PARTNERSHIP HEALTHPLAN OF CALIFORNIA PHYSICIAN ADVISORY COMMITTEE ~ MEETING NOTICE

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1 Members: Jeffrey Bosworth, M.D. Shandi Fuller, M.D. *alternates Jeffrey Gaborko, M.D. (Chair) Michael Ginsberg, M.D. Steve Gwiazdowski, M.D. Michele Herman, M.D. PARTNERSHIP HEALTHPLAN OF CALIFORNIA PHYSICIAN ADVISORY COMMITTEE ~ MEETING NOTICE Willard Hunter, M.D. M. Tracy Johnson, M.D. Melissa Marshall, MD Antoinette Martinez, M.D. Mills Matheson, M.D. Danielle Oryn, D.O. Thomas Paukert, M.D. Mitesh Popat, M.D. Michael Stacey, M.D. *alternates Colleen Townsend, M.D. Lisa Ward, M.D. PHC Staff: Liz Gibboney, Chief Executive Officer Robert Moore, MD, MPH, Chief Medical Officer Wendy West, Northern Executive Director Peggy Hoover, RN, Senior Director, Health Services Patti McFarland, Chief Financial Officer Mary Kerlin, Senior Dir., Provider Relations (PR) Dept. Marshall Kubota, MD, Regional Medical Director Mark Netherda, MD, Regional Medical Director Michael Vovakes, MD, Northern Regional Med. Dir. Jeffrey Ribordy, MD, Regional Medical Director James Cotter, MD, Regional Medical Director Jessica Thacher, Director, Quality & Perf. Improvement (on leave) Debra McAllister, RN, Director of Utilization Mgmt. Stan Leung, Pharm.D., Director, Pharmacy Services Scott Endsley, MD, Associate MD of Quality Kevin Spencer, Director of Member Services Ad Hoc PHC Sonja Bjork, Chief Operating Officer Paula Frederickson, Senior Claims Director Members: Kirt Kemp, Chief Information Officer Bettina Spiller, MD, Associate Medical Director Lynn Scuri, Regional Director Mark Glickstein, MD, Associate Medical Director Kelley Sewell, N. Region Mbr Services & PR Director Carolyn Stewart, Senior Director of Financial Analysis Diane Wong, Pharm.D., Senior Clinical Pharmacist Jennifer Chancellor, Northern Regional Manager Betsy Campbell, Senior Health Educator Nancy Steffen, Northern Region Manager, QI Programs Karen Stephen, Ph.D., Mental Health Clinical Director Linda Melsheimer, RN, Program Manager Ledra Guillory, Senior Prov. Relations Rep. Manager Carly Fronefield, RN, N. Region, Health Services Director Rachael French, Manager, Quality Improvement Prgrms Margarita Garcia-Hernandez, Manager, Health Analytics Rebecca Boyd Anderson, RN, Director, Care Coord. Robin Krohn, N. Region Manager, Care Coordination Alice Mabry, N. Region Manager, Utilization Management cc: PHC Commission Chair Harris Levin, MD Gabriel Samuel Chua, MD Voltaire Velarde, MD Marie Mulligan, MD Gregory Baldwin, MD Kali Stanger, MD Richard Fogg Jerry Douglas, MD Amy Brom, Psy.D. FROM: Linda Largent DATE: September 7, 2017 SUBJECT: PHYSICIAN ADVISORY COMMITTEE MEETING LOCATIONS: The Physician Advisory Committee will meet as follows and will continue to meet the second Wednesday of every month (exception / July and December.) Please review the Meeting Agenda and attached packet, as discussion time is limited. DATE: Wednesday, September 13, 2017 TIME: 7:30 a.m. 9:00 a.m. Via Video Conference Partnership HealthPlan of CA 4665 Business Center Drive (Please Park in Front of Bldg.) Fairfield, CA PHC Sonoma Office 495 Tesconi Circle Santa Rosa Access Via Teleconference Baechtel Creek Medical 1245 S. Main Street Willits Marin Clinic 1177 E. Francisco Blvd. Suite B, San Rafael United Indian Health 1600 Weeot Way Arcata Shasta Community Health Centers 1035 Placer Street Redding PHC - Eureka Office th Street, Suite E Eureka PHC Redding Office 2525 Airpark Drive Redding Redwood Community Health Coalition 1310 Redwood Way, #135 Petaluma Ole Health 1141 Pear Tree Lane Napa Please contact me at (707) , or llargent@partnershiphp.org if you are unable to attend.

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3 REGULAR MEETING OF PARTNERSHIP HEALTHPLAN OF CALIFORNIA S PHYSICIAN ADVISORY COMMITTEE - MEETING AGENDA Date: September 13, 2017 Time: 7:30 9:00 a.m. Location: PHC PUBLIC COMMENTS Speaker 2 minutes Speaker 2 minutes Welcome / Introductions I. Approval of Minutes Chair :30 II. Standing Agenda Items Lead Pg # Time A. Status Update Administration Ms. Gibboney 7:40 Medical / Health Services Report Dr. Moore 7:50 Regional Medical Director Reports - Napa County Dr. Cotter 7:55 - Southeast Counties Dr. Netherda 7:58 - Southwest Counties Dr. Kubota 8:01 - Northwest Counties Dr. Ribordy 8:04 - Northeast Counties Dr. Vovakes 8:07 A1. Update from County Public Health Departments Available 8:10 Representative(s) A2. Committee Member Highlight Dr. Johnson 8:13 B. Quality / Utilization Advisory Committee Activities Report with attachments Consent Review Minutes of the August 16, 2017 meeting - Minutes Internal Quality Improvement meeting 06/13/17 (attached) *Policies &Procedures: * See Pages Note only pages with significant changes are included for policies - Quality Improvement Update - EPSDT Supplemental Shift Nursing Services (MCCP2005) - Transportation Guidelines for non-medical & Non-Emergency Medical Transportation (MCCP2016) - Early Periodic Screening, Diagnosis & Treatment Services (MCCP2022) - New Member Needs Assessment (MCCP2023) New - Provider Request to Discharge Member & Assistance w/ Inappropriate Member Behavior (MP 316) - Grievance Report - HEDIS Results (see Agenda Item IV.A.) - Breast Cancer Staff Incentive Program C. Pharmacy &Therapeutics (P&T) Committee / Consent Review No Meeting in August D. Provider Advisory Group (PAG) Report Consent Review No Meeting in August E. Credentialing Committee Meeting Summary Committee approved Summary of the June 14, 2017 meeting (attached) Dr. Moore Dr. Leung / Dr. Moore Ms. Kerlin / Ms. Sewell 8: Dr. Kubota :19 F. Recommended Committee Appointments / Resignations Dr. Moore III. Old Business Lead Pg # Time IV. A. Consumer Assessment of Healthcare Providers and Systems (CAHPS) - Overall Results of Patient Satisfaction Survey (from October 2016 meeting) Postponement continued pending information from DHCS New Business A. Healthcare Effectiveness Data Information Set (HEDIS) Performance Results for 2016 B. Discussion Topic: Role of Health Centers in Supporting Health Care Needs of Post-Incarceration Populations Ms. Steffen / Ms. Wilson Dr. Moore VI. Adjournment 8:55 8:20 8:40 3 of 130 Page 1 of 2

4 This agenda contains a brief description of each item to be considered. Except as provided by law, no action shall be taken on any item not appearing on the agenda. Government Code requires that public records related to items on the open session agenda for a regular committee meeting be made available for public inspection. Records distributed less than 72 hours prior to the meeting are available for public inspection at the same time they are distributed to all members, or a majority of the members of the committee. The committee has designated the Administrative Assistant to the Chief Medical Officer as the contact for Partnership HealthPlan of California located at 4665 Business Center Drive, Fairfield, CA 94534, for the purpose of making those public records available for inspection. The Physician Advisory Committee Agenda and supporting documentation is available for review from 8:00 AM to 5:00 PM, Monday through Friday at all PHC regional offices (see locations under the Meeting Notice). It can also be found online at In compliance with the Americans with Disabilities Act, PHC meeting rooms are accessible to people with disabilities. Individuals who need special assistance or a disability-related modification or accommodation (including auxiliary aids or services) to participate in this meeting, or who have a disability and wish to request an alternative format for the agenda, meeting notice, agenda packet or other writings that may be distributed at the meeting, should contact the Administrative Assistant to the Chief Medical Officer at least two (2) working days before the meeting at (707) or by at llargent@partnershiphp.org. Notification in advance of the meeting will enable PHC to make reasonable arrangements to ensure accessibility to this meeting and to materials related to it. Meeting Notes Physician Advisory Committee 09/13/2017 Action Items Assigned To: of 130 Page 2 of 2

