $ 512.84    $ 395.11    $ 3.99    $ 399.10    -22.2 %

Mahoning

   HF/HST, Age 1, M & F    959    5.5 %   $ 109.61    $ 117.08    $ 1.18    $ 118.26    7.9 %

Mahoning

   HF/HST, Age 2-13, M & F    8,862    51.2 %   $ 71.58    $ 74.18    $ 0.75    $ 74.93    4.7 %

Mahoning

   HF/HST, Age 14-18, M    1,017    5.9 %   $ 101.19    $ 104.99    $ 1.06    $ 106.05    4.8 %

Mahoning

   HF/HST, Age 14-18, F    1,165    6.7 %   $ 121.54    $ 131.29    $ 1.33    $ 132.62    9.1 %

Mahoning

   HF, Age 19-44, M    598    3.5 %   $ 203.35    $ 179.71    $ 1.82    $ 181.53    -10.7 %

Mahoning

   HF, Age 19-44, F    3,374    19.5 %   $ 211.29    $ 228.23    $ 2.31    $ 230.53    9.1 %

Mahoning

   HF, Age 45+, M & F    214    1.2 %   $ 400.10    $ 383.32    $ 3.87    $ 387.19    -3.2 %

Mahoning

   HST, Age 19-64, F    176    1.0 %   $ 346.92    $ 343.88    $ 3.47    $ 347.35    0.1 %
         
  

 

  

  

  

  

Mahoning

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

 

  

  

  

  

Mahoning

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

 

  

  

  

  

Mahoning

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

 

  

  

  

  

 

Mercer Government Human Services Consulting

  

Page 2 of 4

    


State of Ohio   

Exhibit B

Six Month Rates

2nd Half 2003

   Final

 

County


  

Rate Cohort


   Annualized
Dec 2002
Managed
Care
MM/Delv


   % of MM

    CY 2002
Rate w/
Admin


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


   7/1/2003-
12/31/2003
Rate At Risk


   7/1/2003-
12/31/2003
Rate w/
Admin


   Percent
Increase


 

Montgomery

  

HF/HST, Age 0, M & F

   22,200    6.3 %   $ 602.39    $ 481.06    $ 4.86    $ 485.92    -19.3 %

Montgomery

  

HF/HST, Age 1, M & F

   19,524    5.5 %   $ 123.80    $ 133.49    $ 1.35    $ 134.84    8.9 %

Montgomery

  

HF/HST, Age 2-13, M & F

   177,480    50.2 %   $ 64.80    $ 71.63    $ 0.72    $ 72.35    11.6 %

Montgomery

  

HF/HST, Age 14-18, M

   20,316    5.7 %   $ 74.10    $ 77.90    $ 0.79    $ 78.69    6.2 %

Montgomery

  

HF/HST, Age 14-18, F

   23,388    6.6 %   $ 111.83    $ 125.38    $ 1.27    $ 126.64    13.3 %

Montgomery

  

HF, Age 19-44, M

   11,952    3.4 %   $ 176.03    $ 169.42    $ 1.71    $ 171.13    -2.8 %

Montgomery

  

HF, Age 19-44, F

   71,304    20.2 %   $ 194.95    $ 218.71    $ 2.21    $ 220.92    13.3 %

Montgomery

  

HF, Age 45+, M & F

   4,020    1.1 %   $ 385.54    $ 375.66    $ 3.79    $ 379.45    -1.6 %

Montgomery

  

HST, Age 19-64, F

   3,312    0.9 %   $ 340.60    $ 382.39    $ 3.86    $ 386.25    13.4 %
         
  

 

  

  

  

  

Montgomery

  

Subtotal

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

 

  

  

  

  

Montgomery

  

Delivery Payment

   935    0.3 %   $ 4,146.90    $ 4,751.44    $ 47.99    $ 4,799.44    15.7 %
         
  

 

  

  

  

  

Montgomery

  

Total

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

 

  

  

  

  

Pickaway

  

