What is an Organized Delivery System (ODS) from a Filing and Legal Perspective?

Transcription

1 What is an Organized Delivery System (ODS) from a Filing and Legal Perspective? Presented By: Kevin Joyce: VP, Network & Delivery Systems, QualCare, Inc. Carol Grelecki: Esq, Brach Eichler, LLC July 16, 2014

2 What is an Organized Delivery System? An Organized Delivery System (ODS) is a legal entity that contracts with a carrier for the purpose of providing or arranging for the provision of health care services to those persons covered under a carrier s health benefits plan, but which is not a licensed health care facility or other health care provider. In order to contract with a carrier, an ODS must become licensed or certified. Examples of the types of entities that are an ODS: Preferred Provider Organizations (PPO) Health Maintenance Organizations (HMO) Physician Hospital Organizations (PHO) Independent Practice Associations (IPA) (DOBI) - 2 -

3 Regulatory Requirements Whether an ODS must become licensed or certified, it must meet certain minimum standards regarding the functions that the ODS is or intends to perform under contract with carriers. The standards are substantially similar to those that carriers would have to comply with if they were performing the specific functions themselves in accordance with the Health Care Quality Act. The Organized Delivery System Act states that both licensed and certified ODSs are subject to the Health Care Quality Act. The Health Care Quality Act and rules govern certain operations of carriers that offer health benefits plans with utilization management components and/or on a managed care basis. The Department of Banking and Insurance has established nine broad categories of activities representing functions governed by the Health Care Quality Act that are often delegated by carriers. (DOBI) - 3 -

4 These Functions Are: Performing or arranging for the performance of one or more types of health care services Network management, including recruitment and retention Credentialing and recredentialing Utilization management application Utilization management appeals Member complaints Provider complaints Continuous quality improvement (DOBI) - 4 -

5 Where to Start: Application Package for Certification as an ODS The application checklist in its entirety as well as any forms and/or tables required for filing, can be downloaded from the NJ Department of Banking and Insurance website, under the Insurance Division tab. (DOBI) - 5 -

6 Application Checklist for Certification as an ODS (B3) NJAC 11:24B

7 Network Adequacy Geographic access and availability standards for primary care providers (PCPs) shall be as follows: There shall be at least two (2) physicians within 10 miles or 30 minutes average driving time or public transit (if available), whichever is less, of 90 percent of the enrolled population The HMO shall demonstrate that the projected PCP network is sufficient to meet adult, pediatric and primary ob/gyn needs of the projected enrollment on the basis of the following assumptions: Four primary care visits per year per member, averaging one hour per year per member Four patient visits per hour, per PCP The HMO shall have a policy assuring access to the specialists identified in (a) 1ii (1) through (13) below within 45 miles or one hour driving time, whichever is less, of 90 percent of members within each county or approved subcounty service area: Cardiologist Dermatologist Endocrinologist ENT General Surgeon Neurologist Obstetrician/Gynecologist Oncologist Ophthalmologist Orthopedist Oral Surgeon Psychiatrist Urologist At least one licensed acute care hospital including at least licensed medical-surgical, pediatric, obstetrical, and critical care services in any county or service area no greater than 20 miles or 30 minutes driving time, whichever is less, from 90 percent of members within the county or service area. Source: LexisNexis Online - 7 -

8 Sample Table Required: - 8 -

9 Sample Table Required (1 of 2): - 9 -

10 Sample Table Required (2 of 2):

11 Sample Table Required:

12 Geo Access Map:

13 Sample Table Required:

14 Filing Requirements for Submittal to DOBI Application submitted in a 3-ring binder(s), labeled with the ODS name, and serially numbered, if necessary Application tabbed, exhibits segregated, and shown in order requested on application package All pages numbered All specimen contracts contain unique identifier in lower left corner of each page Payment by check or money order for $2,500, made payable to the Treasurer, State of New Jersey No items left blank

15 Certified ODS Annual Report Filing

16 Certified ODS Annual Report:

17 Approved Licensed Organized Delivery Systems American Imaging Management East American Specialty Health ODS of New Jersey Beacon Health Strategies LLC Block Vision of New Jersey, Inc. CareCentrix of New Jersey, Inc. CareCore NJ, L.L.C. Freedom Health Solutions, LLC Healthplex of NJ, Inc. HN1 Therapy Network of New Jersey Magellan Behavioral Health of NJ, LLC Meridian Geisinger Health Network, LLC Orthonet of Mid-Atlantic, Inc. Prism Health Networks of NJ Triad Healthcare, Inc. ValueOptions of New Jersey, Inc

18 Approved Certified Organized Delivery Systems Academy Orthotic & Prosthetic Associates IPA, Inc. Atlantic Imaging Group, LLC Audiology Distribution, LLC d/b/a HearUSA Avesis Third Party Administrators, Inc. Beech Street Corporation CareCentrix Careington International Corporation Care To Care, LLC CIGNA Behavioral Health Consumer Health Network Plus, LLC Corphealth, Inc. (d/b/a LifeSynch) Davis Vision Dental Benefit Providers, Inc. Dental Health Alliance Dental Network of America, LLC DenteMax Customer Service DentaQuest Ear Professionals International Corp. EyeMed Vision Care, LLC First Health Group Corp. IPA of North Jersey LogistiCare Solutions, LLC Magellan Behavioral Health, Inc. MagnaCare Administrative Services, LLC MagnaCare Ancillary Services, LLC March Vision Care Group, Inc. Med-Net IPA, LLC MedSolutions, Inc. MHN Services Morris Area Integrated Physicians, IPA Morris-Somerset IPA, Inc. MultiPlan, Inc. National Visions Administrators, LLC OptiCare Vision Company, Inc. OptumHealth Care Solutions, Inc. POMAC Metro, LLC Private Healthcare Systems, Inc. QualCare, Inc. Radiology Consultants of New Jersey, Inc. (RADCON) ReliaCare Alliance IPA, LLC Solstice of New York, Inc. Spectera, Inc. Stratose, Inc. Superior Vision Services, Inc. United Behavioral Health United Concordia Companies, Inc. U.S. Imaging Network, LLC Vista Health Systems, LLC

19 Kevin Joyce, VP Network & Delivery Systems QualCare, Inc. 30 Knightsbridge Road Piscataway, NJ Phone: