Regional Generic Provider Agreement - Ohio Department of Job and ...

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MCP: APPENDIX J FINANCIAL PERFORMANCE CFC ELIGIBLE POPULATION 1. SUBMISSION OF FINANCIAL STATEMENTS AND REPORTS MCPs must submit the following financial reports to ODJFS: a. The National Association of Insurance Commissioners (NAIC) quarterly and annual Health Statements (hereafter referred to as the “Financial Statements”), as outlined in Ohio Administrative Code (OAC) rule 5101:3-26-09(B). The Financial Statements must include all required Health Statement filings, schedules and exhibits as stated in the NAIC Annual Health Statement Instructions including, but not limited to, the following sections: Assets, Liabilities, Capital and Surplus Account, Cash Flow, Analysis of Operations by Lines of Business, Five-Year Historical Data, and the Exhibit of Premiums, Enrollment and Utilization. The Financial Statements must be submitted to BMHC even if the Ohio Department of Insurance (ODI) does not require the MCP to submit these statements to ODI. A signed hard copy and an electronic copy of the reports in the NAIC-approved format must both be provided to ODJFS; b. Hard copies of annual financial statements for those entities who have an ownership interest totaling five percent or more in the MCP or an indirect interest of five percent or more, or a combination of direct and indirect interest equal to five percent or more in the MCP; c. Annual audited Financial Statements prepared by a licensed independent external auditor as submitted to the ODI, as outlined in OAC rule 5101:3-26-09(B); d. Medicaid Managed Care Plan Annual Ohio Department of Job and Family Services (ODJFS) Cost Report and the auditor’s certification of the cost report, as outlined in OAC rule 5101:3-26-09(B); e. Medicaid MCP Annual Restated Cost Report for the prior calendar year. The restated cost report shall be audited upon BMHC request; f. Annual physician incentive plan disclosure statements and disclosure of and changes to the MCP’s physician incentive plans, as outlined in OAC rule 5101:3- 26-09(B); g. Reinsurance agreements, as outlined in OAC rule 5101:3-26-09(C);
Appendix J Page 2 h. Prompt Pay Reports, in accordance with OAC rule 5101:3-26-09(B). A hard copy and an electronic copy of the reports in the ODJFS-specified format must be provided to ODJFS; i. Notification of requests for information and copies of information released pursuant to a tort action (i.e., third party recovery), as outlined in OAC rule 5101:3-26-09.1; j. Financial, utilization, and statistical reports, when ODJFS requests such reports, based on a concern regarding the MCP’s quality of care, delivery of services, fiscal operations or solvency, in accordance with OAC rule 5101:3-26-06(D); k. In accordance with ORC Section 5111.76 and Appendix C, MCP Responsibilities, MCPs must submit ODJFS-specified franchise fee reports in hard copy and electronic formats pursuant to ODJFS specifications. 2. FINANCIAL PERFORMANCE MEASURES AND STANDARDS This Appendix establishes specific expectations concerning the financial performance of MCPs. In the interest of administrative simplicity and nonduplication of areas of the ODI authority, ODJFS’ emphasis is on the assurance of access to and quality of care. ODJFS will focus only on a limited number of indicators and related standards to monitor plan performance. The three indicators and standards for this contract period are identified below, along with the calculation methodologies. The source for each indicator will be the NAIC Quarterly and Annual Financial Statements. Report Period: Compliance will be determined based on the annual Financial Statement. a. Indicator: Net Worth as measured by Net Worth Per Member Definition: Net Worth = Total Admitted Assets minus Total Liabilities divided by Total Members across all lines of business Standard: For the financial report that covers calendar year 2008, a minimum net worth per member of $_________, as determined from the annual Financial Statement submitted to ODI and the ODJFS. The Net Worth Per Member (NWPM) standard is the Medicaid Managed Care Capitation amount paid to the MCP during the preceding calendar year, including delivery payments, but excluding the at-risk amount, expressed as a per-member permonth figure, multiplied by the applicable proportion below:
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APPENDIX A OAC RULES 5101:3-26 The
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Appendix C Covered Families and Chi
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Appendix D Covered Families and Chi
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Appendix D Covered Families and Chi
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APPENDIX E RATE METHODOLOGY CFC ELI
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APPENDIX F REGIONAL RATES 2. AT-RIS
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Appendix G Covered Families and Chi
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Appendix N Covered Families and Chi
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Appendix O Covered Families and Chi
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Appendix P Covered Families and Chi
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Appendix P Covered Families and Chi
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