ODJFS Online | Ohio Medicaid

Job & Family Services Ohio Medicaid

Ohio Health Plans

Medicaid Enhanced Care Management
Request for Applications

Questions and Answers

Issued: October 21, 2003

Due to the large number of questions received on November 12, we will not be able to post answers prior to the Applicant Conference to all inquiries submitted. We plan on having as many answers available as possible for distribution on the 19th. Answers to any remaining questions, along with answers to questions submitted during or within 2 days following the Applicant Conference, will be posted as soon as possible, but no later than December 3, 2003.

Question #1: The data presented in Appendix B of the RFA is very small and difficult to read. Is a larger version available?
Answer #1: Click here for a pdf file or for a non-pdf MS Excel version contact the BMHC at: bmhc@odjfs.state.oh.us

Question #2: Are we supposed to submit multiple RFA's for different counties?
Answer #2: If the organization submitting the RFA is the same for each county being proposed, a single application may be submitted. However, tabs should clearly identify the specific collaboratives being formed in each county and related roles and responsibilities for each partner indicated. Also, if any component, such as PCP reimbursement or outreach approaches, varies among the counties, separate information should be provided for each.

While a single application for all counties can be submitted, implementation dates for those counties may differ based on the criteria specified in the RFA: the readiness of the ECM provider collaborative, the readiness of the community, and the administrative resources of ODJFS. Also, the ability of a single applicant to implement an ECM program in multiple counties on the same date is likely to be a challenge and should be considered when estimating implementation dates for each proposed county of service.

Question #3: Can the ODJFS provide interested parties with provider information as it relates to the targeted population identified in the RFA (i.e., who are the providers serving the population under FFS Medicaid and a breakdown of expenditures by provider)?
Answer #3: ODJFS has posted a Provider Utilization Summary (Medicaid FFS) report in the ECM Applicant Library. These files provide information, including payment and claims data, on Medicaid FFS providers who rendered services to the ECM eligible population during calendar year 2002. There is a separate file for each condition being targeted.

Question #4:Is formal credentialing required for the PCPs [primary care physicians]?
Answer #4:Currently, there are no formal credentialing requirements for ECM PCPs. However, all providers associated with the ECM program must be licensed in accordance with their responsibilities. Depending on final ECM program approval by the federal Centers for Medicare and Medicaid Services (CMS), this answer may require modification.

Question #5:Will PVS [Provider Verification System; a component of the risk-based managed care program] submissions be necessary?
Answer #5:No. Information on ECM PCPs and other participants will be required, but we will not use the PVS.

Question #6:Can we execute an addendum to the current MCP [managed care program] contract for participating PCPs?
Answer #6:The draft ECM-PCP agreement is intended for use either as a stand-alone document or as an amendment to an existing contract. It should not be used as an amendment to the Medicaid addendum used in the current managed care program.

Question #7: Will the rate adjustments for membership size be made based on program wide membership or per service area?
Answer #7: The rate adjustments for membership size will be based on the provider's entire service area. For example, if a provider is participating in three service areas, the adjustment will be based on the total combined membership of all three service areas.

Question #8: Will ODJFS share FFS [fee for service] claims history (including pharmacy) for new enrollees?
Answer #8: Yes. The intent is to share FFS claims history data for ECM members with the ECM provider as it becomes available.

Question #9: What case management staffing ratio assumptions did Mercer use in the rate calculation?
Answer #9: The case management staffing ratio assumptions were developed by Mercer clinicians and actuaries considering specific diseases, published literature, and clinical judgment.

Question #10: Will the pharmacy co-pay planned for implementation in January 2004 be waived for ECM members?
Answer #10: Yes.

Question #11: If the new member's established PCP refuses to contract, can they be assigned to a participating PCP?
Answer #11: Yes. However, the ECM should keep in mind that the member will be able to access any Medicaid FFS provider as well as exercise the option to terminate ECM membership each month.

Question #12: What is the method and timeliness planned to share precertification and prior authorization decisions?
Answer #12: These processes are still under development. The intention is to share the information related to such decisions at or near the same time as providers and/or members are notified.

Question #13: Will all the ODJFS quality studies listed be performed annually?
Answer #13: As most of the studies listed are based on administrative data, the intent is to conduct the studies annually. There will also be a limited number of medical record reviews required, primarily focusing on target conditions; these will occur annually dependent upon available resources.

Question #14: What is the process ODJFS will use to evaluate and approve the PCP reimbursement rate?
Answer #14: The PCP reimbursement rate will be reviewed to ensure that it reflects the minimum amount required by the ECM RFA. ODJFS and Mercer expect the level of PCP reimbursement will vary by provider depending on the services provided by the PCP. In addition, the fee distribution across the other program components will be evaluated to verify that adequate funding is proposed across all other service requirements. Before executing any PCP agreement, the ECM provider must obtain ODJFS approval for the reimbursement proposed.

Question #15: Please clarify that a full member services call center is not required in addition to the 24 hour, 7 day-a-week nurse advice line.
Answer #15: In addition to the 24/7 health advice line, the ECM provider must have a toll-free member services call-in telephone number that is available to ECM members during business hours (ODJFS expects ECM providers to operate with core hours of at least 8:30 a.m. - 4:30 p.m.). Member services staff must understand and be knowledgeable of ECM policies/procedures, so that they can answer member questions and resolve concerns and problems; distribute member handbooks, provider directories, and other relevant information; and work with ECM members to identify a PCP.

Question #16: Can you provide the Provider Utilization Summary information in Excel to aid in sorting for analysis?
Answer #16: The Provider Utilization Summary (Medicaid FFS) reports contained in the ECM Applicant Library is in Adobe PDF format. At this point in the ECM RFA process, ODJFS will not be able to convert data reports into different formats. However, once ODJFS enters the readiness review phase with selected applicants, such requests will be considered.

Question #17: Under the chart of condition/measure: ACE Inhibitor (Angiotensin Converting Enzyme) should read /ARB (Angiotensin II Receptor Blocker). Also Ace Inhibitor use by patients with Congestive Heart Failure (CHF) should be /ARB.
Answer #17: The measure will be changed to assess whether patients with CHF received an Angiotensin Converting Enzyme (ACE) Inhibitor or an Angiotensin receptor blocker (ARB).

Question #18: Are ECM providers responsible to manage all diseases or can they just provide different segments of care in different locations? Some PCP's populations are more active with adult diabetes and cardiovascular diseases and others have greater numbers in adult and pediatric asthma.
Answer #18: The ECM Provider is responsible for managing all targeted clinical conditions. However, ECM Primary Care Physicians may serve only a specified subset of clinical conditions, such as adult aged, blind, or disabled (ABD) members with a diagnosis of diabetes.

Question #19: The CHF category should expand into Hypertension which could be with the ICD-9 codes of 401. or 250.82 for diabetes.
Answer #19: We are planning to extend CHF to include certain hypertension patients.

Question #20: Under Coronary Artery Disease (CAD) can we use the diagnosis code 272.0, for elevated lipids since this condition often leads to CAD?
Answer #20: Although in theory including patients with elevated lipids in a cardiac program is sound, it is not recommended for inclusion in care management programs for several reasons. Abnormal lipid levels are very common, very variable, and sometimes hereditary and not managed very easily. The state might do targeted educational mailings to increase awareness.

Question #21: Will the FFS [fee-for-service] history be available member specific?
Answer #21: Yes. Individual claims histories will be available for each ECM member. The information will only be available to an ECM provider upon the member's enrollment in the ECM program.

Question #22: Is a COA [Certificate of Authority] required from the Department of Insurance for each of the specific service area county(ies)?
Answer #22: No COA is required for the ECM program.

Question #23: For the Zanesville SA [service area] is a plan required to serve all 6 counties?
Answer #23: Strong preference will be given to those ECM applicants who can serve all the counties in the Zanesville Service Area.

Question #24: Page 5 includes mention of "additional strategies to educate consumers regarding the use of their Medicaid benefits." What are these?
Answer #24: The ECM provider will be expected to educate consumers in a variety of ways to improve health outcomes and encourage the most beneficial and efficient use of services. Section II. D. of the RFA, Scope of Services, provides more information. In addition, the ECM is expected to propose creative initiatives for member education. This includes not only assistance with treatment plan compliance for the targeted condition, but additional approaches that would inform and educate the member about the appropriate use of medical services through a variety of strategies.

Question #25: Page 6 includes mention of ODJFS' intent to enter into agreements with applicants. Does ODJFS envision one ECM provider for each of the geographic areas noted on page 10?
Answer #25: It is not likely that the number of ECM eligibles in most counties/service areas would be sufficient to support more than one ECM provider and demonstrate a timely return on investment and outcomes. However, it is possible that in the largest county(ies), depending on volume and provider capacity, that ODJFS could enter into an agreement with more than one ECM provider.

Question #26: Page 10. Are we correct in assuming that ODJFS will determine the geographic areas for the first phase as a result of reviewing the applications submitted? If not, which two geographic areas will launch this effort?
Answer #26: Yes. Program implementation in any geographic area will be based on the ECM provider's demonstrated capacity and provider agreement readiness; the readiness of the community; and the administrative resources of ODJFS.

Question #27: Page 13. Please clarify the last sentence in Section 4 Utilization Management. Specifically, how will the flow of data/information be handled? What is it that ODJFS is expecting the ECM provider to do in terms of provider and consumer education as it relates to this topic?
Answer #27: The processes for sharing precertification and prior authorization decisions are still under development. The intention is to share the information related to such decisions at or near the same time as providers and/or members are notified.

Our expectation is that the ECM provider will analyze the services being requested, as well as the frequency of requests among providers and/or members in order to determine if better care coordination or education would result in more efficient service utilization. We also anticipate that ECM providers will be creative in merging various data and information to inform and target its care management as well as provider and consumer education.

Question #28: Page 35. If a provider operates in more than one service area, will the incentive/penalty calculations be done by area or collectively for all areas operated by the contractor?
Answer #28: The goal is to calculate incentives/penalties based on the ECM provider's entire service area. Some initial variation may occur as the result of different start dates in separate service areas.

Question #29: Page 29. Section V.A. states that the amount of the base premium will be evaluated at least biannually and that adjustments resulting from changes in membership size will occur as necessary. Will adjustments made because of membership size be evaluated and made each month? What other factors will be considered when adjusting premium amounts?
Answer #29: : We do not anticipate that an ECM provider's membership size will change each month in the volume that would necessitate a premium adjustment. However, we will monitor membership on a monthly basis and would update the premium if necessary. In terms of adjustments over time, the premiums will be evaluated with the assistance of a contracted actuarial firm and will consider factors similar to other premium-setting activities, such as reviewing submitted cost data and information related to which members are choosing to enroll in the program.

Question #30: Page 30. Should a separate premium allocation chart be prepared for each area proposed by the bidder or should one schedule reflecting average allocations for all areas be presented?
Answer #30: The premium allocation chart should be completed for the entire service area in which the ECM provider will participate. If an applicant foresees that specific allocation categories, such as PCP reimbursement allocation, may differ among service areas due to different unit costs or other factors, please note this in your response and provide an average across the entire service area in the premium allocation chart.

Question #31: What is the agenda for the November 19th Mandatory Applicant Information Conference?
Answer #31: The agenda will have three principal items. First, ODJFS' actuary will present information regarding premium development. Second, there will be an opportunity for potential applicants to ask for clarification of any responses already posted in the question and answer section of the Applicant Library. Third, potential applicants will be provided an opportunity to ask new questions. Any new answers provided will not be considered final until the final RFA question and answer document is posted by ODJFS on or before December 3, 2003.

Question #32: Are you going to limit the number of "plans" in each service are? If so, how many per service area?
Answer #32: ODJFS will not limit the number of ECM providers in each service area. However, it is not likely that the number of ECM eligibles in most counties/service areas would be sufficient to support more than one ECM provider and demonstrate a timely return on investment and outcomes. It is possible in the largest county(ies), depending on volume and provider capacity, that ODJFS could enter into an agreement with more than one ECM provider.

Question #33: How will the enrollment process work for 1 "plan" and more than 1 "plan"?
Answer #33: Individuals eligible for the ECM program will be identified based on the most current fee-for-service (FFS) claims data available. Membership in the ECM program will be automatic unless the consumer calls the ODJFS designated toll-free number to indicate that he/she does not want to be an ECM member. Appendix C of the ECM RFA provides information on the methodology used to identify ECM eligibles.

If there were a county or service area with more than one ECM provider, ECM eligibles who did not choose between the options would be assigned to an ECM provider based first on assuring that any existing physician relationship could be continued. In other words, the ECM provider with a documented relationship with an ECM eligible's physician would receive the assignment. For eligibles with no identifiable provider relationship, the ECM provider panels would be assessed to determine which offered the most comprehensive coverage in terms of geography and the strength of the ECM collaborative, with the stronger ECM provider receiving a greater number of assignments.

Question #34: Will there be an annual open enrollment process?
Answer #34: As "Preferred Option," ECM members will be able to change their membership status each month. There will be no "lock-in" and therefore no need of an open enrollment period.

Question #35: How will the "plans" be marketed?
Answer #35: ODJFS will convene community-based meetings to inform local stakeholders of the availability of the ECM program and its benefits. ECM providers are expected to participate in and cooperate with these and other community-based information activities. Direct marketing to ECM eligibles by ECM providers is prohibited. However, there will be opportunities at events such as health fairs and through ODJFS-processed mailings for an ECM provider to share information with Medicaid consumers.

Question #36: There is reference to case management staffing ratio assumptions in question #9 of the questions and answers on the web page. ODJFS answered that Mercer looked at actuary studies per disease categories. Will the staffing ratios be made available?
Answer #36: As stated in the response to question #9, the case management staffing ratio assumptions were developed by Mercer clinicians and actuaries considering specific diseases, published literature, and clinical judgment. The ratios used represent a range and an estimate and are not intended to be a target or requirement, nor do we expect the same ratio will apply to all programs. ODJFS will carefully review the proposed premium allocations as submitted by applicants for the ECM program components, including care management, for reasonableness. Further information in the case management assumptions may be provided as part of the readiness review phase.