5 Committee: Physician Advisory Committee Date / Time: August 9, :34 to 8:53 am PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES PAGE 1 OF 12 Members Present: Members Excused: Members Absent: Jeffrey Bosworth, MD - TC Jeffrey Gaborko, MD (Chair) Steven Gwiazdowski, MD Shandi Fuller, MD Lisa Ward, MD Michael Ginsberg, MD Danielle Oryn, DO Michele Herman, MD Willard Hunter, MD - VC Tracy Johnson, MD Thomas Paukert, MD Melissa Marshall, MD TC Antoinette Martinez, MD TC (8:55 start) Mills Matheson, MD - TC Mitesh Popat, MD - TC Michael Stacey, MD Colleen Townsend, MD - TC Visitors: Note: via Video Conf. (VC) via Teleconference (TC) PHC Staff Present: Liz Gibboney, Chief Executive Officer Patti McFarland, Chief Financial Officer Wendy West, Northern Executive Director Kirt Kemp, Chief Information Officer Jennifer Chancellor, N. Regional Mgr.- VC Ledra Guillory, Sr. Prov. Relations Rep. Mgr. Carly Fronefield, RN, N. Region HS Dir. - VC Robert Moore, MD, Chief Medical Officer Peggy Hoover, RN, Sr. Director, Health Services James Cotter, MD, Regional Medical Director Scott Endsley, MD, Assoc. Medical Director, Quality Debra McAllister, RN, Dir. Utilization Management Rebecca Boyd-Anderson, RN, Dir. Care Coordination Vic Patel, Pharm.D., Clinical Pharmacist Marshall Kubota, MD, Regional Medical Director - VC Michael Vovakes, MD, Northern Region Med. Dir - VC Jeff Ribordy, MD, NW Regional Medical Director - VC Mark Netherda, MD, Regional Medical Director Bettina Spiller, MD, N. Associate Medical Director Jess Liu, Manager, Quality Incentive Programs Barbara Selig, Senior Project Manager, Quality AGENDA ITEM Public Comments Quorum DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE Committee Chairman, Dr. Gaborko, asked for public comments. None were N/A presented and no members of the public were in attendance. Committee quorum requirements met. DATE RESOLVED N/A I. Approval of Minutes II.A. Status Update Administration The HealthPlan s Chief Executive Officer (CEO) provided the following status report on PHC activities. - Affordable Care Act (ACA) Repeal There has not been much change over the past few weeks on repealing the ACA, with the exception that a bipartisan effort has been emerging. Their focus is on addressing some marketplace issues that are impacting some communities across the country. This new group is called the Problem Solvers Caucus (Caucus), and is made up of half Democrat and half Republican representatives. MOTION: Dr. Gwiazdowski moved to approve Agenda Item [I.] as presented, seconded by Dr. Johnson. ACTION SUMMARY: [11] yes, [0] no, [0] abstentions. Motion carried. For information only, no formal action required. 08/09/17 08/09/17 5 of 130

6 Physician Advisory Committee Minutes 08/09/17 - Page 2 of 12 AGENDA ITEM II.A. Status Update Administration, Continued DISCUSSION / CONCLUSIONS The Caucus is reviewing ways to stabilize the insurance markets, amidst the uncertainties around subsidy reductions that the Federal Government gives to the Exchanges, and the continuous threat of those funds going away. This doubt made some commercial insurers more ready to leave the market entirely, rather than wait for the outcome. The cornerstone of the Caucus is to require the Corporate Social Responsibilities (CSRs) stay in place, and to move the control of the CSRs away from the White House and into Congress. The Caucus is also looking at repealing the Medical Device Tax under ACA, which is about 2.3%, along with increasing the minimum size of an organization mandating employer coverage from 50 to 500 employees. This current platform leaves Medicaid alone. However, looking at the Federal Budget (fiscal year beginning October 1) there are still some significant cuts proposed to Medicaid, which would likely fund the Tax Reform and tax cuts proposed by the Administration. Plan staff will continue to monitor these efforts. RECOMMENDATIONS / ACTION DATE RESOLVED - Drug Medi-Cal Program There is a presentation later on the agenda by Margaret Kisliuk. Ms. Kisliuk is the Plan s new Behavioral Health Administrator, most recently in the role of Northern Region Executive Director. She is transitioning from that role and will be working out of the Fairfield office, where she will administer the Plan s Behavioral Health unit. That oversight includes Drug Medi-Cal, as well as the Mild to Moderate benefit that the HealthPlan has partnered with Beacon Health Strategies to manage. - Housing Initiative The Board previously approved $25 million of the HealthPlan s reserves to fund housing initiatives across its service area. The Request for Proposal (RFP) was out early July, and the Plan is expecting to get its first round of applications later this month. There has been a lot of interest from providers. Applicant questions, and the Plan s responses, have been posted to the Plan s website. This Committee will be updated in September regarding the types of applications received. In the event that funds do not get extended under the first round, the Plan will hold those funds for future applicant counties. - Transportation Benefit This benefit is up and running as of July 1. In the first 6 weeks of the benefit, the Plan s vendor arranged or provided over 2,400 rides (mainly taxis, with some mileage reimbursement). There has only been a handful of grievances. Given the early stage of the benefit and all the uncertainty with its rollout, that is a good sign. It is expected that the State will provide more policy clarification as health plans administer the services and issues arise. There are extensive reporting requirements under the Department of Health Care Services (DHCS). As a reminder, the HealthPlan will be obligated to cover transportation to services it is not responsible for starting October (i.e. dental and seriously and persistently mentally ill). It is still unknown what the Plan will be paid for this benefit. For information only, no formal action required. For information only, no formal action required. For information only, no formal action required. 08/09/17 08/09/17 08/09/17 Funds set aside by the State for the benefit ($6 million statewide) are significantly lower than what is expected to cost health plans. PHC does not know its financial impact at this point, but estimations have been made based on anticipated utilization (administrative costs, contracting with the vendor, and actual transportation expenses). Partnership already has a medically supported transportation benefit. That data was used for projections. Staff will continue to monitor, knowing that some of the benefit may have to be funded out of reserves, until actual costs for administering the benefit are recognized by the State. The other 6 of 130

7 Physician Advisory Committee Minutes 08/09/17 - Page 3 of 12 AGENDA ITEM II.A. Status Update Administration, Continued DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION concern has to do with starting the benefit with wide allowances, which will make it extremely difficult to scale back in the future. The HealthPlan has been trying to provide the benefit within the confines of DHCS, though clear guidelines have not been offered. DATE RESOLVED - National Committee for Quality Assurance (NCQA) Accreditation Readiness HeathPlan staff are intensifying efforts with the goal of being accredited in By the end of June 2018, it is expected that all required standards will be met for the first round of the process. There are many internal goals underway related to delegation oversight, member portal, provider directory, and Healthcare Effectiveness and Data Information Set (HEDIS) scores (though not a major component for the first round). For information only, no formal action required. 08/09/17 II.A. Status Update Medical The HealthPlan s Chief Medical Officer (CMO) presented an overview of some Health Services activities. - Medical Director Newsletter The most recent newsletter was included in the meeting packet, and contains information on PHC and non-phc events. Committee members are encouraged to read through the information. - State Budget o Within the Budget is a new benefit to start July 2018, Diabetes Prevention Program. DHCS has already begun to hold discussions on this, which leads Plan staff to believe the benefit will begin on schedule. This Committee will be updated as information becomes available. o Medically Tailored Meals This is a pilot program based on studies that included increased outcomes for patients with the human immunodeficiency virus (HIV), along with other chronic diseases. Legislation targeted five organizations within the state to pilot the program, two of which are in Sonoma County. It is unknown who would administer this new benefit. The target date for the pilot to start is January For information only, no formal action required. 08/09/17 - Hospital Quality Symposiums This week, PHC will host two symposiums that are in conjunction with the Plan s Hospital Quality Improvement Program (QIP) efforts. The first was held yesterday for the Southern Region hospitals, was well received, and had a great turnout. There was a higher percentage of rural hospitals, which do not often have the resources to send staff to national conferences. There was particular focus on patient safety. The Northern Region s symposium is scheduled for tomorrow. - Medication Synchronization Pilot The pharmacy that piloted this new program was Owens Pharmacy, which has been a great partner to PHC in the Northeastern Region. Members come into the pharmacy once a month to fill all their medications, versus coming in several times during the month. Aside from patients not running out or not taking their medications, pharmacies will benefit financially by filling prescriptions regularly for the patient. Until the process becomes familiar to pharmacy, there is an initial lift for staff. A couple of additional pharmacies are also interested in trying this pilot. Not surprising, chain pharmacies are not as interested in this program, as point of sale transactions are integral to their business models. 7 of 130