HF/HST, Age 0, M & F

   148    5.5 %   $ 501.13    $ 403.29    $ 4.07    $ 407.37    -18.7 %

Pickaway

  

HF/HST, Age 1, M & F

   149    5.5 %   $ 123.14    $ 122.25    $ 1.23    $ 123.48    0.3 %

Pickaway

  

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

   1,378    51.2 %   $ 70.44    $ 73.24    $ 0.74    $ 73.98    5.0 %

Pickaway

  

HF/HST, Age 14-18, M

   158    5.9 %   $ 87.67    $ 90.86    $ 0.92    $ 91.78    4.7 %

Pickaway

  

HF/HST, Age 14-18, F

   181    6.7 %   $ 122.78    $ 130.76    $ 1.32    $ 132.08    7.6 %

Pickaway

  

HF, Age 19-44, M

   93    3.5 %   $ 219.16    $ 210.10    $ 2.12    $ 212.22    -3.2 %

Pickaway

  

HF, Age 19-44, F

   525    19.5 %   $ 214.34    $ 241.07    $ 2.44    $ 243.50    13.6 %

Pickaway

  

HF, Age 45+, M & F

   33    1.2 %   $ 416.49    $ 430.49    $ 4.35    $ 434.84    4.4 %

Pickaway

  

HST, Age 19-64, F

   27    1.0 %   $ 346.07    $ 361.94    $ 3.66    $ 365.60    5.6 %
         
  

 

  

  

  

  

Pickaway

  

Subtotal

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

 

  

  

  

  

Pickaway

  

Delivery Payment

   9    0.3 %   $ 3,384.09    $ 3,508.09    $ 35.44    $ 3,543.52    4.7 %
         
  

 

  

  

  

  

Pickaway

  

Total

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

 

  

  

  

  

Richland

  

HF/HST, Age 0, M & F

   417    5.5 %   $ 435.57    $ 362.45    $ 3.66    $ 366.11    -15.9 %

Richland

  

HF/HST, Age 1, M & F

   420    5.5 %   $ 119.58    $ 125.70    $ 1.27    $ 126.97    6.2 %

Richland

  

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

   3,882    51.2 %   $ 65.11    $ 74.16    $ 0.75    $ 74.91    15.1 %

Richland

  

HF/HST, Age 14-18, M

   446    5.9 %   $ 73.40    $ 84.99    $ 0.86    $ 85.84    16.9 %

Richland

  

HF/HST, Age 14-18, F

   510    6.7 %   $ 130.13    $ 142.23    $ 1.44    $ 143.67    10.4 %

Richland

  

HF, Age 19-44, M

   262    3.5 %   $ 163.01    $ 160.46    $ 1.62    $ 162.08    -0.6 %

Richland

  

HF, Age 19-44, F

   1,478    19.5 %   $ 176.92    $ $202.52    $ 2.05    $ 204.56    15.6 %

Richland

  

HF, Age 45+, M & F

   94    1.2 %   $ 323.07    $ 336.51    $ 3.40    $ 339.91    5.2 %

Richland

  

HST, Age 19-64, F

   77    1.0 %   $ 266.88    $ 300.05    $ 3.03    $ 303.09    13.6 %
         
  

 

  

  

  

  

Richland

  

Subtotal

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

 

  

  

  

  

Richland

  

Delivery Payment

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

 

  

  

  

  

Richland

  

Total

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

 

  

  

  

  

Stark

  

HF/HST, Age 0, M & F

   348    4.2 %   $ 433.74    $ 340.28    $ 3.44    $ 343.72    -20.8 %

Stark

  

HF/HST, Age 1, M & F

   372    4.5 %   $ 98.56    $ 108.09    $ 1.09    $ 109.18    10.8 %

Stark

  

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

   4,392    53.4 %   $ 62.03    $ 68.02    $ 0.69    $ 68.71    10.8 %

Stark

  

HF/HST, Age 14-18, M

   552    6.7 %   $ 68.52    $ 75.71    $ 0.76    $ 76.47    11.6 %

Stark

  