Question #37: Will Core Plus recipients be included and if so will the care managers for those persons be actively involved with the ECM care managers?
Answer #37: No, they will not be included.

Question #38: Can you provide us with the eligibility numbers by county for the Zanesville Cluster?
Answer #38: Please click here for the ECM population patient count by county for the Zanesville service area.

Question #39: Is it possible to receive two years historical claims on this group for data analysis prior to implementation of the program?
Answer #39: Yes. Two years of historical claims can be provided prior to program implementation. Aggregate claims history beyond what is provided in the RFA will be made available during the readiness review phase. Individual claims histories will not be available until there is a signed provider agreement between ODJFS and the ECM provider. At that time, the ECM provider will receive a claims history for each ECM member.

Question #40: Will the ECM perform precertifications on the individuals enrolled, or will Permedion perform them?
Answer #40: The ECM will not perform precertifications for ECM members, but our intent is provide member-specific, as well as provider-based information on requests and determinations to the ECM provider.

Question #41: Can we get a list of services that require precertification and/or prior authorization from Medicaid?
Answer #41: Yes. For a list of services requiring precertification see the Hospital Handbook Transmittal Letters. Then click on 3352-03-1.
For further information about the following issues please follow the directions provided:

ODJFS prior-authorization policy: click here then click on "5101: 3 Medical Assistance" then click on "5101: 3-1" then click on "5101: 3-1-31"

Hospital services not typically covered by Medicaid: click here then click on "5101: 3 Medical Assistance" then click on "5101: 3-2" then click on "5101: 3-2-03"

Outpatient services requiring prior authorization: click here then click on "5101: 3 Medical Assistance" then click on "5101: 3-2" then click on "5101: 3-2-21"

Transplants requiring prior authorization: click here then click on "5101: 3 Medical Assistance" then click on "5101: 3-2" then click on "5101: 3-2-07.1"

Question #42: Can we get a list of comorbidities on the folks being targeted for participation?
Answer #42: A report identifying comorbidities for the ECM population is under development and should be available in the Applicant Library by November 19, 2003.

Question #43: Will we receive the pharmacy data as well as the medical claims for data integration and analysis?
Answer #43: : Yes.

Question #44: For adult ABD population, may the bidder propose selected conditions listed on page 8 or all conditions?
Answer #44: Please see the response to Question #18

Question #45: Are pharmacy costs included or excluded in the calculation of the baseline and program periods?
Answer #45: Pharmacy costs are included.

Question #46: Will the State make decisions on final denials/appeals as part of the utilization management (UM) process?
Answer #46: As described in Section II. D. 4, of the RFA, providers serving ECM members will continue submitting prior authorization of services directly to ODJFS. The Medicaid fee-for-service system utilizes several utilization management strategies that may affect ECM members, including precertification of certain hospital admissions and prior authorization for certain services or procedures not routinely covered directly by Medicaid.

Question #47: Is the ECM vendor required to provide UM or will the ECM coordinate with your existing UM provider?
Answer #47: See previous answer.

Question #48: Is UM included in the premium payment (this category is omitted from the ECM Provider Premium Allocation Chart on page 30 of the RFA)?
Answer #48: Direct utilization management, that is, precertification and prior authorization of specific medical services, is not the responsibility of the ECM. It is expected that the ECM will receive and use this information as part of care management, and the cost of this activity is included as care management.

Question #49: Does the State anticipate an RN fulfilling the care manager role? If not, what health professional is recommended to provide the anticipated disease management services?
Answer #49: Yes. ODJFS expects that an RN, LPN, physician assistant, or physician would serve as the care manager. In addition, care management services should be coordinated in consultation with a team of professionals, such as specialists, pediatricians, social workers, etc., appropriate to the ECM member's condition.

Question #50: From which types of organizations are you looking for responses? Do you have a preference for disease management company fulfilling the ECM role or is a provider vendor preferable?
Answer #50: ODJFS is not seeking responses from any one specific "type" of entity. Instead, we are interested in identifying qualified organizations or collaborations of organizations, with the requisite skills, capabilities, and experience in providing the services described in the RFA, and which also have a basic knowledge and understanding of the local health care marketplace.

Question #51: Is the discount (page 28 of the RFA) applied at a regional basis?
Answer #51: The adjustment based on membership size will be applied to the ECM's overall membership.

Question #52: Are you expecting one ECM per region or one for the state?
Answer #52: In general, we are anticipating one ECM provider per service area. See response to Question #25 for additional information.

Question #53: Are dual eligibles excluded from the population?
Answer #53: Yes, at this time. Please see II. C. of the RFA (ECM Population and Service Areas) for a description of excluded groups.

Question #54: Please provide clarification regarding the types of payments provided to physicians the ECM vendor is being asked to manage (just the care management and performance fee or these fees plus medical claims)
Answer #54: Physician claims for medical services will continue to be paid on a fee-for-service basis. Please see Section II. D. 5. of the RFA (ECM Scope of Services) and Section V. (Financial Information) for a detailed description of physician payments for care coordination and performance.

Question #55: Who are the current UM vendor and medical claims processing / payment vendors?
Answer #55: The current contractor for precertification for Medicaid fee-for-service consumers is Permidion. Prior authorization and claims adjudication for pharmacy claims are handled by First Health Services Inc.

Question #56: Will the respondent be responsible for covering the costs of the waived copays as part of the risk agreement.
Answer #56: No.

Question #57: How flexible is the state on the "30 day" contact rule (bottom of page 11).
Answer #57: Timely contact of the ECM member is essential to the assessment of the individual's condition and development of the care treatment. We believe the 30 day time period for the initial contact is reasonable and therefore we are not flexible on this provision.

Question #58: Does case management refer to a disease management care plan or is this different? (page 12 of the RFA).
Answer #58: In general, we view disease management as a component of case management. While the ECM program includes a focus on a small number of disease-specific conditions, there is in addition an emphasis on care management performed collaboratively by a team of professionals, management of members' co-morbidities, attention to psychological and community supports, and as appropriate, coordination with local agencies and/or support services.

Question #59: Is there a limit to the upside shared savings?
Answer #59: Yes. As presented in the chart on page 36 of the RFA, the limit is the amount associated with the per member per month variance of $56 or more. The most the incentive payment would be is the 10% identified.

Question #60: ODJFS has placed an emphasis on the development of collaboratives by successful applicants. Can ODJFS elaborate on its expectations as to what a collaborative might look like?
Answer #60: We are reluctant to specify what we think a collaborative would look like, as the expectation is that it will be developed locally to reflect the community to be served. We are most interested in the capacity to perform and coordinate all the activities included in the RFA, which could be one organization or several. Since there are administrative, analytical, clinical, provider and member services, and care management components, we are looking for one organization or a group of organizations that can demonstrate the capacity to address all of these areas for the target population.

Question #61: Please clarify whether traditional provider contracts, if structured appropriately, will be considered?
Answer #61: Please explain what is meant by "traditional provider contracts."

Question #62: What is the anticipated length of the contracts between ODJFS and each ECM Provider?
Answer #62: Provider agreements are signed for annual periods with renewals.

Question #63: The Request for Applications Section II.C. Page 9. says "Membership in the ECM program will be automatic unless the consumer calls the ODJFS designated toll-free number to indicate that he/she does not want to be an ECM member." Does this mean that all potential ECM members in a county will be assigned to successful proposers at contract inception? Or will they be phased in over a period of time?
Answer #63: Membership will be phased in order to permit adequate opportunities for outreach and assessment of new members.

Question #64: If not phased in at contract inception, would an ECM provider be granted an extended deadline (longer than those specified in Sections II.D.1. and 2.) to perform the large number of assessments and care treatment plans for its initial membership?
Answer #64: The membership will be phased in.

Question #65: We assume that physicians that participate in Ohio fee-for-service Medicaid submit claims for all office visits including those associated with general health issues. If a PCP office visit is required as part of development of the assessment and/or care treatment plan, please confirm that the PCP may submit a claim to Ohio fee-for-service Medicaid for such office visit.
Answer #65: Yes, we anticipate that such a visit would be covered by fee-for-service Medicaid as long as it meets all other claim submission requirements.

Question #66: (p.3) Will MCOs currently participating in the State's managed care program be eligible to submit applications for this procurement?
Answer #66: Yes.

Question #67: (p.6) Will the ECM provider be allowed to manage the pharmacy benefit for their enrollees or will the pharmacy management function remain under the authority of the fee-for-service system?
Answer #67: It will remain under FFS.

Question #68: (p.7) The managed care provider agreement contained in the applicant library indicates a one-year term with subsequent one-year renewals and sets conditions for premature termination. Will the term and termination conditions of the ECM provider agreement be consistent with these?
Answer #68: At this time, we believe the length of the provider agreement and the termination arrangements would be the same.

Question #69: (p.9) Co-pays will be waived for ECM members as an incentive to remain in the ECM program, including a pharmacy co-pay to be implemented in January 2004. Are any other co-pays currently in place or planned for implementation prior to June 2004?
Answer #69: None at this time.

Question #70: (p.10) Medicaid ABD consumers receiving treatment for transplants, cancer, ESRD, AIDS, severe trauma or who are Medicare-eligible will not be eligible for the ECM program. However, if an ECM member ends up in one of these categories, they may only be disenrolled from the ECM program at the member's request. The RFA notes that the Department will take this continued enrollment into consideration when evaluating ECM provider performance. While this will afford the opportunity to maintain continuity of care, will the Department exclude these costs from the performance analysis?
Answer #70: Because of the unique costs that would be associated with these members, their expenditures would be excluded from the growth rate calculation. The assessment of clinical quality specific to the ECM condition would still occur.

Question #71: (p.10) Is the Department considering selecting a single vendor for this entire procurement? If a vendor submits an application for all of the service areas but is not selected for all of the service areas, will the entire application be rejected or just the portion addressing those service areas for which it was not selected?
Answer #71: Given the variation among the communities included in the RFA, it seems to us that one vendor statewide is unlikely. However, an application for all service areas would not be rejected completely but would be considered separately for each service area. See the response to Questions #2 for additional information.

Question #72: (p.11) The ECM provider will be required to contact each ECM member within 30 days. In the event of inaccurate demographic data, is there an ODJFS contact or other resource that the ECM provider can work with to research and resolve inaccurate addresses and/or phone numbers?
Answer #72: We recognize the challenge of contacting Medicaid consumers due to the lack of current telephone or address information and are open to working with the ECM providers on creative approaches to improve this situation. Assessment or performance targets in this area will reflect the reality that some portion of ECM members may not be reachable.

Question #73: (p.12) The 24/7 Health Advice Line will need to provide personalized information, including "relevant utilization data." Will the ECM provider have access to utilization/claims data more frequently than the monthly extract provided by ODJFS?
Answer #73: ODJFS' goal is to send the ECM provider two years of FFS claims history for each new enrollee upon enrollment. After enrollment, ODJFS will be sending weekly files of new claims for all ECM members.

Question #74: (p.13) Will the ECM provider be allowed to develop utilization management strategies (pre-certification, prior authorization, referral management, etc.) beyond those that may currently exist in the fee-for-service system? If so, how will the ECM provider interface with the claims system to implement these strategies?
Answer #74: At this time, ECM-specific prior authorization and precertification will not be possible. We intend to share information on any prior authorizations requests, approvals, or denials and precertifications as close to the time they are made as possible, but no less frequently than monthly. Our expectation is that the ECM provider will analyze the services being requested, as well as the frequency of requests among providers and/or members in order to determine if better care coordination or education would result in more efficient service utilization. We also anticipate that ECM providers will be creative in merging various data and information to inform and target its care management as well provider and consumer education. We are hopeful that, over time, the influence of the care management and the ECM's understanding of member utilization patterns will result in improvements.

Question #75: (p.13) The ECM provider will need to develop a contracted PCP network. Will contracts be required for submission of the application or will a contracted network in time for the readiness review be sufficient?
Answer #75: The signed contracts will be part of the readiness review. The application should identify and demonstrate the ECM provider's capacity and progress in this area.

Question #76: (p. 16) The ECM provider will need to assure that all providers with the ECM program meet all applicable licensure requirements. Are providers currently "credentialed" for participation in the fee-for-service program and, if so, will this suffice for demonstration of a provider's licensure?
Answer #76: The ECM provider will be responsible for assuring the qualifications for providers that are delivering ECM services in accordance with federal requirements for prepaid ambulatory health plans (PAHPs). These are comparable to those for managed care organizations and are reflected in the Ohio Administrative Code at 5101:3-26-05(C). The provision will be modified to reflect the more limited scope of ECM services.

Question #77: (p.20) May we obtain a list of guests attending the Applicant Conference and organizations submitting a letter of intent?
Answer #77: Yes. Both will be posted on the web page and a list of guests attending the Applicant Conference will be available at the conference.

Question #78: (p.24) The response requires documented evidence of existing collaborations for current patients or members. Does this preclude building partnerships specifically for the ECM program?
Answer #78: No. We understand that out-of-state applicants may not have such relationships in Ohio. However, the demonstration of comparable relationships in other locations is encouraged, especially those serving Medicaid consumers.

Question #79: (p.33) How will ODJFS set the ECM Member Expected Growth Rate Reduction? What factors and assumptions might be included in calculating this expected reduction?
Answer #79: The ECM Member Expected Growth Rate Reduction is based on ODJFS return on investment (ROI) expectations for the ECM program. The current 17% factor assumes that ECM providers who do not achieve breakeven results for ODJFS (1:1 ROI) will be penalized, while ECM providers who produce greater than a 2:1 ROI will receive incentive payments. ODJFS expectations for ROI may change in future program years. The Expected Growth Rate Reduction is dependent on the ECM base premium of $43.62, Claims Cost per ECM Eligible (assumed to be $1022.06) and the Baseline Growth Rate (assumed to be 12.5%).