8 Physician Advisory Committee Minutes 08/09/17 - Page 4 of 12 AGENDA ITEM II.A. Status Update Medical, Continued DISCUSSION / CONCLUSIONS Dr. Stacey asked if Partnership was seeking other pharmacies to participate in the program, as Solano County utilizes a pharmacy that may be interested. PHC s CMO advised that the Plan is interested in getting the word out and its Director of Pharmacy is gathering information on best practices. A meeting may be hosted with the pilot pharmacies to better understand the learning curve. RECOMMENDATIONS / ACTION DATE RESOLVED - Confidential Screening/Billing Report (PM 160) Claim Form The official determination by the State was that all Child Health and Disability Prevention (CHDP) providers, who see Medi-Cal Managed Care patients, need to continue to submit the PM 160 forms (Federally Qualified Health Centers [FQHCs] or not). A meeting of various medical directors was held. Anthem and Health Net wanted to extend the form another 18 months, as opposed to County Organized Health Systems (COHS), who would like to get rid of the form as soon as possible. Anthem and Health Net get some HEDIS data from it, so they are not as concerned about the time required to complete the forms. The purposefulness of the PM 160 by the State seems to be limited to collecting data from the Centers for Medicare & Medicaid Services (CMS). Pulling down that information without a PM 160 has been achieved for fee-for-service providers already. The HealthPlan is pushing for the same fix for COHS organizations, and providers should utilize their advocacy groups to promote the system change and ceasing the use of PM 160 forms. - Final Rule Since the Committee s meeting in July, staff has also been working on the Final Rule. CMS issued a number of changes in requirements for Medicaid Managed Care. There is now a 24-hour turnaround for pharmacy Treatment Authorization Requests (TARs), which used to be one business day. This has required pharmacy and Medical Director staff to schedule weekend hours. There is some disagreement between the Plan and the State regarding the pending status interpretation under the Final Rule. The HealthPlan is opting for the more conservative definition. - Regional Medical Director Reports Due to how busy the Committee s agenda typically is, there has been agreement to focus on items that are believed to be of most interest to the Committee. - HEDIS Scores have been received and will be reviewed with the Committee next month. PHC s Regional Medical Director for Napa County presented a brief overview. - Intensive Outpatient Care Management (IOPCM) Program There are fourteen counties and fourteen sites involved in this project, with approximately 550 members currently. At least three of the counties (Marin, Solano, and Napa) have Whole Person Care (WPC). Plan staff is working with those sites on how they communicate with the patients. WPC is a connection program for homeless people. IOPCM has a homeless component, and the two seem to have some overlap in finding the same patient. Staff needs to ensure that the patient gets to the right place, since there seems to be a lot of question about this in Solano and Marin counties. PHC is attempting to bridge this communication, but will need to learn more about WPC to do so. - Palliative Care Benefit As many know, the Plan initiated a pilot program in 2015, which was extended on July 1st to more sites. Senate Bill (SB) 1004 will go into effect January The Plan anticipates receipt of an All-Plan Letter (APL) from DHCS, and expects the benefit to resemble the program For information only, no formal action required. 08/09/17 8 of 130

9 Physician Advisory Committee Minutes 08/09/17 - Page 5 of 12 AGENDA ITEM II.A. Status Update Medical, Continued DISCUSSION / CONCLUSIONS previously slated to begin April Though it may change slightly, PHC is moving forward on the benefit as it was described in the previous APL. Sites that have active patients are in Humboldt, Napa, and Yolo counties. Sites with contracts, actively looking for members, are in Lake and Mendocino counties. Solano and Shasta counties have contracts in place or in process. PHC s goal is to have every county covered with Palliative Care. A couple years ago, this was a new concept, but it is quickly taking hold. SB 1004 will make this a statewide benefit for Medi-Cal members. Hopefully, Medicare will get on board with a similar benefit. In review of the program, staff found that the pilot programs saved money, patients were happy, and they received better care achieving the triple aim. RECOMMENDATIONS / ACTION DATE RESOLVED PHC s Regional Medical Director for the Southeastern (SE) counties presented a brief overview. - La Clinica s Transitions Clinic This is for transitioning incarcerated individuals back into the health care system upon release, which was funded in part by one of PHC s Social Determinants of Health grants. Congratulations are due, as La Clinica was accepted to present their progress at a national conference. For information only, no formal action required. 08/09/17 The Plan s CMO noted that last month s issue of Health Affairs contained a summary of all the transitions programs, and La Clinica s program was included in the data summary. PHC s Regional Medical Director for the Southwestern (SW) counties presented a brief overview. - Medically Tailored Meals As mentioned earlier, Federal grants have been awarded to two Sonoma County providers, which equates to several million dollars. If the pilot program proves to be beneficial, then it would become a benefit. The program will not include chronic renal disease, but there would be a large number of individuals with diabetes. PHC is not responsible for this program, but staff did meet with grant recipients to offer their perspectives. - Petaluma Health Center Staff continues to work with the Center, which received a grant for a Specialty Hub. This regional model allows specialists to see patients at the Hub, while not incurring the overhead costs of another office. - Lake County The County received grant funds under the Way to Wellville program, by way of the Esther Dyson Foundation. The program serves as an advisor to health organizations. Lake County is one of five recipients nationwide. - New Treatment for Hepatitis C This week, a new treatment for Hepatitis C became available. The eight week program is considerably less in cost (around $26,000) than the other treatment spanning 12 weeks (around $100,000). For information only, no formal action required. 08/09/17 PHC s Regional Medical Director for the Northwestern (NW) counties presented a brief overview. Access - Dual Diagnosis Treatment Facility This treatment facility will function as a detoxification (detox) center, as well as a facility to treat mental health disorders. This is a huge value for the area, which does not currently have either. Local agencies, Humboldt County, and Dr. Ruby Byron will be For information only, no formal action required. 08/09/17 9 of 130

10 Physician Advisory Committee Minutes 08/09/17 - Page 6 of 12 AGENDA ITEM II.A. Status Update Medical, Continued DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION DATE RESOLVED running the facility, which is expected to open September 11th. The facility previously housed a homeless transitions program, but, it was determined that 90% of the population had substance overuse and/or mental health disorders. The result was that the participants were failing that program. - Pediatric Director, Open Door Community Health Center Dr. Devon Wong, Pediatric Director at Open Door, will be leaving the practice in October. This combined with other pediatric losses recently will dramatically decrease the number of pediatric physicians in the area. The HealthPlan s Northern Regional Medical Director presented a brief overview on activities for the Northeastern (NE) counties. Access - Redding Rancheria opened their Weaverville clinic, holding their grand opening on Monday. - Mental Health Visits Data is showing an increase in mental health visits from last year in some of the Northern Counties. A goal of 6% of Plan members accessing these services was set, and some counties have met that goal. - HEDIS Results Though PHC staff spent considerable time pulling the data, it is the providers who are providing the care and improving the HEDIS scores in the area. Scores have improved in the Northeast and Northwest Regions. For information only, no formal action required. 08/09/17 II.A1. Update County Public Health Dr. Stacey shared that there was nothing to report at this time. N/A -- II.B. Quality/ Utilization Advisory, II.C. Pharmacy & Therapeutics, II.D. Provider Advisory, & II.E. Credentialing committees PHC s CMO acknowledged the new policy supporting the Palliative Care program, included under the Quality / Utilization Advisory Committee s (Q/UAC s) activities. The Care Coordination Program Description was pulled from consent, due to its change in structure and oversight, which now includes the HealthPlan s Board. MOTION: Dr. Gwiazdowski moved to approve Agenda Items [II.B., II.C., II.D., & II.E.] with the exception of the Program Description extraction, which was seconded by Dr. Stacey. ACTION SUMMARY: [12] yes, [0] no, [0] abstentions. Motion carried. 08/09/17 II.B. Excerpt / Care Coordination Program Description pulled for Review / Approval The Plan s Director of Care Coordination advised that the Care Coordination Program Description is being pulled from consent, noting that the document was entirely redrafted to reflect all the work being done in the department. New areas include the creation of a Maternal / Child unit. Changes to the document include those relative to NCQA Accreditation. MOTION: Dr. Gwiazdowski moved to approve Agenda Item II.B. Excerpt, as presented, seconded by Dr. Johnson. ACTION SUMMARY: [12] yes, [0] no, [0] abstentions. Motion carried. 08/09/17 10 of 130

