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

Appendix M
Covered Families and Children (CFC) population
Page 6
Regional-Based Statewide Minimum Performance Standard for Measures 1 and 2: The level of
improvement must result in at least a 20% decrease in the difference between the target and the
previous report period’s results.
Penalty for Noncompliance for Measure 1 : The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future
noncompliance instances with the standard for this measure will result in ODJFS imposing a
monetary sanction. Upon all subsequent measurements of performance, if an MCP is again
determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary sanctions will not be
levied for consecutive quarters that an MCP is determined to be noncompliant. If an MCP is
noncompliant for a subsequent quarter, new member selection freezes or a reduction of assignments
will occur as outlined in Appendix N of the Provider Agreement. Once the MCP is determined to be
compliant with the standard and the violations/deficiencies are resolved to the satisfaction of
ODJFS, the penalties will be lifted, if applicable, and monetary sanctions will be returned. For SFY
2008 and SFY 2009, measure 2 is a reporting-only measure.
1.c. Clinical Performance Measures
MCP performance will be assessed based on the analysis of submitted encounter data for each year.
For certain measures, standards are established; the identification of these standards is not intended
to limit the assessment of other indicators for performance improvement activities. Performance on
multiple measures will be assessed and reported to the MCPs and others, including Medicaid
consumers.
The clinical performance measures described below closely follow the National Committee for
Quality Assurance’s Health Plan Employer Data and Information Set (HEDIS). Minor adjustments
to HEDIS measures are required to account for the differences between the commercial population
and the Medicaid population, such as shorter and interrupted enrollment periods. NCQA may
annually change its method for calculating a measure. These changes can make it difficult to
evaluate whether improvement occurred from a prior year. For this reason, ODJFS will use the
same methods to calculate the baseline results and the results for the period in which the MCP is
being held accountable. For example, the same methods were being used to calculate calendar year
2005 results (the baseline period) and calendar year 2006 results. The methods will be updated and
a new baseline will be created during 2007 for calendar year 2006 results. These results will then
serve as the baseline to evaluate whether improvement occurred from calendar year 2006 to
calendar year 2007. Clinical performance measure results will be calculated after a sufficient amount
of time has passed after the end of the report period in order to allow for claims runout. For a
comprehensive description of the clinical performance measures below, see ODJFS Methods for
Clinical Performance Measures for the CFC Managed Care Program. Performance standards are
subject to change based on the revision or update of NCQA methods or other national standards,
methods or benchmarks.
For an MCP which had membership as of February 1, 2006: MCP performance will be evaluated
using an MCP’s county-based statewide result for the counties in which the MCP had membership