Question #80: (p.33) The growth rate variance will factor in any ECM premiums paid. Will these ECM premiums include any incentives/penalties imposed during the evaluation period?
Answer #80: No, the Growth Rate Variance will be calculated using the ECM premium based on the ECM Provider's membership size before adjustment for incentives or penalties.

Question #81: (p.33) Could you please further define and clarify the distinction between the Minimum ECM Eligible Growth Rate Reduction (5% in the example) and the ECM Member Expected Growth Rate Reduction (17% in the example)?
Answer #81: ODJFS expects a higher reduction in growth in the program participant group versus the entire ECM eligible group. Therefore, only a minimum of 5% Growth Rate Reduction is expected for the ECM eligible population and a 17% reduction in the ECM member population (participating in the ECM program). As noted in the RFA (page 32) these figures might change as conditions or populations covered under the program change.

Question #82: (p.34) The RFA states, "The Baseline Performance Period will start six months after enrollment begins." Should this read, "The Initial Performance Period will start six months after enrollment begins?"
Answer #82: Yes. This language will be amended in the RFA.

Question #83: (p.35) The scenario presented in the chart assumes program entry on July 1, 2004. Given the Baseline Performance Period covers January 1, 2004 through December 31, 2004, won't there be some overlap between the baseline and the initial intervention period?
Answer #83: In order to include the expected growth rate reduction in the provider agreement between ODJFS and the ECM provider, the baseline period is being amended from calendar year 2004 to state fiscal year 2003 (July 1, 2002 - June 30, 2003) for the example given on page 35 of the RFA.

Question #84: (p.35) How will the last performance period be handled as far as assessing any potential penalties or incentives against ECM premiums given the six-month lag in assessing performance?
Answer #84: For ECM providers terminating or not renewing their provider agreement, ODJFS will require a monetary assurance to cover potential penalties that occur after the provider agreement has ended.

Question #85: (p.36) The target growth rate and incentives/penalties associated with growth rate variance may be adjusted in the future. Will the ECM provider have the opportunity to review proposed changes prior to implementation?
Answer #85: We intend to present proposed changes for review and comment by the participating ECM providers prior to implementation.

Question #86: (p.37) ECM providers will be held accountable for performance standards established in the ECM provider agreement. Will ECM providers/bidders have an opportunity to review these standards and measures before they are incorporated in the ECM provider agreement where they vary from standards included in the current managed care program/agreement?
Answer #86: Yes.

Question #87: (p.38) The RFA notes that baseline and performance level determinations for clinical performance will take place four months after the end of the evaluation period while the claims lag for determining the growth rate variance will be six months. Should the two lag periods be consistent?
Answer #87: ODJFS has studied the effect of claims lag on the results of clinical performance measures. The study showed negligible differences between four and six months claims lag when measuring improvement over a baseline year with the same claims lag. The growth rate variance methods were determined by ODJFS' actuary and they have recommended a longer run out on claims to assure a higher percentage of claims are included in the overall cost calculation.

Question #88: (p.38) The table at the bottom of the page showing Report Periods indicates a Baseline Performance Period of January to December 2005 assuming program entry in October 2004. Shouldn't the baseline actually be January to December 2004?
Answer #88: No. Because the clinical performance measures are based on the ECM provider's members only, the baseline performance period cannot start until after program entry.

Question #89: (p.38) Assuming that the Baseline Performance Period should be January to December 2004 and the Initial Performance Period then becomes January to December 2005, this allows only three months between program entry and the beginning of the initial performance period whereas the reporting period for determining the growth rate variance allows for six months. Should the two "lead-in" periods be consistent?
Answer #89: See answer to previous Question.

Question #90: We are unable to locate a number of the cited OAC Rules (5101:3-26...) in either the applicant library or the state legislative website. Are these rules currently available elsewhere?
Answer #90: Any difficulty accessing the rules website is likely due to incompatibility between the user's network and the website. If you are experiencing access problems please notify your network administrator who should be able to make a simple port adjustment to permit access to the rules. Hard copies of the rules will be available at the Applicant Conference.

Question #91: (Appendix E) Can this Draft ECM-PCP Model Contract be revised (with ODJFS approval) and if so, is there a specific process the department would like us to follow regarding submission of proposed revisions?
Answer #91: We suggest that if the ECM provider has other provisions that are specific to their program that they be included in a "baseline" agreement or contract with the PCPs with the model agreement attached as an addendum. We have found that this approach streamlines the approval process.

Question #92: (RFA - page 7) For "high cost users of care," please provide additional detail on ways you will identify this population, i.e., threshold dollar amounts.
Answer #92: The population selection criteria for the Enhanced Care Management (ECM) program is not based on individual total medical dollars. The program is designed to target selected Medicaid consumers with certain chronic health conditions (diabetes, COPD, CHF, Hypertension and Asthma) in part because their health conditions are those that, especially if un-managed, result in high- cost users of care. These individuals will be identified through their claims history using the multiple criteria specified in Appendix C of the RFA.

Question #93: (RFA - page 9) Will disenrollment at the time a member enters a disenrollment status (waiver, hospice program, nursing facility, etc.) be automatic or will the contractor (ECM provider) need to be able to identify these members, through surveillance?
Answer #93: Disenrollment at the time a member enters a disenrollment status (waiver, hospice program, nursing facility, etc.) will be automatic.

Question #94: (RFA - Page 32) Can you provide a definition for the "medical costs" included in the Growth Rate calculation? Does this include all claims for ECM members, including pharmacy, social services, ambulance and costs for medical conditions outside of the targeted conditions? For example, are pregnancy costs included for someone who is in the ECM program due to a diagnosis of asthma?
Answer #94: The Growth Rate calculation includes medical costs for all services rendered to the ECM eligible population with the exception of services related to transplant, AIDS, cancer, ESRD, severe trauma, and hospice. Pregnancy claims for asthma patients will be included under total medical costs.

Question #95: (RFA - Page 35) If the penalty/incentive is used to reduce or increase the ECM premium for the future 12-month period, will the premium be applied to the membership level during the performance period (retroactive) or the current period (prospective)? If prospective, how will significant membership changes or termination of the ECM provider contract effect the penalty/incentive?
Answer #95: The RFA is being revised to instead provide for one-time payment of the incentives and recovery of penalties. This question would therefore no longer be applicable.

Question #96: (Appendix A, A-4) Is the predominant second language for this population Spanish? If not, what? Is there any data on the percentage of targeted households where little to no English is spoken?
Answer #96: The predominant second language of the population varies with geographic locations. We encourage the ECM vendors, as they start building collaboratives, to understand the community and find out more about the people in the county that they are interested in serving.

Question #97: Will enrollees be permitted to re-enroll once they have terminated the ECM Option? If a member is on spend-down and receives retroactive Medicaid coverage, how will their enrollment (or re-enrollment) and payment procedures in the ECM Option be handled?
Answer #97: Enrollees are permitted to re-enroll once they have terminated the ECM option. Delayed spenddown individuals are not included in the ECM program at this time.

Question #98: (RFA - Appendix B) Can the population profiles be made available to bidders with age/sex demographics?
Answer #98: The data has not been produced to this level of specificity at this time. If there is sufficient interest and if found to be necessary, this information could be provided during the readiness review phase.

Question #99: (Clarification to Question #4 on the website) Who will assume financial responsibility for license verification and sanction compliance?
Answer #99: The ECM is not responsible for license verification of providers who are duly enrolled in the Medicaid program. However, if the ECM is employing other health professionals for providing ECM services it is the ECM's responsibility to assure license verification and sanction compliance for those providers. Please see response to Question #76 for additional information.

Question #100: The topic of many questions was data collection and information exchange. Below is a brief description of the processes for which ODJFS received questions.
Answer #100: ODJFS is currently finalizing methods for all data collection and transmission related to the ECM program and details of these processes will be available for the readiness review phase. Many of these processes will be similar to the data collection and exchange methods currently used in the full-risk managed care program (see ODJFS Methods and Specifications for Data Quality and Performance Measures). ODJFS has third party partners it uses for some file transmissions.

Identification
ECM providers will have ECM program-specific Medicaid provider IDs that are unique. If a current Medicaid provider (e.g., managed care plan) also becomes an ECM provider, at present, we believe the submitter ID for this provider will remain the same for both programs.

FFS Claims
ODJFS' goal is to send the ECM provider two years of FFS claims history for each new enrollee upon enrollment. After enrollment, ODJFS will be sending weekly files of new claims for all ECM members. All claim types will be in this transmission, including pharmacy. The file format has not been finalized at this point. Real time on-line access is currently being assessed. Access would be limited to individual claims of ECM members only.

Outreach, Assessments, & Case Management
ECM providers will be responsible for collecting and submitting outreach, assessments, & case management data. These data will be collected in a similar manner as the full-risk managed care program, in which ODJFS uses an FTP (file transfer protocol) method for data transfer of these text files.

Enrollment and Premium Payment
This information will be transmitted monthly to the ECM providers via the HIPAA 820 (Premium Payment) and 834 (Membership) files. Information on these files will indicate ECM members to be covered the following month. In addition, ODJFS' Selection Services contractor will supply weekly records of processed ECM eligibles on the CCR (Consumer Contact Record). Data on this file is informational only and is not the official membership roster, as ECM members may yet opt in or opt out of the program. (The 834 is the official membership roster.)

Prior Authorization
ODJFS will be processing prior authorizations for the ECM members in the same manner it currently does for FFS consumers. ODJFS' goal is to send the ECM provider a copy of all denied or approved prior authorizations. The ECM member and the FFS provider will be notified by the current method, a hard copy letter. The method of transfer to the ECM provider has not been finalized at this point.

Members' PCP
The ECM members' designated PCP file will be separate from the current file submitted under the full-risk managed care program. The file requirements will be similar to what is used in the full-risk program.

Question #101:Please provide the status of coexisting mental health disorders of the initial population of patients being targeted.
Answer #101:The RFA will be amended to include a new report: Co-Morbidities of ECM Eligibles, which will be added to the Applicant Library, by no later than December 3, 2003.

Question #102:Please explain how there can be an ABD population of child asthmatics. Additionally, what impact will that have on the eligible population in the current risk-based managed care program?
Answer #102:Some children with disabilities are eligible for Medicaid as "disabled" and are therefore in the Aged, Blind, or Disabled (ABD) category. There should be no impact on the current program as it does not enroll the ABD population.

Question #103:Will ECM providers have the ability to offer supplemental benefits, such as transportation, and nominal financial incentives (e.g., prenatal/immunization incentives)?
Answer #103:Yes, additional benefits such as transportation are permissible as are nominal member incentives subject to ODJFS prior approval.

Question #104:If an ECM eligible/member opts out of the program, what is the ability/timing to opt back in?
Answer #104:The ECM eligible could choose to again become an ECM member the next month.

Question #105:How is eligibility for the ECM program determined by the County Department of Job and Family Services (CDJFS) and how often are benefits determined for the targeted population?
Answer #105:The CDJFS determines eligibility for Medicaid. Eligibility for the ECM program is based on the most current fee-for-service claims data available. See Appendix C of the RFA for a description of the methodology used to identify ECM eligibles. For the ABD population, there is a 12-month redetermination of eligibility.

Question #106:What is the expected ratio of case managers to ECM members?
Answer #106:See response to Question #36.

Question #107:Would disease management be permissible in this population of patients, or would only case management be allowed?
Answer #107:ODJFS is seeking applicants with experience in providing a comprehensive care management program, including both disease and case management approaches. In general, we view disease management as a component of case management. While the ECM program includes a focus on a small number of disease-specific conditions, there is in addition an emphasis on care management performed collaboratively by a team of professionals, management of members' co-morbidities, attention to psychological and community supports, and as appropriate, coordination with local agencies and/or support services.

Question #108:There is no mention of a grievance & appeal file in Appendix F. However, Appendix G describes required processes/specifications to accept, resolve and track member complaints. Will a separate ECM grievance & appeals file need to be submitted?
Answer #108:: While grievances and appeals are not a federal requirement for the ECM program, ODJFS will require a basic report from ECM providers on the number and type of member complaints received and their resolution. More detailed information will be provided during the readiness review phase.

Question #109:Need a breakdown of membership by zip code plus disease category. This will give a sense of possible migration patterns.
Answer #109:This information is not available at this time.

Question #110:Will there be an identifying ID card indicating that these members are enrolled in the ECM program as well as information specific to that ECM? If so, is this something ODJFS will coordinate or will the ECM?
Answer #110:ODJFS will issue a Medicaid card to ECM members with an identifier indicating ECM membership.

Question #111:For eligibility purposes, what is the system for unique identification for these members? Is it all driven by social security number? On the disenrollment and enrollment file that is sent monthly [to plans currently operating under the full-risk managed care program], will members be identified by their subgroups/disease? If so, what is the unique identifier?
Answer #111:ODJFS will notify each ECM provider by the first working day of each calendar month of those Medicaid eligibles who are new or continuing ECM members and those who have disenrolled, either by choice or due to the loss of program eligibility. The Medicaid Management Information System (MMIS) number will be the identifying number. The membership roster will not provide information on the member's condition; that information will be provided through the Consumer Contact Record which will be forwarded to the ECM provider by the ODJFS Selection Services Contractor.

Question #112:The document states that ODJFS will not be notifying ECM eligible/members of participation. If that is the case, is there any type of education/informational materials that ODJFS will develop related to the program? Are there plans to disseminate? Method? Frequency?
Answer #112:This is incorrect. Per Section II. E. of the RFA, ODJFS will identify and notify Medicaid consumers who are eligible for the ECM program. Information regarding the program will be provided in writing to all ECM eligibles and will also be available by telephone through a toll-free number.

Question #113:If a member chooses to disenroll, can the ECM contact the member to explain benefits of the program to encourage re-enrollment?
Answer #113:Information on the reasons for a member's termination will be provided to the ECM provider by ODJFS. The ECM provider could also contact or survey the former member to obtain feedback on its performance or the individual's experience but should be cautious about engaging in any communication that could be construed as direct marketing, which is prohibited.

Question #114:What are the FFS prior authorization/pre-certification services?
Answer #114:Please see response to Question #41.

Question #115:As an ECM, it appears that ODJFS is looking for HEDIS-type data utilizing hybrid methodology (administrative data and medical record review). Need to understand scope and frequency of reporting. Is it similar to the encounter data measures that are currently employed for the risked-based population?
Answer #115:For the clinical measures that will be used by ODJFS to hold ECM providers accountable for minimum performance levels, a straight administrative method will be used. We will be calculating these results internally based on claims data. For the Quality of Care studies described on page 39 of the RFA, a hybrid method will be used, if applicable. ODJFS' EQRO will be conducting these quality studies.

Question #116: Similar to the above, what are the member satisfaction survey requirements? Will ODJFS coordinate or will the ECM? Frequency? Method restrictions?
Answer #116:ODJFS will conduct an annual member satisfaction survey based on the Consumer Assessment of Health Plan Satisfaction (CAHPS). ECM providers may conduct their own surveys as well.

Question #117:If a provider chooses not to sign an ECM agreement and is not participating in the Plan, are there still obligations to pay them the incentive?
Answer #117:No, the only PCP payments the ECM is required to make are those to physicians who sign the ECM-PCP agreement.

Question #118:Do participating providers in the Plan need to also sign the ECM agreement?
Answer #118: If "participating providers" means those providers currently under contract to or employed with the managed care or other organization, the answer is "yes." The separate "ECM-PCP" agreement for PCPs (see Appendix E) or agreements for other ECM services must be in writing and specific to the program.

Question #119:Please define criteria for denoting PCP? Is it the provider who serves facilitates the greatest service for the individual? Or are there other qualifiers? Does and incentive need to be paid to PCPs only or any and all ECM providers regardless of membership base?
Answer #119:The ECM provider, based on information from ODJFS and that obtained from the ECM member, must identify the physician (if any) that is managing the overall care of the individual at the time of ECM membership. The ECM provider must contact that physician, if not already a participant with the ECM provider, an offer the opportunity to participate as a PCP, including the signing of a contract with the ECM specifying the additional expectations (see Appendix E for the Draft ECM-PCP Model Contract).

The PCP coordination and performance payments (if applicable) are paid to the PCPs. Other payments related to the delivery of ECM services or performance are to be determined by the ECM provider.

Question #120:Is there an eligibility verification vendor (or other means for that matter) who can help us to determine when people present at the ER or are hospitalized?
Answer #120:While some hospitals may have eligibility staff on-site, we do not have that information. (The County Departments of Job and Family Services have the responsibility for eligibility determinations.) The ECM provider is expected to have or develop the relationships necessary for the timely identification of the use of emergency department utilization and/or hospital admissions. Claims data provided by the State will be another source of this information, but will of course, be subject to a claims lag.

Question #121:Does the state have an estimate of the number of beneficiaries without PCP's?
Answer #121:This information is not available for those covered by fee-for-service Medicaid.

Question #122:How does the state pay hospitals for services, i.e., DRG, etc.? Is there a benefit to the state for reduced length of stay?
Answer #122:The Ohio Medicaid fee-for-service system is based on DRGs. The immediate financial benefit to the State as a result of enhanced care management would be a reduction in hospital admissions, although over time a reduction in length of stay would also benefit the program. Of course, there is also a benefit in terms of quality of care.

Question #123:What is the penetration of Medicaid Primary Care Physicians out of the total PCP's in the state? Are there any known geographic holes? How about availability for specialists for heart disease, diabetes or pulmonary disease?
Answer #123:This information is not available. There are underserved areas but these are not necessarily specific to PCPs or by individual specialties.

Question #124:What percent of Medicare is Ohio Medicaid reimbursement?
Answer #124:The Medicaid fee schedule is developed independently.

Question #125:What is the average length of eligibility for your blind and disabled clients?
Answer #125: 75% of ECM eligibles are found to be continuously enrolled for at least 3 years.

Question #126:Does the state have a preference on ideal size of the consumer population being managed by each Enhanced Care Management vendor?
Answer #126:This would depend on the local community and capacity of each ECM provider, although we expect the number to be sufficient to support the ECM provider's costs within the premium paid and also to achieve documentable savings. The ECM provider should consider the number necessary to make its participation viable.

Question #127:Will the state entertain a higher capitation rate if the Enhanced Care Management vendor proposes a higher expected savings?
Answer #127:No. The premium paid and incentive structure are designed to meet federal tests of actuarial soundness.

Question #128:Can the state give us an estimate of the percentage of beneficiaries without telephones, inaccurate phone numbers or incorrect addresses?
Answer #128:We recognize the difficulty often found in reaching this population by telephone and will provide the most recent information we have available. We do not have a specific percentage available.

Question #129:Which kinds of organizations does the state envision bidding on this RFA, i.e., Medicaid HMO's, provider groups, disease management vendors, etc.?
Answer #129:See response to Question #50.

Question #130:Page 1, 24 - Other than the capabilities listed on page 24, does ODJFS have a specific "scoring tool" to quantitatively measure applicants responses? For example, what weight is given to each proposal section (listed in Section II.D of the RFA)?
Answer #130:ODJFS will use the requirements and objectives described in the RFA as the basis for the review and evaluation of applications. No specific weights have been assigned to the various components at this time.

Question #131:Are additional proposal points awarded to PRO-like entities to reduce the overall cost of these services to ODJFS (due to the fact that CMS may provide an enhanced federal match for these services)?
Answer #131:No additional points are being awarded to PRO-like entities for this program. Ohio has an existing contract with such an entity as its managed care external quality review organization and those are the activities eligible for the enhanced federal match.

Question #132:Page 4 - Can ODJFS comment on the depth of focus on pharmacy management, and the ability of ECM provider(s) ability to enhance this focus? (I.e., make recommendations for PDL [preferred drug list] modification or Pharmacy PA [prior authorization] related to the selected ECM disease conditions).
Answer #132:The current pharmacy benefit manager (PBM) for the department, First Health Inc., is responsible for pharmacy management activities such as updating the PDL, PA, and adjudicating pharmacy claims. The ECM providers can enhance the benefit by adding member-specific pharmacy management, such as assuring that the ECM member is getting the prescriptions filled timely, taking the medication as directed by the physicians, checking for drug to drug interactions or drug reactions, and checking with the physician to resolve any drug related complications that can occur.

Question #133:Page 9 - How are the conditions (and service) listed on this page identified? (transplants, AIDS, cancer, end stage renal disease (ESRD), severe trauma, and hospice.)
Answer #133:The specific conditions are identified using diagnosis codes from individual claims history. The MEDSTAT episode grouper is used to further define the disease stages and the severity of the illnesses. Please see Appendix B of the RFA.

Question #134:Does the FFS population currently receive a health risk assessment upon enrollment? If so, could EC bidders receive a copy of the HRA that ODJFS uses for incoming?
Answer #134:No, this FFS population does not receive a health risk assessment upon enrollment.

Question #135:Can the ECM providers request this risk identification tool be sent from ODJFS to the ECM provider for those members enrolled with the provider?
Answer #135:See response to previous question.

Question #136:Page 12 - Can the assessment conducted within 60 days be done over the phone or must it be done in person?
Answer #136:Although the RFA does not have such a requirement, we believe that to the extant possible the initial assessment of ECM eligibles, all of whom have a chronic health condition, should be done in person. This is a very critical step because information gathered during an assessment about the individual's health condition and health care needs directs the development of the care treatment plan for that individual.

Question #137:Page 17 - To support joint ECM applications, can ODJFS provide a list of all applicants (corporate entity - including contact name and phone number) submitting questions and attending the mandatory applicant conference? For further support of joint applicants, can ODJFS request that each potential bidder list what service area(s) their respective company is considering for a proposal?
Answer #137: The list of all persons who signed in at the Applicant Conference will be posted on the web. As described in the RFA, questions about the RFA are unattributed. Also, potential applicants should keep in mind that the letter of intent be submitted by no later than December 10, 2003 at 3:00 p.m. EST, is non-binding.

Question #138:Page 19 - Can ODJFS further clarify the "phase-in" process. For example, over what length of time might all 8 service areas be phased in? Six months? Ten months?
Answer #138:Please refer to page 10 of the RFA.

Question #139: Page 16 and 19 - Page 16 indicates an expectation of having an administrative office in Ohio no later than 90 days prior to the effective date of the provider agreement. Page 19 indicates an "Initial Program Phase-in" starting June 1. Considered together, this appears to indicate the need for an office in Ohio on March 1st (June 1 minus 90 days). This is only three weeks after the date of February 6 - "ODJFS Issues Notification Letter(s)." Is there an expectation that readiness reviews could begin in March, only three to four weeks after contract award?
Answer #139:Yes. ODJFS intends to begin the readiness review as soon as possible after notification letters are issued. Please note that selection for readiness review should not be construed as contract award. In response to the office location in Ohio, please remember that the program will not be initiated in all service areas on the earliest anticipated implementation date. Part of the readiness review process will be to determine when each applicant and service area is prepared for program implementation.

Question #140:Page 32, bottom - The target growth rate is a critical figure in the estimation of the staffing needed for this program. Can ODJF comment on the exact timing of when this figure will be made public - how far ahead of the time when the ECM provider agreement will need to be signed.
Answer #140:ODJFS expects to have the target growth rate available at least 90 days prior to signing of any provider agreements.

Question #141:Do the applications/systems have to reside in Ohio?
Answer #141:If by applications/systems you are referring to Information Systems the answer is no. However, we encourage and expect potential ECM providers to build local collaborations and work with local organizations as much as possible for conducting other ECM activities so that it reflects the health care needs and characteristics of the local community. Gaining an understanding of the local health care marketplace is a key point that has been emphasized throughout the RFA.

Question #142:Currently the ECM provider is the recipient of claim/pharmacy/member/premium files from ODJFS. Will the ECM provider ever be asked to perform any claim or premium payments in the future?
Answer #142:The ECM provider will be responsible for payment of the PCP premium and PCP performance incentives as described in the RFA.

Question #143:No specific reporting formats are indicated in the RFA. Will there be required reporting formats the ECM provider will need to employ in order to effectively meet the reporting requirements? When will the ECM provider receive the reporting formats?
Answer #143:ODJFS will have specific reporting requirements available for the readiness review phase. These formats will be based on the full-risk managed care program which can be viewed at: http//:jfs.ohio.gov/ohp/bmhc/appendix.stm#M.

Question #144:What assurances has Ohio received from CMS [Center for Medicare and Medicaid Services] that the funding and structure of the program comply with CMS regulations? Have funds been allocated and approved by CMS and the State for administration of this program?
Answer #144:ODJFS has been in ongoing communication with CMS and has been developing the program to be in compliance with federal regulations and therefore eligible for funding. State funding is available but does assume that the program will provide a "return on investment" in the future.

Question 145:What will the role of the enrollment broker be? Will CCR [consumer contact record] information be shared in addition to an enrollment file?
Answer #145:The selection services contractor will act in much the same way as in the current full risk-based managed care program. The contractor will take selection or "opt-out" calls, process membership and termination of membership requests, and complete and forward to ECM providers the Consumer Contact Record forms. Please see the response to Question #100 for additional information about membership files and the consumer contact record.

Question 146:Will information on the original qualifying disabling condition (for ABD status) of the ECM member be shared at enrollment?
Answer #146:The intent is to include information upon enrollment on the condition that qualifies the individual as ECM eligible. (This condition may or may not be the original condition which leads to ABD eligibility). The specifications for all data files will be provided during the readiness review process, as ODJFS is currently developing file and transmission specifications.

Question 147:Will there be a phase in of enrollment when an initial service area is brought up to allow for outreach and assessment activities?
Answer 147:Yes. Membership will be phased in order to permit adequate opportunities for outreach and assessment of new members.

Question 148:How will preferred option enrollment be handled if there are two ECM providers in a service area? Will PCP continuity be considered?
Answer 148:Please see response to Question #33.

Question 149:Will there be a mandated percentage of members to receive intensive case management activity? If so what percentage?
Answer 149:We do not anticipate mandating a specific percentage, although a target may be established to assess performance.

Question 150:: Is the premium base adjustment for enrollment above 5,000 (or 10,000) for the whole membership or just for that above the 5,000 (or 10,000) level?
Answer 150:The adjustment would be for the entire membership.

Question 151:Will ECM member hospitalization information be shared real time to allow concurrent UM and discharge planning activities by the ECM provider (in particular at non-ECM collaborative hospital providers)?
Answer 151:If there is precertification involved, the information will be shared as soon as available. Since other hospitalization information becomes available to ODJFS only as a result of claim submission, the notification to the ECM will depend on the timing of claim submission and processing. The expectation is that the ECM provider collaborative will include hospital relationships that will provide an alternative to ODJFS as the sole source of information on hospitalization.

Question 152:Will there be requirements of what types of professionals can complete outreach and/or assessment activities? If so, what types?
Answer 152:Given the special health needs of the ECM population, we consider the use of appropriate health professionals essential to the success of the ECM provider as well as the program overall. To some degree, the type of professional for specific activities will depend on the approach taken to outreach and assessment; for example, if the two activities are separate, the outreach portion could be handled by a staff member other than an RN. However, the assessment, which should initiate the care treatment plan and formation of the care management team, should be conducted by a physician, physician assistant, or RN.

Question 153:: How is patient educated/enrolled in the program? What member education materials are available? Is it going to emphasize PCP usage? Will there be a discussion on the benefits of case management programs? What is member's responsibility for making changes in venues of care?
Answer 153:ODJFS will identify and notify Medicaid consumers who are eligible for the ECM program. Basic information regarding the program will be provided in writing to all ECM eligibles and will also be available by telephone through a toll-free number. Regarding the last question, ECM members may access any Medicaid FFS provider as well as exercise the option to terminate ECM membership each month. Please see section II. D. 5. of the RFA, Scope of Services, for a description of PCP access.