11 Physician Advisory Committee Minutes 08/09/17 - Page 7 of 12 AGENDA ITEM IV.A. Palliative Care Quality Improvement Program (QIP) DISCUSSION / CONCLUSIONS The Plan s CMO opened the discussion, sharing that a couple of incentives were included in the palliative care pilot programs. One of which was for lack of emergency room (ER) use and hospital utilization, which aligned with how the program s cost is covered. The second incentive was related to a certain quality system for data gathering. The decision was to adapt the incentives for the Palliative Care Quality Improvement Program (QIP), and retain as part of the expanded benefit. Since it is a quality program, it was logical to mimic the infrastructure used for other incentive programs. The financial structure is the same as used with the pilot programs. RECOMMENDATIONS / ACTION DATE RESOLVED PHC s Manager of Quality Incentive Programs (QI Manager) and Senior Project Manager in Quality (Project Manager) were introduced. The Plan s Project Manager presented the measures, as highlighted by the CMO. 1) Avoiding Hospitalizations and ER visits The expectation is that the Palliative Care Team is the primary point of contact for patients enrolled in the Palliative Care Program (Program). It is anticipated that savings will be rolled back into the Program. Providers will receive $200 per month for every enrolled patient who is able to avoid ER use and inpatient hospitalizations during that month. This will be paid based on a 6-month lookback measurement period. 2) Completion of the Physician Orders for Life-Sustaining Treatment (POLST) form, and use of the Palliative Care Quality Network (PCQN) tool. Within the pilot, the use of the PCQN was tested. The tool was developed by the University of San Francisco (UCSF), which tracks patient engagement. The system allows for documentation of completing POLST forms. If both of these tasks are completed / used, another $200 per month will be received for the enrolled member, which also uses a 6-month lookback measurement period. The Plan s Regional Medical Director for Napa noted that the PCQN is a valuable tool. Pilot sites have determined that it takes less than 5 minutes per visit to record the data. The benefit is that the team can track and trend their patients (i.e. pain scores), and the HealthPlan can audit the data on-line, eliminating the need to pull medical charts at the provider s site. The tool also acts as a reminder for providers to address certain issues with their patients. Documentation in the PCQN is done by the palliative care provider, or a staff member of the team, and is a quick process. Once the patient is entered in the system, it does not need to be repeated. UCSF sponsors a conference twice a year, where information on the PCQN is shared. Partnership s CMO advised that the model is similar to the Diabetes Registry providers are familiar with, only for palliative care. Getting providers started at the beginning of the benefit will alleviate the issues that arise later on, when different systems are in use. Dr. Marshall recognized the advantage to the PCQN, but shared that provider systems need to be able to interact going forward. Otherwise, staff is having to document in two different locations. It was noted that UCSF is working on ways to extract the data from the chart. The issue is that many of the sites use different systems. It is agreed that double entry should be avoided as much as possible. 11 of 130

12 Physician Advisory Committee Minutes 08/09/17 - Page 8 of 12 AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION IV.A. Palliative Dr. Herman confirmed with staff that non-palliative care patients, who are completing POLST forms, do not Care Quality have to be logged into the PCQN system. Also, is the Program to a point that all clinics can submit patient Improvement recommendations? PHC s Regional Medical Director advised that, once a site is available in Solano County, Program (QIP), then patients can be recommended for the Program. Continued IV.B. Vaccination Refusal: Use of a Form Completed by Parents The Plan s CMO advised that the discussion topic was proposed by a provider. The American Academy of Pediatrics (AAP) has suggested that parents should sign-off when refusing vaccinations for their children, and should understand all the implications of that refusal. Those who do not want their children vaccinated often believe that the supporting documentation is improperly slanted toward the benefits of the immunization, and downplays the negative aspects. The question for the Committee is whether they are currently using the form and information in their organizations, or believe there are issues in doing so. Responses can be summarized in a future Medical Director Newsletter. MOTION: Dr. Johnson moved to approve Agenda Item IV.A., as presented, seconded by Dr. Gwiazdowski. ACTION SUMMARY: [12] yes, [0] no, [0] abstentions. Motion carried. DATE RESOLVED 08/09/17 Committee comments included: - Dr. Marshall advised that the information is already being used with patients at CommuniCare Health Centers. - The Committee s Chair noted that Kaiser Permanente had a similar form, which was used for a while. When the universal law went into effect, Kaiser took the position of assuming that the vaccinations need to be done. Looking at the form and logic behind the need for vaccinations, the forms may get providers farther with parents who refuse to have their children immunized. - Dr. Gwiazdowski shared that the form, and scope of vaccines used in the neonatal unit, are not as broad, but he supports the concept and believes the refusal form and documentation can impact the decision process of the parent. It is important for the parent(s) to understand that they place their children at risk for getting into school, due to the legislation that recently passed. That information should also be included with the consent form. - The Plan s NW Regional Medical Director advised that there is a segment of parents who simply do not believe the information or reasoning behind the need for vaccinations. They do believe that the information is more of a plot by pharmaceutical companies. How are providers dealing with families who refuse the vaccinations? The Committee Chair advised that there are patients who can be nudged to accept the need for vaccinations, knowing that staff will routinely contact them to get the appointment scheduled. However, staff also takes into consideration the hassle factor, for those who adamantly refuse to have their children vaccinated, though the need for immunizations are still addressed at appointments. - Dr. Matheson shared that his clinic has families who avoid all well visits, as they do not want to deal with the vaccination issue, which is a concerning trend. 12 of 130

13 Physician Advisory Committee Minutes 08/09/17 - Page 9 of 12 AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION IV.B. Vaccination Dr. Marshall advised that CommuniCare drafted a letter to parents addressing Dr. Marshall will forward a copy of Refusal: Use of a that issue and expressing the importance of well-child visits, even for those who the well-child importance letter to the Form Completed refuse vaccinations. The Plan s CMO asked that Dr. Marshall forward a copy Plan s CMO, for inclusion in his by Parents of the letter, which he will include in his summary of the discussion for the next discussion summary for the next Continued Medical Director Newsletter. Medical Director Newsletter. For discussion purposes only, no formal action required. TARGET DATE August 2017 DATE RESOLVED 08/09/17 IV.C. Drug Medi-Cal Waiver Program PHC s Behavioral Health Administrator (BH Administrator) shared that among the many things exciting about the program is the integrated care model, an enhanced version of what the State is rolling out. This will be a real opportunity for the Partnership and its partners (counties, clinics and providers) to work together to do something that may be unique within the state. For years, there has been a very limited Medi-Cal funded substance use benefit in the state. Most services were only available for perinatal patients, and not for the general population. In 2011, the State started releasing inmates early from prisons, and offering some subsidies to counties to offset costs for serving those individuals. This led to more funds being added to substance use services by the criminal justice system. In 2015, the Federal Government approved the State s Waiver to provide comprehensive substance use treatment to the entire Medi-Cal population, which was the impetus for the program PHC has been developing. Until the most recent Waiver, primary care was separated from the rest of the behavioral health system. Unfortunately, that appears to continue with the program being planned by the State. Under the Waiver, Drug Medi-Cal services include outpatient and residential care, detoxification (detox) patient services, along with recovery services. There is also an emphasis on Medication Assisted Treatment (MAT). All services are provided according to the clinical and medical necessity models developed by the American Society for Addiction Medicine (ASAM). This benefit was rolled out by the State, similarly to that of the seriously mentally ill. Whereas, counties were informed that if they wanted to provide the benefit, some county funds would need to be allocated in order to pull down the Federal matching funds. Thereafter, the county would be responsible for running the program. Four of PHC counties (Marin, Yolo, Napa, and Sonoma) have elected to establish their own models within their county. To date, Marin County is the only entity providing services. 13 of 130

