July 16, 2014 What is an Organized Delivery System? An Organized - - PowerPoint PPT Presentation

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

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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)

Source: State of NJ Department of Banking and Insurance (DOBI)

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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

• ffer health benefits plans with utilization management components and/or
• n 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.

Source: State of NJ Department of Banking and Insurance (DOBI)

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These Functions Are:

Source: State of NJ Department of Banking and Insurance (DOBI)

 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

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Where to Start: Application Package for Certification as an ODS

Source: State of NJ Department of Banking and Insurance (DOBI)

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.

www.state.nj.us/dobi

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Source: State of NJ Department of Banking and Insurance

Application Checklist for Certification as an ODS (B3) NJAC 11:24B-2.4

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Network Adequacy

Source: LexisNexis Online

 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 sub- county service area:

 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.

• Cardiologist
• Dermatologist
• Endocrinologist
• ENT
• General Surgeon
• Neurologist
• Obstetrician/Gynecologist
• Oncologist
• Ophthalmologist
• Orthopedist
• Oral Surgeon
• Psychiatrist
• Urologist

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Source: State of NJ Department of Banking and Insurance

Sample Table Required:

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Source: State of NJ Department of Banking and Insurance

Sample Table Required (1 of 2):

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Source: State of NJ Department of Banking and Insurance

Sample Table Required (2 of 2):

Sample Table Required:

Source: State of NJ Department of Banking and Insurance

Geo Access Map:

Sample Table Required:

Source: State of NJ Department of Banking and Insurance

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Filing Requirements for Submittal to DOBI

Source: State of NJ Department of Banking and Insurance

 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

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Certified ODS Annual Report Filing

Source: State of NJ Department of Banking and Insurance

Certified ODS Annual Report:

Source: State of NJ Department of Banking and Insurance

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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.

Source: State of NJ Department of Banking and Insurance

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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

Source: State of NJ Department of Banking and Insurance

Kevin Joyce, VP Network & Delivery Systems QualCare, Inc. 30 Knightsbridge Road Piscataway, NJ 08854 kjoyce@qualcareinc.com Phone: 732-562-2811