Question 154:We are concerned that this contract is dependent on a waiver from the Federal Government, what is the work plan if time frame is not met? What are the options for our Health Plan once we review the OAC [Ohio Administrative Code] and waiver requirements?
Answer 154:ODJFS has been in ongoing communication with the federal government and at this time is optimistic that the process of obtaining federal approval will be a smooth one. However, administrative delays when there are multiple organizations involved are always a possibility. If such delay occurs, the implementation of the program would be delayed and all parties involved notified of any revisions in the time lines. The submission of an application and/or entrance into the readiness review process would not be binding if at any point the ECM applicant finds a federal or state requirement would preclude their participation as an ECM provider. Applicants are again advised to reference federal provisions related to "prepaid ambulatory health plans" and current Ohio Medicaid managed care program rules and provider agreement to assess the likely parameters and scope of program requirements.

Question 155:Will there only be one provider per county selected?
Answer 155:Please see response to Question #25.

Question 156:What kind of contract is needed for PCP's? Would we be able to use a model addendum like the current Medicaid agreement?
Answer 156:The Draft ECM - PCP Model Contract contained in Appendix E of the RFA, is intended for use either as a stand-alone document or an amendment to an existing contract. It should not be used as an amendment to the Medicaid addendum used in the current managed care program.

Question 157:Vague on incentive to PCP's, are we allowed designing incentive program or are their mandatory requirements?
Answer 157:The ECM provider is expected to design a PCP incentive program subject to ODJFS approval. Applicants should keep in mind that federal provisions related to provider incentive plans will apply. There is, of course, the minimum requirement to reimburse PCPs a minimum of $3 PMPM.

Question 158: What is the ID Card requirement? Would the member be required to have an ID card or will the card come from ODJFS?
Answer 158:ODJFS will issue a Medicaid card to ECM members with an identifier indicating ECM membership.

Question 159:Can we assign a PCP if our members do not choose one? Would the process be the same as Medicaid managed care rules?
Answer 159:Yes, the ECM provider could identify a PCP for any ECM member who does not already have a doctor willing to participate as the PCP or who fails to select one. The process is likely to be similar to that in the current managed care program. But please keep in mind that ECM members may access any Medicaid FFS provider as well as exercise the option to terminate ECM membership each month.

Question 160:What is the average length of enrollment for this population in Medicaid? When does Medicare become primary?
Answer 160:Seventy-five percent of ECM eligibles are continuously enrolled in Medicaid for at least 3 years. For anyone eligible for both Medicare and Medicaid, Medicare is the primary payer beginning at the time Medicare eligibility is established.

Question 161:If a member agrees to participate what alternatives do we have for non-compliance?
Answer 161:: Short of a limited number of circumstances that would allow an ECM provider to propose disenrollment (for example, fraudulent behavior), only the member can request disenrollment. The State expects the ECM provider to encourage and promote compliance among the majority, if not all, ECM members.

Question 162:What are the rules for opting out of this ECM agreement?
Answer 162:Provisions for ECM provider termination of the provider agreement will be the same as those for the current managed care program provider agreement; i.e.; notice must be provided to ODJFS at least 75 days in advance of the termination or renewal date provided that the termination or non-renewal must be effective the last day of a calendar month. Please refer to Article VIII of the current ODJFS-MCP provider agreement for more information.

Question 163:The Clinical Performance Measures table includes Overall Discharge and Overall ED Visit Rates for each of the four diagnosis categories. These rates are marked "HEDIS." HEDIS rates for these measures are not disease specific. I assume that ODJFS will be calculating these rates from administrative data for the populations identified?
Answer 163:That's correct. ODJFS will be calculating Overall Discharge and Overall ED Visit Rates for each of the populations who have the specified condition.

Question 164:The Clinical Performance Measures table includes "ACE Inhibitor" for CHF. Will this measure be limited to those CHF participants that have demonstrated left ventricular systolic dysfunction? Also, will the physician have to document in the medical record why an ACEI was not prescribed even though the participant has a documented medical condition for which ACEIs are clearly contraindicated?
Answer 164:Currently, the measure assesses whether anyone with CHF received an ACE Inhibitor. However, the method is being changed so that it will be limited to eligibles with left ventricular systolic dysfunction. Regarding the second question, data from the medical record will not be used to calculate the measure. The measure will be calculated using administrative data only.

Question 165:The HEDIS measure, Use of Appropriate Medications for People with Asthma includes in the population only those members with "persistent asthma." As the ECM vendor successfully moves more of the managed asthmatic population out of this defined denominator, the possibility exists that an increasing portion of the remainder are non-compliant with respect to getting prescriptions filled. This will have a negative effect on this rate for the successful ECM vendor.
Answer 165:Eligibles with persistent asthma whose asthma is controlled properly will not necessarily be moved out of the denominator of the HEDIS measure since one of the criteria for being included in the denominator is to have "at least four asthma dispensing events." These eligibles would be included in the denominator even if they did not have any hospital admissions or emergency department visits.

Question 166: If program participants can receive services from non-network providers on a FFS reimbursement basis through the state, will the state be obtaining these medical records for quality monitoring projects when the ECM vendor has no agreement with the provider?
Answer 166:Yes, the providers are required under Medicaid rules to provide ODJFS, or its designee (e.g., the External Quality Review Organization (EQRO)), with a copy of the records.

Question 167:The Quality of Care Studies table includes the diabetes indicators of Foot Exam, Triglyceride, and HDL Cholesterol marked as HEDIS. The HEDIS measure, Comprehensive Diabetes Care does not include such indicators.
Answer 167:You are correct that these are not components of HEDIS. While the EQRO is obtaining the data to calculate the HEDIS components (i.e., HbA1c, LDL-C, Eye Exam) from the medical record, they will also be collecting data to calculate, for informational purposes only, the non-HEDIS components.

Question 168:The Quality of Care Studies table includes the asthma indicator of "Influenza." Would this be the percentage of asthmatic participants that have received the influenza vaccine? If so, couldn't these data be obtained administratively from claims without necessitating medical record reviews?
Answer 168:: Yes, this would be the percentage of asthmatic eligibles who received the influenza vaccine. Immunization administrative data is typically less complete than non-immunization administrative data. For this reason, medical records will be the source of data for this measure.

Question 169:Will we receive prior authorization from ODJFS regarding utilization of services? Data on prior authorizations need to occur concurrently rather than retrospectively.
Answer 169:ODJFS will be processing prior authorizations for the ECM members in the same manner it currently does for FFS consumers. ODJFS' goal is to send the ECM provider information on all denied or approved prior authorizations. The ECM member and the FFS provider will be notified by the current method, a hard copy letter. The method of transfers to the ECM provider has not been finalized at this point.

Question 170:What is the mortality rate of this population?
Answer 170:Of ECM eligibles in calendar year 2002, the deaths per 1000 eligibles is as follows: Adult Asthma - 3.4, Adult CAD - 38.6, Adult CHF - 99.8, Adult COPD - 28.5, Adult Diabetes - 14.1, Adult Hypertension - 15.4, and Child Asthma - 1.2.

Question 171:What are the secondary diagnoses of this population?
Answer 171:A new report, Co-Morbidities of ECM Eligibles, will be posted to the Applicant Library by December 3, 2003.

Question 172:Will the Bureau of Managed Health Care be assisted by the same EQRO for both the CFC and ABD ECM programs? Can we get more specifics on these programs? With such small numbers of eligible are the studies statistically valid?
Answer 172:Yes, this will be the same EQRO that conducts studies for the managed care program. More specifics on these programs can be found at http://jfs.ohio.gov/ohp/bmhc/managed.stm If the numbers are too small to obtain a statistically valid sample, then the entire population will be studied.

Question 173:Does our nurse telephone advice service need to have access to each participant's entire treatment plan? Could person give information later for treatment plan? We are concerned about the HIPAA [Health Insurance Portability and Accountability Act] implications of releasing treatment plan information over the phone.
Answer 173:If you are referring to the 24/7 Health Advice Line, the answer is yes. In order for the Health Advice Line to provide ECM members with personalized information and guidance, we believe the health care professionals staffing that Line must have access to the member's treatment plan. Of course, provisions to assure that the information is being released only to the member or other authorized party should be made. It is also possible that HIPAA security regulations, which are anticipated in spring 2004, may alter how these situations are handled.

Question 174:How does ODJFS plan to accommodate benefit changes (new technology, new pharmaceuticals) related to growth rate performance?
Answer 174:ODJFS understand that there may be factors that will affect trend for the ECM eligibles differently than other ABD consumers, such as a new treatment for diabetes. However, there also may be factors that affect ABD consumers that are not in the ECM program. The goal of the program is to reduce the growth rate in medical expenses for the member population. The growth rate will reflect the impact of new technology and benefit changes. The non-member ABD consumer population is the best proxy we have for trend in the member population if the program had not been in place.

Question 175:What accommodation is made for the fact that these people are chronically ill with increasing acuity?
Answer 175:ODJFS expects the ECM program to slow the progression of the ECM members' chronic conditions. The expectation is that the acuity level of the ABD population will progress faster than the ECM population due to the enhanced care management in the ECM program. This progressing acuity level will be reflected in the ABD consumer trend calculation. The ECM provider is then expected to reduce the ABD consumer trend. In addition, if the program covered only a closed population we would expect the average acuity to increase over time. Because the program will receive a continuous flow of new members we do not expect the average acuity of the population to increase over time.

Question 176:If a member chooses a PCP that will not contract with us do we have to apply the cap or incentive plan?
Answer 176:: If a PCP does not sign an ECM agreement with the ECM provider, the ECM provider is not required to make any payments to the PCP.

Question #177: Is this a competitive bid contract or will all qualified bidders have opportunity for readiness review?
Answer #177: This is not a competitive bid. The premium payment is established and specified in the RFA. All qualified applicants will have an opportunity to be selected for the readiness review phase. Please also see the response to Question #25.

Question #178: Does the state intend to have a minimum or maximum number of ECM providers per county? If yes, how many?
Answer #178: Please see responses to Questions #25 and # 26.

Question #179: If there are multiple ECM providers per county, how does the state intend to distribute the recipient members as they enroll?
Answer #179: Please see response to Question #33.

Question #180: Does the state consider this a mandatory or voluntary enrollment plan?
Answer #180: This is a voluntary approach known as "preferred option." Please see response to Question # 33, and Section II. C. of the RFA, ECM Populations and Service Areas.

Question #181: Would the state consider allowing the ECM provider to assume the responsibility for pre-certification and prior-authorization of services to allow full coordination of care?
Answer #181: As described in Section II. D. 4 of the RFA, providers serving ECM members will continue submitting prior authorization of services directly to ODJFS. The Medicaid fee-for-service system utilizes several utilization management strategies that may affect ECM members, including precertification of certain hospital admissions and prior authorization for certain services or procedures not routinely covered directly by Medicaid.

Question #182: Will the state consider a 1-year enrollment period for ECM eligibles as it has in its voluntary and mandatory MCPs? If recipients are permitted to enroll and disenroll at will, it will be very difficult to manage their care or have any impact on their health status.
Answer #182: Under the "preferred option" voluntary approach, ECM members will not be required to remain in the ECM program and will have the option to end their membership each month. We believe that ECM members will value the individualized care and education they will receive on their health care condition from the ECM providers and will voluntarily chose to stay in the program to continue to receive the added benefits to improve their health. It should also be noted that based on the experience of the current managed care program in Ohio, the rate of voluntary disenrollment in designated Preferred Option counties remains very low (around 1% per month).

Question #183: How are recipients determined eligible for the ABD categories? Are they just those in SSI categories by SSA or does the state make a determination? If the latter, what criteria will the state use to identify recipients eligible to enroll? Will it be recipient self-declaration of condition, existence of claims with diagnosis codes of targeted diseases/conditions, multiple inpatient admissions, etc? Will enrollment occur early in the disease or after it has been well established?
Answer #183: Individuals who are either aged (65 and over) or blind or disabled and whose income and resources are within Medicaid limitations are determined eligible for the ABD category. The state follows the disability definition set by SSA but makes its own eligibility determination as the resource limits vary slightly from those used by SSA.

For the specific selection criteria for the ECM program, please refer to pages 8 and 9 and Appendix C of the RFA.

Question #184: Will there be a point at which the recipient's condition is under control and he/she may be disenrolled from ECM because care management is no longer necessary or will they stay in the program as long as they are covered by Medicaid?
Answer #184: We expect the ECM member's health condition to improve while enrolled in the program because of the enhanced care coordination and education efforts put forth by the ECM providers. However, these are not curable conditions and therefore the ECM member would remain eligible even if their health status improved. In addition, disenrolling members as their condition improves could result to a return to a less stable health status and would be counter-productive.

Question #185: Will recipients be moving in and out of ECM from waiver programs?
Answer #185: If by "waiver programs" you are referring to the ODJFS Home and Community Based Services' waiver programs, an ECM member entering a waiver program during the time of ECM membership will be disenrolled from the ECM program (see page 9 of the RFA). Those already in a waiver program would be excluded from ECM. We therefore do not anticipate members moving in and out of the ECM program from waiver programs.

Question #186: If recipients under age 21 enroll, do EPSDT program requirements and services have to coordinated by the ECM provider?
Answer #186: To assure the maximum benefit for the member, we expect ECM providers to co-ordinate all services required by an ECM member, including EPSDT services. The ECM provider should take a comprehensive approach to managing the ECM member's condition, including co-morbidities, behavioral health, and related issues such as the lack of social or family support.

Question #187: At what point will recipients first learn about ECM? Will the state or the ECM provider have first opportunity to educate them?
Answer #187: The ODJFS is responsible for identifying and notifying the ECM eligible about the program. The State will provide information in writing to all ECM eligibles and will also be available by telephone through a toll-free number. Please refer to the RFA, page 17.