14 Physician Advisory Committee Minutes 08/09/17 - Page 10 of 12 AGENDA ITEM IV.C. IV.C. Drug Medi-Cal Waiver Program Continued DISCUSSION / CONCLUSIONS There are eight counties (Humboldt, Lassen, Mendocino, Modoc, Shasta, Siskiyou, Solano, and Trinity) working with the HealthPlan on a more integrated Regional Model, which will be administered by PHC. The balance of the counties (Lake and Del Norte) are undecided at this point. But, it is unlikely that either would do the program on their own. The HealthPlan has submitted its implementation plan to the State, which stretches the State s term of integration (historically viewed as mental health and substance use). Partnership s model encompasses all, including primary care. Much of what PHC is proposing is not what the State is accustomed to. Discussions are ongoing between the State and Plan staff, who have a go-live target date of July Of note, the State is behind in its approval process statewide. PHC previously allocated $2 million in grant funds to help establish a network for this purpose. The dual diagnosis facility mentioned during the NW Regional Medical Director s report is one of the projects that received grant funds. A variety of workgroups have been set up to help address key protocol and planning issues for the HealthPlan, including a medical advisory group. The program will be part of the Plan s overall quality system. It is essential to PHC s model that the clinics are involved. The State has allocated funds for MAT to an assortment of providers (methadone and Suboxone), none of whom are currently part of the Plan s network. Fortunately, those providers would like to work with the HealthPlan and its contracted clinics, and discussions are ongoing. The State model requires methadone be available. The HealthPlan expects other grant opportunities for focusing on opiate overuse to become available. The final phase of the State s Waiver implementation will be with Native American clinics. PHC s Regional Model includes the Native American clinics, so that they do not have a delay in the services. Plan staff is aware of a number of clinics that have extensive experience in providing substance use services. The hope is that those services will be coordinated with the HealthPlan s Regional Model, in a way that is cohesive to both systems. The program is something the Plan is committed to, even if Senate Bill 323 is not enacted. Of note, the State s requirement is that Drug Medi-Cal providers must be Drug Medi-Cal Certified by the State. With the exception of CommuniCare, which somehow got grandfathered into the program, clinics cannot get Certified. Discussions with clinic associations are ongoing regarding the setting up of a workgroup that will focus on the clinic role, an area unclear at the state level. The State s model does not include clinics in a straightforward way. It is expected that SB 323 will be addressed in the next legislative session, and will specifically allow clinics to become Drug Medi-Cal Certified. Even if that does not pass, PHC s integrated model is structured to allow clinics an ability to provide some services. Providers can utilize Partnership s designated for updates, which are also included in the Plan s Provider Newsletters. Those needing additional information can contact PHC s BH Administrator. Dr. Gwiazdowski noted that some clinics in the past may not have had their financial incentives aligned with the ultimate goal of getting patients off medications, and may have been reticent in their data transparency. In the new program, are those two important factors being addressed? PHC s BH Administrator expects both to be dealt with. As of now, the State is contracted with clinics to provide Suboxone and, in some cases, methadone, and the clinics are not going through Partnership for their billing. When the Drug Medi-Cal model is up and running, those clinics will have to contract with PHC. This is a high priority, which has previously been discussed and will be part of the Plan s negotiations with the State. PHC s CEO advised that the HealthPlan will add another layer of oversight, more intensive than the State s. Additionally, along with other Chief Financial Officers of local health plans, PHC is petitioning the State for a partnership to start taking risk for the carved out medications (i.e. Suboxone). The HealthPlan can administer that part of the benefit as well, giving the Plan even more leverage. 14 of 130

15 Physician Advisory Committee Minutes 08/09/17 - Page 11 of 12 AGENDA DISCUSSION / CONCLUSIONS ITEM IV.C. IV.C. PHC s BH Administrator advised that part of the work being done on the model includes the development of an Drug Medi-Cal evaluation on the savings to the physical health side, due to having a comprehensive set of substance use services. Waiver Plan staff is working with the counties to develop before and after evaluation models, to ascertain the impact on Program the health system. It is expected that there will be savings under the criminal justice portion. The State will be Continued requiring documentation showing the link between physical health care and substance use services in all of the participating counties. Partnership hopes to establish methods of communications to support integrated care, which will also apply to the seriously mentally ill side. Dr. Hunter shared that Open Door Community Health Center has a robust MAT program, serving around 500 patients. It is unclear how the new dual diagnosis facility will impact their program or staffing, or its potential to destabilize services underway. Open Door staff has concerns in this regard. The Plan s BH Administrator advised that it is her understanding that the facility would like to meet with Dr. Hunter directly. If there are any informal commitments from them that should be reinforced by PHC, please contact the Plan. RECOMMENDATIONS / ACTION DATE RESOLVED IV.D. Additional Business - Meeting Evaluation - Start Time of Meetings Partnership s CMO advised that there have been internal discussions regarding the structure of this Committee meeting, which has not deviated much over the years. In general, do the Committee members have ideas or comments on the running of the meeting? Additional comments or suggestions can be directed to the Plan s CMO via . Areas mentioned by the Committee members included: - Dr. Johnson noted that the meeting is always evolving, so nothing specific to recommend. - Considering the volume of pages packets can include, Dr. Gwiazdowski recognized the benefit of having a synopsis of changes or highpoints to the material being presented, allowing members to focus on areas with more importance. This may help focus the Committee reviewers. On a separate note, the Plan can take pride in the staff who coordinate meeting packets for the committees, due to the level of proficiency exhibited. - Dr. Martinez recognized the difficulty in following the location of the packet content being discussed, when participating over the telephone. There are also other modalities that allow simultaneous viewing of material on a conference call (i.e. WebEx). - The Committee discussed the Consent Calendar, as it applies to the Physician Advisory Committee (PAC). Unlike the subcommittees that review much of the material at length and in detail, and present their recommendations to the PAC, this Committee does not typically review the material at that level of detail. The Committee s Chair noted that, if there are issues expected to require additional review, or that become apparent during the meeting, those should be pulled for discussion. PHC s CMO reported that Plan management discussed ways to improve efficiency with the timing of meetings, allowing participants a cushion of time between back-to-back meetings. Partnership s meeting standard has been updated so that all meetings start on time, and finish 5 minutes before the hour / half hour. This will be addressed at other meetings as well. It is hoped that the Chair will give a 5 minute warning before the meeting is to wind up. For discussion purposes only, no formal action required. 08/09/17 Adjournment The Committee adjourned at 8:53 AM Respectfully submitted: Linda Largent Page 12 of 12 for Signature Only 15 of 130