HF/HST, Age 14-18, F

   576    7.0 %   $ 116.83    $ 129.05    $ 1.30    $ 130.36    11.6 %

Stark

  

HF, Age 19-44, M

   300    3.6 %   $ 152.83    $ 154.63    $ 1.56    $ 156.19    2.2 %

Stark

  

HF, Age 19-44, F

   1,440    17.5 %   $ 185.77    $ 211.52    $ 2.14    $ 213.65    15.0 %

Stark

  

HF, Age 45+, M & F

   144    1.8 %   $ 383.72    $ 385.12    $ 3.89    $ 389.01    1.4 %

Stark

  

HST, Age 19-64, F

   96    1.2 %   $ 277.06    $ 315.24    $ 3.18    $ 318.42    14.9 %
         
  

 

  

  

  

  

Stark

  

Subtotal

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

 

  

  

  

  

Stark

  

Delivery Payment

   23    0.3 %   $ 3,036.07    $ 3,464.84    $ 35.00    $ 3,499.84    15.3 %
         
  

 

  

  

  

  

Stark

  

Total

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

 

  

  

  

  

Summit

  

HF/HST, Age 0, M & F

   27,504    5.0 %   $ 544.75    $ 442.59    $ 4.47    $ 447.06    -17.9 %

Summit

  

HF/HST, Age 1, M & F

   27,600    5.0 %   $ 106.04    $ 116.01    $ 1.17    $ 117.18    10.5 %

Summit

  

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

   268,860    49.0 %   $ 63.11    $ 70.76    $ 0.71    $ 71.47    13.2 %

Summit

  

HF/HST, Age 14-18, M

   32,988    6.0 %   $ 85.66    $ 92.28    $ 0.93    $ 93.21    8.8 %

Summit

  

HF/HST, Age 14-18, F

   37,812    6.9 %   $ 122.35    $ 138.62    $ 1.40    $ 140.02    14.4 %

Summit

  

HF, Age 19-44, M

   24,096    4.4 %   $ 171.17    $ 170.65    $ 1.72    $ 172.37    0.7 %

Summit

  

HF, Age 19-44, F

   114,744    20.9 %   $ 202.85    $ 230.77    $ 233    $ 233.10    14.9 %

Summit

  

HF, Age 45+, M & F

   10,764    2.0 %   $ 401.55    $ 399.71    $ 4.04    $ 403.75    0.5 %

Summit

  

HST, Age 19-64, F

   4,884    0.9 %   $ 324.03    $ 367.39    $ 3.71    $ 371.10    14.5 %
         
  

 

  

  

  

  

Summit

  

Subtotal

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

 

  

  

  

  

Summit

  

Delivery Payment

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

 

  

  

  

  

Summit

  

Total

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

 

  

  

  

  

 

Mercer Government Human Services Consulting

  

Page 3 of 4

    


State of Ohio   

Exhibit B

Six Month Rates

2nd Half 2003

   Final

 

County


  

Rate Cohort


   Annualized
Dec 2002
Managed Care
MM/Delv


   % of MM

    CY 2002
Rate w/
Admin


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


   7/1/2003-
12/31/2003
Rate At Risk


   7/1/2003-
12/31/2003
Rate w/
Admin


   Percent
Increase


 

Trumbull

  

HF/HST, Age 0, M & F

   775    5.5 %   $ 512.84    $ 389.00    $ 3.93    $ 392.93    -23.4 %

Trumbull

  

HF/HST, Age 1, M & F

   781    5.5 %   $ 109.61    $ 119.54    $ 1.21    $ 120.75    10.2 %

Trumbull

  

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

   7,211    51.2 %   $ 71.58    $ 78.25    $ 0.79    $ 79.04    10.4 %

Trumbull

  

HF/HST, Age 14-18, M

   828    5.9 %   $ 101.19    $ 97.81    $ 0.99    $ 98.80    -2.4 %

Trumbull

  

HF/HST, Age 14-18, F

   948    6.7 %   $ 121.54    $ 133.68    $ 1.35    $ 135.03    11.1 %

Trumbull

  