Question #188: Will the state's Selective Services Entity be involved in informing the eligible recipients of the ECM program?
Answer #188: Yes, the Selective Services Contractor will be involved in informing ECM eligibles of the program. See the response to Question #145 for additional information.

Question #189: Will recipients be enrolled at any particular point during phase in (e.g. at time of eligibility review) or will all eligible recipients in a county/service area be enrolled at the same time?
Answer #189: : Please see response to Question #33.

Question #190: If the ECM proposes that a Home Health provider do the home visits to complete the assessments may that activity be billed to FFS by the Home Health provider or does the ECM provider have to meet this cost from the PMPM?
Answer #190: Home health visits will only be covered when medically necessary as part of the FFS medical benefit package and in accordance with home health coverage rules. If a home health provider is used by an ECM to conduct assessments aside from the above, it must be covered by the ECM provider.

Question #191: Does the state do any Rx [pharmacy] prior-authorization?
Answer #191: Yes, Rx prior-authorization is done by the State through First Health Inc.

Question #192: If the care management team recommends a treatment that requires pre-certification or prior-authorization, will the state expedite approval?
Answer #192: The State makes every attempt to expedite all prior-authorization requests in order to serve the Medicaid consumers as timely as possible. If medical necessity requires special handling of a recommended treatment, it will be considered in the processing of the request.

Question #193: What are the recipient to PCP standards that must be met by the ECM provider in order to 'pass' Readiness Review?
Answer #193: No specific requirements have been set in the RFA.

Question #194: : If a provider is already in the FFS network, can the ECM provider assume the standards for licensing, etc. have been met and proceed with the ECM PCP agreement?
Answer #194: The ECM is not responsible for license verification of providers who are duly enrolled in the Medicaid program. However, if the ECM is employing other health professionals for providing ECM services it is responsible for license verification and sanction compliance for those providers.

Question #195: How will the state determine 'community readiness' prior to implementation?
Answer #195: The State wants to assure that the ECM providers have a good understanding of the community that they want to serve. The state is interested to find out from the potential applicants how their skills and capabilities, and creativity in program design match the local health care marketplace to make the program feasible in that area.

Question #196: : Is there a dollar-value limit placed on incentives to members the ECM provider may propose to encourage compliance?
Answer #196: : Although there is not a dollar limit specified in the RFA, ECM applicants should be aware that incentives must be prior-approved by ODJFS and should not be in the amount or of the type that would jeopardize the ECM member's Medicaid eligibility.

Question #197: Will ECM provider performance always be measured against the initial Baseline be used continuously?
Answer #197: For the growth rate variance, the baseline period will remain the same throughout the program. ECM Providers will be measured from a baseline eligible cost that does not include the impact of the program.

Question#198: Will ECM provider rates be renegotiated from time to time to provide for inflation?
Answer #198: The ECM premium will be reviewed at least once every 2 years. The rate of inflation will be considered in this review.

Question #199: : How will FFS providers know that a recipient is enrolled with an ECM provider? Do they get ID cards? If yes, who issues them?
Answer #199: The ODJFS intends to issue ECM members a Medicaid ID card with a unique identifier to indicate a member's enrollment in the ECM program.

Question #200: If the State is calculating the benchmarks and improvement ratios for the ECM, will the ECM also receive data to conduct the same calculation?
Answer #200: The FFS claims data will be shared with the ECM providers.

Question #201: If the ECM is to present reports on activity, will the ECM receive claims data from the State?
Answer #201: The ECM providers will receive FFS claims data from ODJFS but the ECM provider is expected to collect and report information regarding ECM services and activities that track, monitor, and evaluate the timely delivery of appropriate ECM services.

Question #202: Is there any guarantee on the funding of this program? Is it subject to a budget process each year or multi-year funded?
Answer #202: All Medicaid programs are contingent upon appropriations by the state legislature.

Question #203: Please explain the criteria to be used in evaluating the contract responses.
Answer #203: Please see the response to Question #130.

Question #204: Without prior data concerning premium allocation, accurate assignment of specific premium cost is challenging. Will the state recognize the plan's necessity for flexibility?
Answer #204: ECM applicants are expected to demonstrate a thorough understanding of the components involved in the successful performance of the ECM program. One indication of this understanding will be assumptions made in developing the premium allocation. Once the proposals have been submitted, allocations and any other supporting documentation provided by the ECM providers will be reviewed. If there are questions or concerns around the allocations or assumptions, they will be discussed during the initial review and subsequent readiness review process.

Question #205: Will ODJFS mandate a ratio of ECM patients to PCPs?
Answer #205: ODJFS will not mandate a ratio, but will consider in reviewing proposals whether applicants have demonstrated adequate capacity to offer specified services to ECM members.

Question #206: Will the 30/60/90 day requirements for the recruitment, assessment and completion of care plans be waived at initial startup in anticipation of a large numbers of already-identified ECM eligibles, or will the initial numbers of eligibles be phased in? If the latter, how many eligibles will be forwarded each month?
Answer #206: Enrollment will be phased in order to permit adequate opportunities for outreach and assessment for new members. Specific monthly numbers will be discussed with each individual applicant during the readiness review phase, but we expect the number to be no fewer that 100 - 200 per month.

Question #207: If there are multiple bidders for a single service area, is it possible that the area will be divided among two or more bidders? If so, will the 2,500 "minimum" be maintained?
Answer #207: Please see responses to Questions #25 and #33. If by "2,500 minimum" you are referring to the table in Section V. A. of the RFA, ECM Premium, this table describes possible adjustments to the base premium depending on the of number of members enrolled with the ECM provider. ECM providers with less than 2,500 members will receive an additional $4.03 PMPM. This would remain the number to qualify for the premium adjustment regardless of the number of ECM providers.

Question #208: The RFA indicates that "applications for additional service areas or for additional counties contiguous to those listed above will be considered…" Will data regarding ECM eligibles in other counties be made available, either generally or upon request?
Answer #208: ODJFS would consider an application for additional service areas but would be unable to provide the additional data until after the submission of a letter of intent. In addition, please refer to page 10 of the RFA, which states: "Applications for additional service areas or for additional counties contiguous with those listed (in the RFA) will be considered based on available resources."

Question #209: What are the most prevalent co-morbid conditions for the ABD population in Cuyahoga County?
Answer #209: A report identifying comorbidities for the ECM population has been posted to the ECM web page.

Question #210: It is our understanding that individuals in nursing facilities are not eligible for membership. Those members entering nursing facilities for "short term" stays are not disenrolled. Please define "short term". Will these patients be "exempted" from program requirements while in the facility? For example, if a member enters a NF shortly after enrollment and contact must be made within 30 days, will they be exempted from the contact requirement while confined?
Answer #210: You are correct, individuals residing in nursing facilities are not eligible for the ECM program. ECM members entering nursing facilities for short-term rehabilitative stays will not be disenrolled, except at the member's request. We expect that the number of members who would experience such rehabilitative nursing facility stays would be small and may be best addressed on a case-by-case basis if the quality of care or care coordination appears to be compromised.

Question #211: Can an ECM Provider maintain a membership limit based upon capacity?
Answer #211: : The number of members to be served by any ECM provider should be sufficient to support the ECM provider's costs within the premium paid as well as achieve documented savings. The ECM provider should consider the number of members necessary to make its participation viable. While the capacity of the ECM may limit the number of ECM members it can serve, ODJFS expects that such restrictions would be temporary until the ECM expands. In order to obtain the maximum benefit for all ECM eligibles and for the program itself, ECM providers should have the ability over time to serve as many members as are eligible and interested. (Please recall that membership into an ECM will be a gradual process to allow ECM providers to adequately serve all new members).

Question #212: Is the ECM Provider able to request disenrollment from those members (e.g., homeless) who cannot be reached to perform interventions or for those who verbally refuse to participate in the program but make no effort to disenroll themselves?
Answer #212: Short of a limited number of circumstances that would allow an ECM provider to propose disenrollment (for example, fraudulent behavior) only the member can request disenrollment. The state expects ECM providers to encourage and promote compliance among ECM members.

Question #213: Will membership be phased in, in order to meet the requirements for start up? For instance, if an ECM Provider were to receive 5,000 members in the first month, it would be difficult to contact all members within 30 days.
Answer #213: Membership will be phased in order to allow an appropriate amount of time to make the initial contact and conduct assessments. Specific monthly numbers will be discussed with each individual applicant during the readiness review phase, but we expect the number to be no fewer than 100-200 per month.

Question #214: Will ODJFS provide working phone numbers for those enrolling to ease in the ECM Provider's ability to contact or locate members?
Answer #214: ODJFS recognizes the difficulty often found in reaching this population by telephone and will provide the most complete and current information we have available. In addition, we are open to working with ECM providers on creative approaches to locating hard-to-reach members. Performance targets in this area will reflect the fact that some portion of ECM members may not be reachable.

Question #215: If the ECM Member's PCP refuses to participate in the ECM Program or sign the agreement, can the ECM Provider mandate a reassignment of the ECM Member to another PCP?
Answer #215: Yes. However, keep in mind that ECM members may access any Medicaid FFS provider as well as exercise the option to terminate ECM membership each month. Nonetheless, ECM providers are encouraged to contact any physician identified as the member's PCP who is not already affiliated with the ECM provider in order to include them as an ECM PCP. If this is not possible, the ECM provider is expected to ask members to choose a PCP affiliated with the ECM. If a member is unwilling to change PCPs, they may opt out of the ECM program. ODJFS' priority is to offer enhanced care management services, while minimizing disruptions of care.

Question #216: Has an assessment been done to assess PCP willingness to participate in the ECM program?
Answer #216: The larger provider community has been involved in the development of the ECM program. The program parameters and objectives have been shared with the various provider associations and the feedback has been encouraging. However, the department has not done an assessment to assess PCP willingness to participate in the program. The expectation is that the ECM providers will work with local provider groups and organizations in order to build successful collaboratives to meet the need of the local communities.

Question #217: If an organization does not initially apply to become an ECM Provider, will they have the ability to participate in the program at a later date?
Answer #217: As indicated in the RFA, page 10, the ECM program will be implemented in different phases depending on the ECM provider's demonstrated capacity and provider agreement readiness; the readiness of the community; and the administrative resources of ODJFS. If an organization does not initially apply to become an ECM provider, their chance in participating at a later date will depend on whether the particular county or service area already has an ECM provider and whether it has sufficient ECM eligibles to support more than one ECM provider and demonstrate a timely return on investment and outcomes. Please also see response to Question #25.

Question #218: If an ECM Provider wants to opt out of the program, what are the terms for termination of the provider agreement?
Answer #218: The terms for termination will be similar to the suspension and termination provisions governing the current full-risk managed care program. Please see Article VIII, Suspension and Termination, and Appendix P, MCP Terminations/Nonrenewals/Amendments, of the SFY 2004 Provider Agreement.

Question #219: The ECM Program is to offer services to persons with chronic conditions who are/are at risk of becoming frequent/high cost users of care. Is "at risk" determined by diagnosis only or is there some predictive modeling that is employed?
Answer #219: At risk patients are initially identified using diagnoses from individual claims history. The severity of the disease stage or the level of illness is determined by running the claims data through the MEDSTAT Episode Grouper as indicated in Appendix B, page B-1.

Question #220: The RFA states that services will include those "adults with diagnosis of COPD or asthma". Is it an either/or choice by the ECM Provider or is it actually for both conditions?
Answer #220: It is for both conditions, COPD and Asthma.

Question #221: Are the various required assessments and care treatment plans standardized, or will each ECM Provider build/use their own?
Answer #221: While the state may specify certain required components for patient assessments, the expectation is that the ECM will design comprehensive assessment tools and conduct a thorough evaluation of ECM eligibles to assess their health status and health care needs so that it can guide the development of the proper treatment plans. As indicated in the RFA, page 12, treatment plans should be developed to fit the individual's total health care needs and should address not only the primary medical diagnosis and condition but also any co-morbidities as well as any psychological and community support needs.

Question #222: Must the members continue with their existing PCPs if coordination of care can be assured during the transfer to another PCP?
Answer #222: No, but keep in mind that ECM members may see any FFS Medicaid provider they wish. Please see page 13 of the RFA, Primary Care Physician Access, for additional information.

Question #223: How will ECM Provider receive eligibility information? CCR? Paper files?
Answer #223: Please see response to Question #100.

Question #224: Screening and assessment" How will reporting to SACMS work? What are the consequences if member cannot be screened? Can members be closed for no phone number or address? Are there due diligence requirements? When will ODJFS provide assessment tool specifications? What data will ODJFS use to set completion levels for screening and assessments?
Answer #224: A screen is not required because all ECM members are identified as having a chronic condition through a claims review and all ECM members are expected to be case managed. An outreach contact is required as described on page 11 of the RFA. Members without a phone number or address will not be disenrolled from the program. Performance targets in this area will reflect the fact that some ECM members may not be reachable. Reporting assessment and case management information will work in a similar manner as with the current full-risk program. Details of these requirements and file format and submission specifications will be provided during the readiness review phase.

Question #225: Case Management expectations. What are the documentation expectations for care team members (physicians, specialists, pharmacist, etc.)? For example, how does ODJFS expect the ECM Provider to demonstrate involvement and coordination among team members?
Answer #225: : We would expect the care treatment plan to document the involvement of health care professionals and coordination of care. Please see the RFA, page 12, number 2, Case Management.

Question #226: How will ODJFS notify the ECM Provider when a prior authorization has been approved? What will be the time frames? How will urgent requests be handled? What is the expectation of "monitoring? What documentation will be required? Who will notify members when services are denied? Who will notify members when services are approved?
Answer #226: Please see the response to Questions #100.

Question #227: What are the time requirements to contract with non-participating member identified PCPs?
Answer #227: While time requirements have not been specified in the RFA, we expect the ECM provider to contact the member's physician as soon as possible in order to offer the PCP the opportunity to participate in the program, including the signing of a contract.