16 PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES Committee: Quality and Utilization Advisory Committee [QUAC] Meeting Date/Time: Wednesday, August 16, :30AM - 9:00AM Napa/Solano Room, 1 st Floor Members Present: Members Absent: PHC Members Present: PHC Members Absent: Choudhry, Sara, M.D. Gwiazdowski, Steven, M.D., FAAP Manalo, Rod, M.D. Murphy, John, M.D. Namihas, Steven, M.D. Pirruccello, Michael, M.D. Borde, Madhusudan, M.D. Montenegro, Brian, M.D. Barresi, Katherine, RN, Associate Director of Care Coordination Endsley, Scott, MD, Associate Medical Director, Quality French, Rachael, Senior Manager, Quality Compliance and Accreditation Guillory, Ledra, Senior Provider Relations Representative Manager Glickstein, Mark, MD, Associate Medical Director Hoover, Peggy, RN, Health Services Senior Director Krohn, Robin, Care Coordination Team Manager Kubota, Marshall, MD, Regional Medical Director Liu, Jess, Manager of Quality Incentive Programs McAllister, Debra, RN, Utilization Management Director Boyd Anderson, Rebecca, Care Coordination Director Brandeburg, Heather, Provider Relations Associate Director Chancellor, Jennifer, Regional Manager Fronefield, Carly, Northern Region Health Services Director Garcia-Hernandez, Margarita, Manager Health Analytics Jenkins, Shauncey, Member Services Supervisor Kerlin, Mary, Provider Relations Senior Director Kisliuk, Margaret, MPP, JD, Northern Region Executive Director Leung, Stan, Pharmacy Services Director Quon, Robert, M.D. Thomas, Randolph, M.D. Threlfall, Alexander, M.D. Paukert, Thomas, M.D. Strain, Michael, PHC Consumer Member Moore, Robert, MD, MPH, MBA Chief Medical Officer Chairman Netherda, Mark, MD, Regional Medical Director Siblisky, Susanna, Northern Region Health Educator Spiller, Bettina, M.D. Northern Region Associate Medical Director Stamps, Sara, Quality Improvement Project Coordinator Steffen, Nancy, Northern Region Associate Director Quality, Analytics and Project Management Stevenson, Lauri, Northern Region Manager of Quality and Patient Safety Summers, Ro, Quality Improvement Project Manager West, Wendi, Northern Region Executive Director of Claims Wilson, Megan, HEDIS Program Manager Ribordy, Jeff, Northern Region Medical Director Russell, Joan, Provider Education Senior Manager Santos, Rosemenia, Manager of Quality Assurance/Patient Safety Scuri, Lynn, Administration Regional Director Sewell, Kelley, Northern Region Director of Member Services & Provider Relations Stephen, Karen, PhD, Health Services Mental Health Director Thacher, Jessica, MPH, Director Quality, Performance Improvement Vovakes, Michael, MD, Northern Region Medical Director AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION I. Call to Order Dr. Robert Moore called the meeting to order at 7:35 a.m. Motion: Dr. Steven Approval of Minutes from the 6/13/2017 IQI meeting were reviewed and accepted. Gwiazdowski Minutes Minutes from the 6/21/2017 QUAC meeting were reviewed. Second: Dr. Robert Quon I. Standing Agenda Items TARGET DATE DATE RESOLVED 8/16/17 1. Status of Open Action Items There were no action items discussed. 8/16/17 16 of 130

17 2. QI Update Jess Liu, Manager of Quality Incentive Programs gave the update. Quality Improvement Programs (QIP s) - o The PCP QIP is wrapping up the year. There is a new validation period this year for both the clinical data as well as the manually submitted data. In September preliminary reports will be sent out that will summarize the manually submitted data. o The perinatal QIP pilot has started, we are partnering with Mercy Maternity in Redding and Northbay in Fairfield to pilot the program. This program will run through December 31, 2017 and will help inform PHC s decision to launch a plan-wide program in o Hosted our first Hospital Quality Symposium last week, turnout was great with over 40 external attendees at both the Redding, CA and American Canyon, CA events. We had great speakers on the panel and received a lot of feedback around potential future topics. Quality Improvement Training s o This internal program; QI-EX, will run August through December. Participants will include QI and Pharmacy staff (21 trainees). Goals of the training include learning performance improvement methods and applying skills to specific HEDIS improvement projects; developing crossfunctional/multi-disciplinary teams to help break down silos; building capacity/supporting personal growth and development. The training will focus on four HEDIS measures: Asthma Medication Ratio; Childhood Immunization Status - Combo 3; Immunizations for Adolescents - Combination 2; Annual Monitoring for Patients on Persistent Medications. HEDIS Score Improvement - The recent and final submission of state-mandated PDSAs (cycle 2) demonstrated success in HEDIS improvement in Prenatal and Post-partum care in the Northern Region. For further information, please reference pages 22 and 23 in the packet. 8/16/17 3. Healthplan Update On today s agenda we will be presenting HEDIS 2017 Final Performance. Patient Safety o A Palliative Care - Site Review tool was developed and will be piloted with three contracted providers. o The Patient Safety team has completed the final User Acceptance Testing for the esite Review tool in June. Enhancements for the next release of the tool will open a new development cycle on 10/1/17. NCQA Accreditation o The team has finalized a global project plan which captures all NCQA requirements at the Element and Factor level for Interim, First and Renewal survey. In addition, the NCQA team identified key stakeholders, business owners, target start/end dates, and current progress. Robert Moore, MD gave the HealthPlan update Governor s budget This budget has come out, the changes impacting the Health Services side are: o Planning to reinstate dental in of 130 8/16/17

18 o Vision services in PHC is currently funding Vision Services with no reimbursement. This will support PHC, as this money comes out of our Strategic Use of Reserves. o Diabetes Prevention Program, is the new main benefit, targeted to launch in July, DHCS is gearing up to talk further about the program. Zero guidance, other than what is in the bill has been provided. Information within the bill did include the CDC certification requirements and process. More to come. Approved two Medically Tailored Meals pilots This is approved across many counties. In our regions, they are both in Sonoma County. These pilots will start in January As of now, it looks as though this pilot will be going directly through the state, not through PHC. In terms of benefits: o o Palliative Care Expansion - Was planned for July 1 st, this program is moving along nicely, PHC has had some sites jump on board and have started to provide services such as; Lake County. Other sites have signed on and are gearing up and some planning to sign up in the future. The sites that have expressed interest are moving along in the contracting process, slower than we expected. There are still some uncovered counties; Marin, Sonoma Counties. In the North, they are gearing up to provide services, especially in the more rural counties. Medication Synchronization - This is a process where a pharmacy fills all medications at the same time. This pilot program has already expanded in our North Eastern regions, at Owens pharmacy, which have a number of sites participating. This pilot/program has so far been successful, it is estimated that 2000 patients are on it, PHC is estimating about 1000 of those patients are PHC patients. This program takes much effort to do, but in the end patients can pick up their prescriptions on time and are more compliant, and we could see our quality scores get a little better. We are looking at extending it over to Cloneys in the Northwest. Any pharmacy that is interested is welcome to participate as well. PM160 Form DHCS has informed Managed Care Plans (MCP s) that every CHDP provider that is serving any managed care plan had to continue to submit a PM160 for the foreseeable future. Data to be inclusive in a ten-page report that DHCS sends to CMS once a year. They are able to get the data from the fee for service side of claims. We are pushing to move along and do the same thing on the managed care side, pretty vigorously. Fortunately, some of the commercial plans are moving slowly because they get some quality data from those PM 160 s. PHC feels, data collected through the PM160 can be captured through other sources versus the extensive documentation on a PM160, to support capturing minimal data elements that support key quality metrics, which again can be captured through other sources. Changes to the Final Rule - CMS issued a number of changes to Medi-Cal managed care, changes included: o Pharmacy was impacted; we had to institute our reviews to be complete within 24 hours. 18 of 130

19 o There is conflicting advice, the feds are saying no more pending pharmacy prescriptions, and the state is not interpreting it the same way. We are currently airing on the side of the feds and trying to figure out if we can approve or deny it within 24 hours and not pend it for 7 days. III. Old Business There was no old business discussed. 8/16/17 IV. New Business (Committee Members as Applicable) Consent Calendar Utilization Management / Care Coordination MCUG3019 Hearing Aid Guidelines MCUP3012 Discharge Planning (Non-Capitated Members) MCUP3014 Emergency Services (Attachments in policy) Member Services MCUP3133 Wheelchair Mobility, Seating and Positional Components MCUP Continuity of Care MCUP3101 Screening and Treatment for Substance Use Disorders MCUP Appeals / Expedited Appeals of UM Decisions for Medical Necessity Determination (Non-Administrative) Provider Relations MP PR-PL-CR 201 Credentials Committee Review Member Services MP Notification of Provider Termination or Change in Location MP 350 Weight Management Program Quality MPQG1011 Non-Physician Medical Practitioners & Medical Assistants Practice Guidelines 1. MCCP2005 Peggy Hoover presented on policy MCCP EPSDT Supplemental Shift Nursing Services Clarification language was added around beneficiaries who reside in certain counties that have been referred to California Children s Services (CCS). The verbiage was updated to replace the word patient with member. Clarification was made to state that Partnership does not reimburse families for care of their children; it needs to be a licensed provider and the RN needs to coordinate the plan of care with a prescribing physician. Motion: Dr. Steven Gwiazdowski Second: Dr. Robert Quon Approved without changes Motion: Dr. Michael Pirruccello Second: Dr. Steven Gwiazdowski Approved without changes 8/16/17 8/16/17 19 of 130