HF, Age 19-44, M

   487    3.5 %   $ 203.35    $ 201.54    $ 2.04    $ 203.58    0.1 %

Trumbull

  

HF, Age 19-44, F

   2,745    19.5 %   $ 211.29    $ 233.98    $ 2.36    $ 236.35    11.9 %

Trumbull

  

HF, Age 45+, M & F

   174    1.2 %   $ 400.10    $ 380.23    $ 3.84    $ 384.07    -4.0 %

Trumbull

  

HST, Age 19-64, F

   143    1.0 %   $ 346.92    $ 363.68    $ 3.67    $ 367.36    5.9 %
         
  

 

  

  

  

  

Trumbull

  

Subtotal

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

 

  

  

  

  

Trumbull

  

Delivery Payment

   48    0.3 %   $ 3,509.06    $ 3,693.19    $ 37.30    $ 3,730.49    6.3 %
         
  

 

  

  

  

  

Trumbull

  

Total

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

 

  

  

  

  

Warren

  

HF/HST, Age 0, M & F

   204    5.5 %   $ 459.45    $ 371.75    $ 3.76    $ 375.51    -18.3 %

Warren

  

HF/HST, Age 1, M & F

   206    5.6 %   $ 95.81    $ 104.78    $ 1.06    $ 105.84    10.5 %

Warren

  

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

   1,898    51.2 %   $ 64.76    $ 70.08    $ 0.71    $ 70.79    9.3 %

Warren

  

HF/HST, Age 14-18, M

   218    5.9 %   $ 65.83    $ 74.57    $ 0.75    $ 75.32    14.4 %

Warren

  

HF/HST, Age 14-18, F

   249    6.7 %   $ 109.91    $ 126.09    $ 1.27    $ 127.37    15.9 %

Warren

  

HF, Age 19-44, M

   128    3.5 %   $ 182.03    $ 182.47    $ 1.84    $ 184.32    1.3 %

Warren

  

HF, Age 19-44, F

   723    19.5 %   $ 209.88    $ 230.34    $ 2.33    $ 232.66    10.9 %

Warren

  

HF, Age 45+, M & F

   46    1.2 %   $ 458.20    $ 470.19    $ 4.75    $ 474.94    3.7 %

Warren

  

HST, Age 19-64, F

   38    1.0 %   $ 276.50    $ 315.66    $ 3.19    $ 318.84    15.3 %
         
  

 

  

  

  

  

Warren

  

Subtotal

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

 

  

  

  

  

Warren

  

Delivery Payment

   13    0.4 %   $ 3,211.66    $ 3,427.75    $ 34.62    $ 3,462.37    7.8 %
         
  

 

  

  

  

  

Warren

  

Total

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

 

  

  

  

  

Wood

  

HF/HST, Age 0, M & F

   516    5.5 %   $ 436.52    $ 337.53    $ 3.41    $ 340.94    -21.9 %

Wood

  

HF/HST, Age 1, M & F

   432    4.6 %   $ 115.67    $ 152.85    $ 1.54    $ 154.39    33.5 %

Wood

  

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

   4,848    51.9 %   $ 68.00    $ 74.08    $ 0.75    $ 74.83    10.0 %

Wood

  

HF/HST, Age 14-18, M

   564    6.0 %   $ 69.03    $ 67.82    $ 0.69    $ 68.50    -0.8 %

Wood

  

HF/HST, Age 14-18, F

   600    6.4 %   $ 125.18    $ 131.43    $ 1.33    $ 132.76    6.1 %

Wood

  

HF, Age 19-44, M

   564    6.0 %   $ 159.33    $ 151.43    $ 1.53    $ 152.96    4.0 %

Wood

  

HF, Age 19-44, F

   1,608    17.2 %   $ 188.12    $ 208.99    $ 2.11    $ 211.10    12.2 %

Wood

  

HF, Age 45+, M & F

   132    1.4 %   $ 387.37    $ 381.42    $ 3.85    $ 385.28    -0.5 %

Wood

  