Question #228: What is the file format and reporting requirements for the monthly "Member/PCP" report?
"Answer #228: See response to Question #100.

Question #229: What are the PCP education expectations? How often? Focused or general? (based on performance outcomes?) Documentation requirements? (signed attendance sheets?)
Answer #229: ODJFS is seeking qualified organizations or collaboratives of organizations to offer enhanced care management and related services to ECM members. Applicants will be selected, in part, based on their ability to demonstrate through their proposal, that they have the required understanding, knowledge, skills and capabilities to provide the ECM services defined in the RFA. Therefore, we are looking to potential applicants to describe to ODJFS how they will provide or arrange for these services.

Question #230: What does "condition-specific" health education mean? (page 13) Written/oral? Individualized or general class or mailing? Documentation requirements? How will member noncompliance be handled?
Answer #230: Please see response to the previous question. With regard to member noncompliance, as described previously, short of a limited number of circumstances that would allow an ECM provider to propose disenrollment (for example, fraudulent behavior) only the member can request disenrollment. The state expects ECM providers to encourage and promote compliance among ECM members.

Question #231: What does "monitor health service utilization and determine appropriateness," mean? (p. 15) What criteria determines appropriateness? What documentation will be required? What is the expectation if service is determined to be inappropriate?
Answer #231: Please see response to previous question and page 13 of the RFA, number 4, Utilization Management.

Question #232: What does profile PCPs mean? What will be included? Frequency? Reporting requirement to ODJFS? How are areas of improvement determined? (Parameters set by ODJFS or ECM Provider?)
Answer #232: Please see response to previous question and Section VI of the RFA, Program Performance Measures, for a description of minimum performance measures and standards in key program areas.

Question #233: What type of outreach will be required? What criteria will be used to determine need? What is ODJFS expectation of need? Will ODJFS set levels and monitor? (p.30)
Answer #233: Please see response to previous question and Section II. D. ECM Scope of Services, 1., Outreach and Assessment.

Question #234: How does ODJFS define performance standards for PCPs? (outcomes, access, treatment plans?) (p. 31) What is the ODJFS approval process going to be? Based on what criteria?
Answer #234: Please see response to previous question and Section VI of the RFA, Program Performance Measures for a description of minimum performance measures and standards in key program areas.

Question #235: Will an ECM Provider be allowed to use incentives to encourage member compliance? (ED co-pay)
Answer #235: While some incentives would be acceptable, the use of co-pays would not be permitted.

Question #236: Can an ECM Provider use both administrative and chart review data to maximize performance results?
Answer #236: For the clinical measures that ODJHS will be holding ECM providers accountable for minimum levels of performance, a straight administrative method will be used. We will be calculating these results internally based on claims data. For the quality of care studies described on page 39 of the RFA, a hybrid method will be used, if applicable. ODJFS' external quality review vendor will be conducting these quality studies.

Question #237: Will ODJFS provide names of members needing alternative formats or will ECM Provider be required to survey population to determine needs?
Answer #237: If by "alternative formats" you are referring to communication approaches, ODJFS would expect that the ECM provider would identify such needs.

Question #238: Please define "uncooperative behavior" from page A-5? How does ODJFS define "seriously impairs the entity's ability to serve…" on page A-5.
Answer #238: These phrases are from federal requirements governing disenrollment of managed care members and would apply to ECM members. We believe they are self-explanatory and would refer those interested to the current managed care rules.

Question #239: Can ECM Provider require members to use a specific network of providers?
Answer #239: No. ECM members may seek services from any Medicaid FFS provider. The ECM provider is expected to encourage the appropriate utilization of such services in accordance with the care treatment plan.

Question #240: : If more than one ECM Provider is selected per county, how will ODJFS handle the assignment process? What criteria will be used?
Answer #240: Please see response to Question #33.

Question #241: What are the oversight requirements for subcontracted relationships?
Answer #241: Requirement for subcontracts will be similar to those found in the Ohio Administrative Code for the full-risk managed care program. See OAC Rule 5101:3-26-05, Provider Panel and Subcontracting Requirements.

Question #242: With regard to an Episode of Care, what constitutes a clean period? (page B-1)
Answer #242: A clean period is defined as the period of time needed for a patient to recover from a disease or condition. The length of the clean period can vary by specific disease and is clinically and empirically reviewed by MEDSTAT physicians. (MEDSTAT is an ODJFS contractor responsible for the development of a decision support system). In most cases, the length of a clean period is about 60 days.

Question #243: Will ODJFS consider implementing an ECM Program in Mahoning and Trumbull Counties? And if so, how many eligibles lives are available in each of these counties.
Answer #243: ODJFS would consider an application for these two counties but would be unable to provide the additional data until after the submission of a letter of intent. In addition, please refer to page 10 of the RFA, which states: "Applications for additional service areas or for additional counties contiguous with those listed (in the RFA) will be considered based on available resources."

Question #244: How much education does ODJFS plan to do if any with the potential members of this population and with the providers for this population?
Answer #244: Please see response to Question #35.

Question #245: What is the criteria for setting the 17% savings goal?
Answer #245: The ECM Member Expected Growth Rate Reduction is based on ODJFS' return on investment (ROI) expectations for the ECM program. ECM providers who do not achieve breakeven results for ODJFS (1:1 ROI) will be penalized, while ECM providers who produce greater than a 2:1 ROI will receive incentive payments. The Claim Cost per Member produced by the Expected Growth Reduction (17%) is based on a 1.5:1 ROI for ECM members at the midpoint of the incentive/penalty table.

Question #246: Can the formula for calculating the 17% be shared?
Answer #246: Please see the chart below:

ECM Eligible CCPM in baseline period	A	$1,022.06
Expected trend in non-ECM member population	B	12.5%
Expected CCPM for non-ECM member eligible population (A x (1+B))	C	$1,149.82
ECM Premium per member	D	$43.62
Savings at 1.5:1 ROI (D x 1.5)	E	$65.43
Expected CCPM for ECM member population (C + D - E)	F	$1,128.01
Member trend (F/A - 1)	G	10.4%
Trend reduction (1 - G/B)	H	17%

Question #247: For what period of time is the base premium payment fixed?
Answer #247: ECM base premium and adjustments due to membership range will be evaluated at least biannually. The current premium is expected to be effective for the first 2 years of the program. The ECM premium will be adjusted for ECM provider membership size changes as they occur.

Question #248: Is there a maximum amount the administrative fee can change in a one year period?
Answer #248: The maximum penalty based on the growth rate variance calculation is 10% of the ECM premium. This amount will be paid as a lump sum and will not affect the ECM premium level. The ECM premium will be adjusted for membership changes as they occur. There is no maximum limit on this change. In addition, the ECM base premium and adjustments will be updated at least every 2 years.

Question #249: Changes in DRG weights can affect the percentage growth rate experienced by the ECM eligible population as defined (specific diagnoses only), will this be considered in the growth rate calculation?
Answer #249: Changes in DRG weights, benefits and fee schedules will also affect the growth rate in the ABD consumer population, therefore no specific adjustments will be made.

Question #250: Is there any cap (e.g. reinsurance) on the maximum expense for any single case? Would the answer to this be different if the expensive treatment were not related to the diagnosis which made a person eligible for the ECM program?
Answer #250: ODJFS does not anticipate adjusting the growth rate variance calculation for high cost cases except for those conditions noted in Appendix C of the RFA.

Question #251: Is there a minimum number of proposals/areas for ODJFS to move forward with ECM implementation?
Answer #251: : No there is not. While it is the intent of ODJFS to expand the ECM program over the next five years, the initial emphasis will be on those counties or areas where the volume is sufficient to support the ECM provider, as well as to demonstrate the return on investment and quality improvements that will justify further expansion. Please see page 11 of the RFA for a tentative timetable for future ECM program implementation.

Question #252: Will collaborative information (provider panel) be shared in the ODJFS mailing to potential eligibles about the ECM enrollment option?
Answer #252: ODJFS will provide general ECM program information to ECM eligibles with more detailed information on each ECM provider available through the selection services contractor. Also, ODJFS will conduct limited mailings upon request for ECM providers (at their expense) to all ECM eligibles with additional ECM-specific information. Of course, please keep in mind that ECM members will not be subject to a closed provider panel and may seek services from any FFS Medicaid provider.

Question #253: What is the percentage of ECM eligibles that is estimated to drop out of the ECM program during a 12 month period?
Answer #253: Based on our current experience with Preferred Option enrollment (or "opt out") in a full risk-based managed care program, we estimate that at full implementation, at least 65% of the ECM eligible population will be ECM members. Since the ECM program is a less restrictive model, it is likely that a fewer eligibles will choose not to participate but of course that depends on their satisfaction with the ECM provider.

Question #254: What is the percentage of new ECM referrals during a 12-month period?
Answer #254: The percentage or number of ECM eligibles who would be referred to and enrolled in the program each month would depend on the size of the eligible population and the capacity of the ECM provider. The goal is to offer membership to the number of eligibles that can be successfully and timely assessed by the ECM provider.

Question #255: What is the average time lap between delivery of a billable service and submission of a claim under the FFS system?
Answer #255: The average time lag between the date of service and the date the claim is received by ODJFS is 46 days and for pharmacy it is 3 to 4 days.

Question #256: Appendix D of the RFP lists the cost per member per month for the ABD population (with exclusions). Please describe what service codes are included under "Outpatient Hospital".
Answer #256: Outpatient Hospital services include four major service areas: emergency room services; outpatient surgery; laboratory services; and clinic services. The specific service codes are listed in the outpatient rule 5101:3-2-21 and can be accessed by clicking here:

Question #257: Appendix G-1 of the RFP states that the type of staff dedicated to outreach, assessment and care management must be "in accordance with ODJFS specifications". Please provide a listing of the relevant codes, regulations and/or policy manual citations that define these specifications.
Answer #257: Appendix G provides a summary of readiness review submissions. Readiness review tools are currently being developed and will be provided to potential applicants during the readiness review phase.

Question #258: Please provide the number of Medicaid physician providers for each of the 6 service areas in the RFP.
Answer #258: Please see the Provider Utilization Summary report which is posted on the ECM Applicant Library.

Question #259: Can the same provider and patient information be made available soon for all counties contiguous to the counties now being considered?
Answer #259: Provider utilization summaries and ECM eligible numbers by condition can be made available for additional counties. However, the request must be for specific counties and would be provided subsequent to the submission of a letter of intent.

Question #260: Page 2 of Appendix G - The fourth bullet under PCP provisions indicates that the ECM must submit a copy of the ECM - PCP subcontract it will use for State approval, including the reimbursement and incentive information. It also states that fully executed contracts must be submitted. Can the State clarify how both of these will be accomplished during the readiness review? Please clarify the timeline of when the subcontract should be submitted for approval, how long approval will take, when executed contracts should be submitted, and how long all of this will take place prior to program implementation (July 1, 2004).
Answer #260: In regard to the ECM-PCP subcontracts, there will be two sequential steps during the readiness review phase: first, the submission of the subcontract by the ECM provider and the review and approval by ODJFS; and second, which occurs only after completion of the first step, the execution and submission of the individual ECM-PCP subcontracts. Although the time frames are dependent on the need for any changes, in general the first step should take no more than one month. The second step is dependent on the ECM provider and its success in obtaining timely execution. Please keep in mind that the scheduling of readiness review for each ECM applicant will be staggered, since not all service areas will be implemented simultaneously

Question #261: During the readiness review phase, will letters of intent to contract be sufficient substitutes for executed contracts?
Answer #261: Letters of intent will be acceptable as part of the initial application submission. During the readiness review phase, and before entering into a provider agreement with ODJFS, the ECM must provide fully executed subcontracts with PCPs as well as meet all other program requirements.

Question #262: Can the State clarify the substance of the data that the ECM providers will receive regarding their members? Will this consist of adjudicated and paid claims, or submitted claims?
Answer #262: ODJFS will transmit paid claims to the ECM provider. Please see response to Question #100 for additional information.

Question #263: How will the implementation of the ECM program be introduced to eligible individuals? What information on the individual contractors (such as contact information) will be included in those materials?
Answer #263: Per Section II. E. of the RFA, ODJFS will identify and notify Medicaid consumers who are eligible for the ECM program. Information regarding the program will be provided in writing to all ECM eligibles, and will also be available by telephone through a toll-free number. It is expected that this information will be fairly general. In addition, ODJFS will convene community-based meetings to inform local stakeholders of the availability of the ECM program and it benefits.

Question #264: Has the State ever utilized a 24-hour per day, seven day per week health care telephone service? Is any information available regarding the success of this program, or what worked well or did not work well?
Answer #264: Under the current full-risk managed care program, managed care plans are required to provide a 24-hour, call-in system staffed by trained medical professionals. Based on experience to date, the system has worked very well and has been a valuable asset to members in need of personalized and professional information, advice and guidance, 24 hours a day.

Question #265: Who is the State's current utilization management/prior authorization/ precertification vendor? How quickly will this vendor communicate with the ECM contractor after a prior authorization request is made?
Answer #265: ODJFS' hospital utilization and management and precertification vendor is Permedion. Please see the response to question 100 for further information on prior authorizations.

Question #266: If a prior authorization request is made to the ECM contractor or one of our care managers, are there any services that we will have the authority to approve?
Answer #266: ODJFS will be processing prior authorizations for the ECM members in the same manner it currently does for FFS consumers. Therefore, prior authorization requests will not go to the ECM provider.

Question #267: Related to the total number of "eligibles" in the population, is the 34,870 the unique individuals identified during the baseline year? Can you provide an average monthly census of eligibles?
Answer #267: 34,870 is the number of total eligibles identified in the base year and represents unique individuals. ODJFS will provide the average monthly census information during the readiness review phase.

Question #268: Was there a component built into the ECM payment for "development" costs?
Answer #268: Some allowance has been made for development cost in the ECM premium through the PMPM adjustment by membership size.