20 2. MCCP2016 Peggy Hoover presented on policy MCCP2016 Transportation Guidelines for Non-Medical (NMT) and Non-Emergency Medical Transportation (NEMT) DHCS has made changes to state that Partnership and other managed care plans are now required to provide transportation to all medical appointments, including picking up prescriptions. This has expanded the benefit dramatically; beginning October 1, PHC will be required to transport members for benefits that are state of California benefits, not PHC benefits, we will provide transportation for appointments such as dental care, mental health benefits, etc PHC does not pay the claims so this added benefit will be a difficult transition. For example, PHC cannot call mental health and ask if the member has an appointment, due to it being a violation of member s rights, this information cannot be released. For the most part, this policy has been accepted by the state. Committee Discussion: The committee discussed the cost of this new benefit and the financial impact this could have on PHC. Dr. Moore stated that PHC is tracking all the expenses and will ensure transparency to DHCS on the costs associated with the recent change. A large concern of PHC s is, the state is requiring PHC to provide 24/7 coverage for this transportation. The cost for this will be astronomical. In the first month, we provided almost 2000 rides at a cost of over an estimated $100,000. Our vendor; MTM, is providing rides as well as contracting some of the rides through Lyft. Mileage reimbursement is also included in this service that is being provided through MTM. 3. MCCP2022 Rebecca Boyd-Anderson presented on policy MCCP Early Periodic Screening, Diagnosis and Treatment (EPSDT) Services Updated to reflect the contractual language of the APL. 4. MCCP2023 Rebecca Boyd-Anderson presented on policy MCCP New Member Needs Assessment This is a new policy. There is new legislation that requires that PHC assess all new members to the HealthPlan. The state has designed a 10-question form for to be used. This policy has been sent to DHCS, along with our assessment tool. In addition; we also had to describe what we are going to do with the assessment when it comes back. The assessment tool and the policy have been approved by DHCS; PHC is in the process of implementing it. 5. MCUP3131 Robert Moore presented on policy MCUP Genetic Testing The changes made are reflected in attachment A. Codes were added for aneuploidy DNA testing. This test checks the mother s blood for aneuploidy. It is medically indicated in women over the age of 35 as an alternative screening to the older screening techniques, it is also for women that carry a high-risk pregnancy. It has been elected to make it an approved test without needing a TAR. This test has been approved by DHCS. The Fecal Leukocyte Antigen testing that is done to look for transplant compatibility; this test no longer requires a TAR. The state keeps adding in new codes, for instance 81403, which is called the Survival of Motor Neuron One Sequence, which the state added as a once in a lifetime test/code. Code Fetal Aneuploidy and were the two codes that are payable every 9 months; 20 of 130 Motion: Dr. Michael Pirruccello Second: Dr. Robert Quon Approved without changes Motion: Dr. Robert Quon Second: Dr. Michael Pirruccello Approved without changes Motion: Dr. Steven Gwiazdowski Second: Dr. Michael Pirruccello Approved without changes Motion: Dr. Steven Gwiazdowski Second: Dr. Michael Pirruccello Approved without changes 8/16/17 8/16/17 8/16/17 8/16/17

21 6. MCUP3041-A MCUP3049-A MCUG3007-B once per pregnancy with no TAR required unless it is done twice in one pregnancy. If a patient has two close pregnancies, the referral would be sent to PHC which would originally be denied then sent for review which would then be approved once identified as a different pregnancy. Code Testing for Telomerase Reverse Transcriptase(TRT test) is now requiring a TAR. Peggy Hoover presented on attachment A of policy MCUP3041-A, MCUP304-A and MCUG-B. Additional tests that are needed are now added in this policy, in addition, the state has initiated a benefit for Cardiac MRI s which a TAR is now being required. 7. MP 316 Mary Enos presented on policy MP 316 Provider Request to Discharge Several updates were made to policy MP316. For some of our members that the provider is trying to discharge, PHC is having a difficult time locating a PCP due to their behavior, when this happens, we will assign them a medical home that will print on their ID card. A medical home is where the member will receive all their primary care. The provider is paid fee for service. Referrals to specialist are not required. In accordance, with DHCS the policy was updated to include a formal definition of a medical home. This will prevent the member from sitting in a special or other member status category. Within the policy we removed notices that PHC was no longer using, which were included as attachments. General changes were made under the purpose section of the policy. Additional information was included in regards to, request for assistance. This request comes in incomplete and we are unable to get the additional information we need to finish processing the report within a matter of time from the provider, the policy now addresses that we will deny as an incomplete request. Under the section relative to discharge criteria, Care Coordination department was added. Added the language credible threat of a member(s) intent to initiate or pursue legal action is now acceptable. This eliminates the need to have a legal letter to discharge. Changes were made around the process where members refuse to follow recommended medical treatment. Added language to state, if a patient has been discharged from a practice prior to their enrollment in Partnership HealthPlan, we can assess the date in which the member was disenrolled. If the information is received day 61 or thereabouts, it gives us a little flexibility. Section D, 3, language was added surrounding incomplete discharge requests. PHC Member Services we will reach out to provider relations department to request the information needed from the provider. If we receive it within 5 business days, we will process the 21 of 130 Motion: Dr. Robert Quon Second: Dr. Steven Gwiazdowski Approved without changes Motion: Dr. Pirruccello Second: Dr. Gwiazdowski Approved with changes 8/16/17 8/16/17

22 VI. Presentations Grievance Report disenrollment. If the paperwork is not received, we will close out that disenrollment and the provider will be notified. In the notification, it will state what documentation is needed for disenrollment of a member. Section F, the title has been changed to Approved Request ; this section is addressing the requests that were approved. Some of the wording was removed for the type B definition; it is on page one of the policy under definitions. Section J, revisions were made to allow for different alternatives for the providers to provide documentation to the members with no-show appointments. Originally it was one verbal and one written warning, what we were finding is, the providers were sending letters and not having a verbal connection. In order to help the providers, we added that they can either verbally educate the member and send a letter or just send two written notices. The notices must explain that if the member continues the behavior that they are going to be dis-enrolled or discharged from the site. Committee Discussion: If a patient has been abusive and/or threatening, is there a special process if the patient manages to cross the line where they are unable to continue under a special member status? Can the member go to a different practice? At what point does it go into the legal system? Dr. Moore clarified; a restraining order can be obtained but is on the legal side and has nothing to do with PHC. PHC would work hard to communicate with the new practice to give them information to bring the patient on in a way they are more likely to be successful. For instance, in some rare cases, we have had patients that have uncontrolled psychiatric disease not sufficient to be institutionalized but not able to be seen in a primary care practice, the coaching then is, you re welcome to come see us, however certain conditions will be set forth. When a parent causes dismissal to a pediatric patient, there are often other children associated with the parent, what is done in those cases? Dr. Moore responded; Care Coordination will coach and work with the parents; sometimes, one parent is ban from bringing the child but the other parent is allowed to remain attending appointments with that child. Changes: Section VI f & g re-letter each section to align properly. Section VI, C, 2, e. change to say credible threat OR legal action Eric Becerra presented on the 2 nd quarter (April 2017-June 2017) Grievance Report: Please see page 243 of the packet for more detail There were a total of 414 grievances in total. In reference to complaints, 245 complaints were filed. The top 3 reasons for complaints to be filed were: Denial of medication Quality of care or services Discrimination. Appeals: 122 were filed in total Top 3 denials were: 22 of 130 8/16/17