HST, Age 19-64, F

   72    0.8 %   $ 350.29    $ 344.89    $ 3.48    $ 348.37    -0.5 %
         
  

 

  

  

  

  

Wood

  

Subtotal

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

 

  

  

  

  

Wood

  

Delivery Payment

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

 

  

  

  

  

Wood

  

Total

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

 

  

  

  

  

Total Managed Care

  

HF/HST, Age 0, M & F

   250,843    5.1 %   $ 572.95    $ 464.98    $ 4.70    $ 469.68    -18.0 %

Total Managed Care

  

HF/HST, Age 1, M & F

   258,610    5.2 %   $ 114.60    $ 124.73    $ 1.26    $ 125.99    9.9 %

Total Managed Care

  

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

   2,485,156    50.3 %   $ 64.44    $ 72.01    $ 0.73    $ 72.73    12.9 %

Total Managed Care

  

HF/HST, Age 14-18, M

   308,791    6.3 %   $ 75.63    $ 81.22    $ 0.82    $ 82.04    8.5 %

Total Managed Care

  

HF/HST, Age 14-18, F

   341,987    6.9 %   $ 114.83    $ 129.87    $ 1.31    $ 131.18    14.2 %

Total Managed Care

  

HF, Age 19-44, M

   179,004    3.6 %   $ 181.37    $ 178.05    $ 1.80    $ 179.85    -0.8 %

Total Managed Care

  

HF, Age 19-44, F

   982,232    19.9 %   $ 200.51    $ 227.19    $ 2.29    $ 229.48    14.4 %

Total Managed Care

  

HF, Age 45+, M & F

   81,255    1.6 %   $ 395.40    $ 390.60    $ 3.95    $ 394.54    -0.2 %

Total Managed Care

  

HST, Age 19-64, F

   52,682    1.1 %   $ 326.70    $ 368.85    $ 3.73    $ 372.58    14.0 %
         
  

 

  

  

  

  

Total Managed Care

  

Subtotal

   4,940,560    100.0 %   $ 136.60    $ 142.40    $ 1.44    $ 143.84    5.3 %
         
  

 

  

  

  

  

Total Managed Care

  

Delivery Payment

   18,472    0.4 %   $ 3,852.02    $ 4,432.28    $ 44.77    $ 4,477.05    16.2 %
         
  

 

  

  

  

  

Total Managed Care

  

Total

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

 

  

  

  

  

 

Mercer Government Human Services Consulting

  

Page 4 of 4

    


State of Ohio   

Exhibit B

Twelve Month Rates

CY 2004

   Final

 

County


  

Rate Cohort


  

Annualized

Dec 2002

Managed Care

MM/Delv


   % of
MM


   

CY 2002

Rate w/
Admin


  

1/1/2004-
12/31/2004

Guaranteed

Rate


  

1/1/2004-
12/31/2004

Rate At Risk


  

1/1/2004-
12/31/2004

Rate w/

Admin


  

Percent

Increase


 

Allen

   HF/HST, Age 0, M & F    941    5.5 %   $ —      $ 379.21    $ 3.83    $ 383.04    0.0 %

Allen

   HF/HST, Age 1, M & F    948    5.5 %   $ —      $ 116.84    $ 1.18    $ 118.02    0.0 %

Allen

   HF/HST, Age 2-13, M & F    8,757    51.2 %   $ —      $ 69.97    $ 0.71    $ 70.68    0.0 %

Allen

   HF/HST, Age 14-18, M    1,005    5.9 %   $ —      $ 76.56    $ 0.77    $ 77.33    0.0 %

Allen

   HF/HST, Age 14-18, F    1,151    6.7 %   $ —      $ 129.12    $ 1.30    $ 130.42    0.0 %

Allen

   HF, Age 19-44, M    591    3.5 %   $ —      $ 163.19    $ 1.65    $ 164.84    0.0 %

Allen

   HF, Age 19-44, F    3,334    19.5 %   $ —      $ 214.59    $ 2.17    $ 216.76    0.0 %