Question #269: Since the PCP Performance payment is based on PCP performance measures, is this to be paid initially or after some period of time?
Answer #269: The performance measures used by the ECM provider to assess PCPs are to be determined by the ECM provider, subject to ODJFS review and approval. Although it is true some indicators (those related to outcomes, for example) will only be available over time, there are process measures that could be used immediately. These may include a PCPs participation with the care treatment team or submission of various reports.

Question #270: What [is the] maximum actuary penalty/incentive? $15.16?
Answer #267: For financial performance, the maximum penalty/incentive is 10% of the ECM premium.

Question #271: How are patients enrolled with multiple diseases and/or more than one management fee? How did the actuary calculate for these when more disease management services are required?
Answer #271: Only one premium will be paid per member; the ECM provider will not receive an additional premium for members with co-morbid conditions. The premium development assumed varying levels of disease disparity would exist among ECM members, including the impact of co-morbid conditions, and the relative care management effort and cost involved. The ECM provider is expected to manage all medical needs for each member in the interest of comprehensive care coordination and best possible outcomes.

Question #272: If enrollee develops cancer during the program, how are expenses divided out for this or are they just disenrolled? Similar question for those 65 years or older. How about dual eligibles with Medicare eligibility?
Answer #272: The member may stay in the program, but they will be excluded from the growth rate variance calculation. The ECM provider will, however, be accountable for the quality performance measures related to the ECM condition. Similarly, if a member becomes eligible for Medicare, he/she may remain in the program and their costs would be excluded as previously described.

Question #273: By adjusting the premium level bi-annually, are you saying the ECM is contracting for a six-month period or are they required to contract for one year, knowing the premium may be adjusted?
Answer #273: Base premium rates will be evaluated at least once every two years. Provider agreements are signed for annual periods with renewals.

Question #274: When will dual eligibles be phased into the program and is the same or a different model of care planned?
Answer #274: As described in the RFA (p. 9), ODJFS intends to include dual eligibles at a later date subject to federal approval and the confirmation of data availability for ongoing identification and analysis. The same model of care is planned for dual eligibles.

Question #275: There used to be an allocation of administrative funds to counties for non-medically necessary transportation. Have these funds been re-allocated for this program or will additional funds be made available?
Answer #275: No, these funds have not been re-allocated and remain available based on the county's program. No additional funds have been available other than what is estimated in the ECM premium payments for care management. (Ambulance and ambulette remain covered by the FFS program.)

Question #276: Has childhood diabetes management been considered to be included in the program?
Answer #276: Yes, it was considered. However, based on current evidence, the rate of childhood diabetes is low. It is possible that ODJFS may add additional populations and conditions in the future.

Question #277: Give us an idea of what services are being considered for co-pay implementation.
Answer #277: Fee-for-service (FFS) is not planning on any co-pays other than for pharmaceuticals that are not on the preferred drug list. However, ECM members will be exempt from these co-pays.

Question #278: ECM is not performing Authorization of Services; how will we handle conflicting opinions on medically necessary services? This may put plans in a bad position because there will be services authorized that are not necessary in their opinion, yet they will be responsible for the costs.
Answer #278: Prior authorizations and pre-certifications will continue to be handled through the current FFS process. The ECM, as well as and the consumer and the service provider will be notified of these decisions. Please keep in mind that prior authorization decisions made by the Medicaid program are based on a demonstration of medical necessity. By informing the ECM provider of these decisions, ODJFS' intent is that the ECM will begin a process of working with the ECM member and providers to better coordinate prior authorization requests. Currently, we are working with the area in the Office of Ohio Health Plans responsible for prior authorizations to assure that this information is provided in a timely way and perhaps, in the future, develop an approach to provide information when requests are received rather than as the determination is made. Again, consumers will not have a closed panel and so providers outside the ECM panel may be delivering care.

Question #279: Will managed care companies need to submit additional intent-to-participate agreements from PCPs or will current contracts with Medicaid, managed care participation suffice?
Answer #279: The current subcontracts between Medicaid-contracting managed care plans and PCPs will not be sufficient. An additional agreement between the ECM provider and the PCP as specified in the RFA and Appendix E, Draft ECM-PCP Model Contract will be necessary.

Question #280: Can we be provided the staffing info utilized, including the FTEs based on disease type and case load information, as well as salaries.
Answer #280: ODJFS is not sharing this information at this point in time. We will evaluate the applicant's understanding of these issues in reviewing their responses. Please see response to Question #36 for additional information.

Question #281: The ECM model challenges access to a wide panel of PCPs versus a narrow panel for greatest potential of impacting care (smaller number of physicians to engage with larger volume of patients). Please comment on the primary priority of ODJFS and issues with encouraging assignment to a competing provider in a market.
Answer #281: The ECM Program is not based on a "gatekeeper" model. Members can go to any FFS provider and there are no additional restrictions on FFS services. The ECM providers are encouraged to contact any physician identified as the member's PCP who is not already affiliated with the ECM provider in order to include them as an ECM PCP. If this is not possible, the ECM provider is expected to ask members to choose a PCP affiliated with the ECM. If a member is unwilling to change PCPs, they may opt out of the ECM program. ODJFS' priority is to offer enhanced care management services, while minimizing disruptions of care.

Question #282: Define what is included in definition of trend? Any variability claims experienced in year 1, 2, 3?
Answer #282: Trend is reflective of medical costs, including pharmacy costs. In addition, trend will reflect changes in FFS benefits, utilization patterns, and reimbursement rates between time periods. ODJFS has looked at both years, 2001 and 2002.

Question #283: Is there a risk that opting out could affect experience - making it less expensive, thus skewing trend calculations?
Answer #283: Typically, members opting out of a health program have higher health risks than those selecting to participate in a program. However, no relationship between health status and opting out has been assumed. We will not be able to compare these rates until the program is underway.

Question #284: How do you define severe trauma?
Answer #284: Severe trauma is defined as including patients with life threatening traumatic complications such as: severe injury of the skull, severe spinal cord injury, or injuries resulting in paralysis or paresis. The clinical definitions are taken from the MEDSTAT Episode Grouper.

Question #285: How will opt out information be handled when the person develops an exclusionary condition?
Answer #285: ECM members will have the ability to opt out at any time. The ECM provider's member handbook will explain enrollment and disenrollment options (as required by federal regulations), including what the member's options are should they develop one of the specified conditions or circumstances (e.g., dual eligibility) that would have excluded them from membership. The information will also be provided in other member communications, such as those with the selection services contractor.

Question #286: Who tells the member they may opt out? How and when?
Answer #286: Please see previous response.

Question #287: If member opts to stay in but has AIDS etc (high cost, more intensive services by ECM providers), you don't use medical costs for performance measure but would the ECM get a "bump" on PMPM for these members?
Answer #287: If members with the exclusionary conditions (AIDS, etc) decide to stay in the ECM program, they will be excluded from the growth rate variance calculation. However, the ECM provider will be required to manage their health care needs and will be held accountable for the quality performance measures related to the ECM condition. The provider will not be held liable for the health care PMPM costs for these ECM members nor will they realize an increase in the ECM premium for these members.

Question #288: Will the name/phone number of the ECM be on member Medicaid identification cards?
Answer #288: ODJFS will issue a Medicaid card to ECM members with, at a minimum, an identifier indicating ECM membership. We exploring the ability to identify the specific ECM.

Question #289: Regarding population profile total medical expenditures, does net payment category include net payment Rx?
Answer #289: Net payment does include total medical expenditures (medical and pharmacy expenses).

Question #290: What does phase in for membership mean?
Answer #290: "Phase-in" means that not all the eligible ECM members in a service area will become members of an ECM immediately. Membership will occur over a certain number of months dependent on the total number of ECM eligibles in a service area and the ECM provider's capacity. The intent is to assure that the ECM provider has the opportunity to conduct outreach and assessment, as well as treatment planning, in a timely way. Specific monthly numbers will be discussed with each individual applicant during the readiness review phase, but we anticipate that the number will be no fewer than 100-200 per month. The goal is to distribute membership to maximize the potential for success: low enough to allow quality care coordination for new members; high enough to provide sufficient income for the ECM provider; and rapid enough for the state to realize a timely return on investment.

Question #291: What is the number of PCPs with a Medicaid provider agreement statewide?
Answer #291: There are over 30,000 physicians statewide with a Medicaid FFS provider agreement. These providers may see only one or may see many Medicaid consumers. Currently, we are unable to identify accurately how many of those are provider types typically are considered "PCPs" (e.g., family practitioners, internists) or willing to perform the activities required for an "ECM PCP." A significant responsibility for the ECM provider will be to engage providers in a more definitive and accountable role with ECM members.

Question #292: What types of services are expected?
Answer #292: Please see Section II. D. of the RFA, ECM Scope of Services.

Question #293: Appropriate medical nutrition therapy - dietitian services - will reduce costs in caring for all of the target diseases. How do you expect that dieticians will be included in care management?
Answer #293: The ability for potential applicants to forge collaborative relationships is essential to the ECM concept. Potential applicants must explain how they will provide care management services that are performed by a team of professionals. ODJFS does not however, specifically define all the members of the team. We believe that the ECM provider, PCP, and nurse case manager should gather input from the team and include other health care professionals based on the ECM member's condition.

Question #294: How will the split out of the mild hypertension be made? On basis of prior encounter data? ICD codes? This is a gray area.
Answer #294: The hypertension cases will be defined based on ICD9 codes from the individual FFS claims file. The MEDSTAT Episode Grouper will group individual claims into clinical groupings of mild, moderate and severe hypertension.

Question #295: : If a health condition improves, will this member's costs be excluded from calculation?
Answer #295: No. ODJFS expects the ECM member's health condition to improve while enrolled in the program because of the enhanced care coordination and education efforts put forth by the ECM providers. However, these are not curable conditions and therefore the ECM member would remain eligible even if their health status improved. In addition, disenrolling members as their health condition improves could result in a return to a less stable health status and would be counter-productive.

Question #296: The provider summary data for inpatient hospital services doesn't report cost/discharge, cost/claim data. This raises a concern that total costs have not been captured. Can these tables be revised to reflect the number discharged?
Answer #296: On the report, claims provides a close approximation to the number of discharges. During the readiness review phase, ODJFS could provide the number discharged.

Question #297: How does the $15.16 relate to 2 x R01?
Answer #297: $15.16 falls within the 2-1 ROI band. The $15.16 reflects the difference between actual ECM eligible costs and expected ECM eligible costs. ROI is determined based on the savings achieved for the ECM member population. The premium of $43.62 PMPM is paid on members only. An ROI of 2:1 indicates that the ECM vendor is able to produce $87.24 PMPM in medical cost savings for the members. The bands in the Incentive Penalty table reflect .5 increments in ROI expectation for the entire ECM eligible population. Incentive payments begin at a 2:1 ROI level. For example, an ECM provider with actual PMPM costs for the ECM eligible population that are $14-$28 less then expected has provided ODJFS with between a 2:1 and 2.5:1 ROI and will receive an incentive payment equal to 2.5% of ECM premium.

Question #298: Will the growth rate calculations be made by service area or across state-wide of serving multiple counties?
Answer #298: The growth rate calculation (17%) will not vary by service area. However, the baselines, actual claim costs, and the participation rate will be determined for the ECM provider service area.

Question #299: Performance period will include three months of continuous eligibility. Will ODJFS recover/take back any fees paid for those members with less than three months of enrollment? Please verify that these fees will be included in the outcomes measurement.
Answer #299: It is not the ODJFS intent to recover any premiums paid for a month in which the ECM member was in fact enrolled with and being served by the ECM. It is during the first months of membership that the ECM provider will be expected to conduct major tasks such as outreach, assessment, and treatment planning. This definition was only intended to make the financial calculation as fair as possible.

Question #300: What relationship is there between qualifying episode of care and 2002 total costs?
Answer #300: The population was identified by looking for episodes of care in both 2001 and 2002 and the member had to be eligible in the 2nd year (2002).

Question #301: Will the ability to enroll people faster be part of the decision process in selecting ECM providers?
Answer #301: This will not be a deciding factor but will be considered in the context of the overall capacity and qualifications of the ECM applicant.

Question #302: Can we disenroll a provider?
Answer #302: Please see Section II. D. of the RFA, ECM Scope of Services, 5., Primary Care Physician Access, for information on the relationship between ECM providers and PCPs. It is conceivable and permissible that an ECM provider might decide to discontinue its ECM-PCP agreement with a primary care physician. Such terminations must meet certain notification timelines to ODJFS and the ECM members associated with that PCP in order to minimize disruptions of care. These decisions should also consider that ECM members may terminate their ECM membership monthly or may see any FFS provider they wish.

Question #303: Keeping member participation is essential. What is the department going to do to keep members participating in the project? Will there be a co-payment?
Answer #303: Since the ECM program will offer additional services such as care coordination, the 24/7 health advice line, care treatment plan, etc., we expect that members would want to be in the program (and not voluntarily disenroll). The ODJFS will inform ECM eligibles of the benefits of membership, but also expects the ECM to demonstrate that those benefits are worthwhile. ECM members will be exempt from the pharmacy co-payment.

Question #304: Define the participation rate.
Answer #304: The numerator equals member months for ECM participants. The denominator equals member months for ECM eligibles.

Question #305: In order to opt-out, must you actually state that you don't want to participate in the program?
Answer #305: Yes, potential ECM members must call a 1-800 number and inform the ODJFS-contracted selection services organization that they don't want to participate in the program. Please see Section II. C. of the RFA, ECM Population and Service Areas, for a description of the preferred option process.

Question #306: How did you come up with the 65% participation rate?
Answer #306: The basis for the 65% is from preferred option opt-out rates in the current, full risk-based managed care program. We believe the percentage for the ECM program will be higher as it is not as restrictive in terms of provider access.

Question #307: Does it have to be a nurse staffing the 24-hour advice line?
Answer #307: No. As described in Section II. D. ECM, Scope of Services, 3. 24/7 Health Advice Line, the line must be staffed by health care professionals.

12/23/10