Allen

   HF, Age 45+, M&F    211    1.2 %   $ —      $ 372.45    $ 3.76    $ 376.21    0.0 %

Allen

   HST, Age 19-64, F    174    1.0 %   $ —      $ 350.32    $ 3.54    $ 353.86    0.0 %
         
  

 

  

  

  

  

Allen

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

 

  

  

  

  

Allen

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

 

  

  

  

  

Allen

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

 

  

  

  

  

Belmont/Monroe

   HF/HST, Age 0, M & F    335    5.5 %   $ —      $ 361.21    $ 3.65    $ 364.86    0.0 %

Belmont/Monroe

   HF/HST, Age 1, M & F    337    5.5 %   $ —      $ 112.61    $ 1.14    $ 113.75    0.0 %

Belmont/Monroe

   HF/HST, Age 2-13, M & F    3,114    51.2 %   $ —      $ 68.47    $ 0.69    $ 69.16    0.0 %

Belmont/Monroe

   HF/HST, Age 14-18, M    358    5.9 %   $ —      $ 75.95    $ 0.77    $ 76.72    0.0 %

Belmont/Monroe

   HF/HST, Age 14-18, F    409    6.7 %   $ —      $ 123.95    $ 1.25    $ 125.21    0.0 %

Belmont/Monroe

   HF, Age 19-44, M    210    3.5 %   $ —      $ 157.82    $ 1.59    $ 159.42    0.0 %

Belmont/Monroe

   HF, Age 19-44, F    1,185    19.5 %   $ —      $ 210.26    $ 2.12    $ 212.39    0.0 %

Belmont/Monroe

   HF, Age 45+, M& F    75    1.2 %   $ —      $ 361.96    $ 3.66    $ 365.61    0.0 %

Belmont/Monroe

   HST, Age 19-64, F    62    1.0 %   $ —      $ 338.13    $ 3.42    $ 341.55    0.0 %
         
  

 

  

  

  

  

Belmont/Monroe

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

 

  

  

  

  

Belmont/Monroe

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

 

  

  

  

  

Belmont/Monroe

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

 

  

  

  

  

Butler

   HF/HST, Age 0, M & F    7,908    6.1 %   $ 527.77    $ 437.98    $ 4.42    $ 442.40    -16.2 %

Butler

   HF/HST, Age 1, M & F    7,752    6.0 %   $ 110.32    $ 123.62    $ 1.25    $ 124.87    13.2 %

Butler

   HF/HST, Age 2-13, M & F    66,072    50.7 %   $ 70.25    $ 81.05    $ 0.82    $ 81.87    16.5 %

Butler

   HF/HST, Age 14-18, M    7,452    5.7 %   $ 94.50    $ 104.49    $ 1.06    $ 105.54    11.7 %

Butler

   HF/HST, Age 14-18, F    8,184    6.3 %   $ 123.11    $ 142.24    $ 1.44    $ 143.68    16.7 %

Butler

   HF, Age 19-44, M    6,564    5.0 %   $ 221.82    $ 229.95    $ 2.32    $ 232.28    4.7 %

Butler

   HF, Age 19-44, F    23,040    17.7 %   $ 187.85    $ 220.57    $ 2.23    $ 222.80    18.6 %

Butler

   HF, Age 45+, M & F    1,608    1.2 %   $ 490.36    $ 512.08    $ 5.17    $ 517.26    5.5 %

Butler

   HST, Age 19-64, F    1,668    1.3 %   $ 304.21    $ 352.41    $ 3.56    $ 355.97    17.0 %
         
  

 

  

  

  

  

Butler

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

 

  

  

  

  

Butler

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

 

  

  

  

  

Butler

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

 

  

  

  

  

Clark/Madison

   HF/HST, Age 0, M & F    1,203    6.0 %   $ 578.29    $ 464.46    $ 4.69    $ 469.15    -18.9 %

Clark/Madison

   HF/HST, Age 1, M & F    1,132    5.6 %   $ 116.69    $ 128.58    $ 1.30    $ 129.88    11.3 %