23 Denial of Medication RAF to Stanford Power Wheelchairs HEDIS Final Results 47 state hearings were held; 36 of the 47 hearings were withdrawn. At this time 5 are pending a hearing date or decision, 3 were postponed, a couple had a non-appearance to the hearing, and 1 was upheld. Inter Rater-reliability (IRR) Clinical vs. Non-clinical cases; There were 9 out of 10 randomly selected cases which were characterized correctly. The one was characterized as a clinical issue instead of a nonclinical. That put us at 90% accuracy rate, which does meet the threshold. Non-PQI cases were 10/10, achieving 100% for the quarter. The Inter-rater reliability is new to grievances and is something that is being piloted to better enhance our oversight of the grievance process and also having medical reviewers looking at what the nurses are characterizing as clinical vs. non-clinical. Megan Wilson, Sarah Molteni-Casper, Caron Lee presented on the HEDIS 2017 Performance, starting on page 348 of the packet. Megan provided an overview of HEDIS, our plan-wide and regional composite score relative to goal and walked the committee through a comprehensive summary of our 2017 Regional and County Level performance. Major highlights included: 1. Plan-wide composite score increased from a baseline of 42% to 48%. Three out of four reporting regions noted significant improvement. 2. The number of measures below the minimum performance level (MPL) reduced from 16 to 9 relative to last year. 3. Megan directed the committee s attention to the comprehensive summary of performance starting on page , walking through the structure for Regional, County level and trended performance. In addition, Megan highlighted some key successes/challenges: 1. Processed over 12,500 medical records within 11 weeks 2. Passed the first sample of our medical record; which audits the accuracy of data collected through the medical record abstraction process. 3. Abstraction vendor performed with a 98.9% accuracy rate, which exceeded contractual requirements by 0.9%. Key focus areas were noted: 8/16/17 Breast Cancer Screening and Asthma Medication Ration performed below the MPL. DHCS will be holding MCP s accountable for these measures in year two of reporting; HEDIS Megan turned the presentation over to Nancy Steffen, Associate Director of Quality, Analytics and PMO, to provide a high-level overview of PHC s 5 year strategic planning to improve HEDIS scores. 23 of 130

24 Nancy Steffen shared the following: A 5 Year HEDIS Strategic plan was developed last year, (2016), the HEDIS score improvement team involves multiple departments, the regional offices and how we as an organization can improve our overall performance. Goals (set by Executive Team): Raise all HEDIS measures* to: 1) The minimum performance level (25th percentile) across all four regions by July ) Above the 50th percentile across all four regions by July ) Above the 75th percentile across all four regions by July * Includes only the measures for which DHCS holds PHC accountable to a minimum level of performance. Focus Areas: 1) Primary care population health management 2) PHC population health management and direct member engagement 3) Data and analytics infrastructure Although the work is led by Quality and Performance Improvement, HEDIS is a highly collaborative process across the entire organization Committee Conversation: Which vaccines are included in the CIS combo 3 set? D-Tap, IPB (Polio), HIB, Hep B, MMR, PCV, and VZV As we move towards NCQA accreditation, we will be moving towards a larger set of vaccines under the Combo-10 measure. How will Partnership prioritize the 5 year strategic plan with all its measures and trying to get them all above the 75 th percentile? Prioritization first comes from DHCS state mandated work, measures performing below the MPL, DHCS asks that we target, prioritize and follow a specific methodology for conducting performance improvement work. The second prioritization is also state mandated which is the 12-18month long performance and improvement projects (PIPs), those topics are usually topics focused on low performing measures. Do you know what the percentage of electronic medical records come through vs. hand written medical records? The electronic medical records equate to 80-85%. An estimation of 17% of Kaiser Southeast, Southwest pare providing the electronic medical records. Breast Cancer Staff Incentive We have been thinking a lot about how to take the best practices that we are learning and managing them is something we are deep diving into, we are getting to the point where we have a lot of improvement initiatives, many of them are successful, how do we package them and bring them to practices without over whelming them. Ro Summers presented on the Breast Cancer Staff Incentive program: 8/16/17 24 of 130

25 One of the strategies surrounding the staff incentive program is engaging directly with the staff that are in our clinics that can be directly responsible for ensuring the data gets to PHC for the care that is being delivered. Managing Patients on Persistent Medications (MPM) is a measure that has patients screened for certain blood pressure medications for side effects related to kidney function and heart arrhythmias. The staff incentives were not clearly defined as to how they had to be used, however, it was required that sites let the program know how the staff incentive would be benefiting their staff directly. The program operated through communication with providers through an education webinar, data sharing on a monthly basis where gap lists were showed for those who still needed that service. We did have some 1:1 Site visits for those providers that were interested as well. 86 provider sites participated in our program 46 of the 86 sites received an incentive from either meeting the target or showing enough relative improvement from the prior year s data. Fostered 600 compliant labs Total payout was just over $75,000, this was a anywhere from $500-$6000 for individual providers Sites that were enrolled in our staff improvement program did show more improvement than sites that were not enrolled in the program except for the Northwest region where there was great improvement overall. Breast Cancer Screening Measure These screenings are recommended for women from ages 52-74, knowing that mammography is closely related to lowering morbidity and mortality related to breast cancer. These screenings can be more out of the PCP s control so this will probably be a bit more of a challenge. We are trying to target the data gap for the future to know how much more care is needed. We are preparing to send this out in our newsletter as well as hosting a few webinars in the next coming weeks. A communication opt-out form being offered to clinic leadership. This opt-out form includes a couple different options; A. The QIP team will reach out to our usual contacts at each provider site to describe the Staff Incentive Program. No action is needed to utilize this option. B. B. Site commits to participating in Breast Cancer QI sprint, but asks that communication go through the CEO/Executive Director/Practice owner, who will submit the proposal and ensure its implementation. C. Site declines to participate in the special incentive program. Committee Conversation: How many practices do not want direct contact their staff? It was very minimal and was not so much the program itself but that our communication goes to a lot of people. For any given clinic there could be 10 staff members that receive all of our communication so it wasn t that they did not want them to see it, it was that the CEO or CMO level wanted to see the communication first. A couple were just opposed to giving incentives to their staff directly. VII. Additional Business 25 of 130 Page 11 for Signture Only

26 Members Present: Barresi, Katherine, RN, Associate Director of Care Coordination Boyd-Anderson, Rebecca, Director of Care Coordination Cotter, James, MD, Associate Medical Director Cuellar, Dina, Director Regulatory Affairs French, Rachael, Senior Manager Quality Compliance and Accreditation Fronefield, Carly, Northern Region Health Services Director Guillory, Ledra, Senior Director Provider Relations Hoover, Peggy, RN, Senior Director, Health Services Kerlin, Mary, Senior Director of Provider Relations Krohn, Robin, Care Coordination Team Manager Kubota, Marshall, MD, Regional Medical Director Leung, Stan, Pharmacy Services Director Guests: Carter, Danielle, Quality Improvement Project Manager Cabrera, Maria, Member Services Lead Representative Garcia, Rebecca, Provider Relations Representative Members Absent: Bjork, Sonja, JD, Chief Operating Officer Campbell, Betsy, MPH, Senior Health Educator Chancellor, Jennifer, Regional Manager Frederickson, Paula, Senior Claims Director Garcia-Hernandez, Margarita, Manager of Health Analytics Gibboney, Elizabeth, MA, Chief Executive Officer PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES Committee: Internal Quality Improvement [IQI] Meeting Date/Time: Tuesday, June 13, :30PM - 2:30PM Board Room, 3 rd Floor McAllister, Debra, RN, Director of Utilization Management Turnipseed, Amy, Senior Director of External and Regulatory Affairs AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE I. Call to Order Dr. Moore called the meeting to order at 1:35 p.m. Motion: Dr. Cotter Approval of Minutes Minutes from the 5/9/2017 IQI meeting were reviewed. Second: Peggy Hoover II. Standing Agenda Items Moore, Robert, MD, Chief Medical Officer Russell, Joan, Senior Manager of Provider Education Santos, Rose, Manager, Quality and Patient Safety Scuri, Lynn, Regional Director Stamps, Sara, QI Project Coordinator Stevenson, Lauri, Manager of Clinical Quality and Patient Safety Thacher, Jessica, MPH, Director, QI/PI Villanueva, Angelica, Quality Manager, Health Services Vovakes, Michael, MD, Northern Region Medical Director Netherda, Mark, MD, Regional Medical Director Ribordy, Jeff, MD, Regional Medical Director Rosel, Melissa, Team Manager, Utilization Management Siblisky, Susanna, Northern Region Health Educator Smith, Lyle, Director of Operations Excellence and PMO Steffen, Nancy, Northern Region Associate Director of QI, Analytics, PMO DATE RESOLVED 6/13/ Status of Open Action Items 2. QI Department Update There were no action items discussed. 6/13/2017 Jessica Thacher gave the Quality Improvement program update. QI Trainings An ABC s of Quality event was hosted in Yreka in May, there will be a second session in Ukiah on July 25 th. Advance Cohort 3 met Thursday, June 8 th and Friday, June 9 th. Advance is a training for the provider network to help build QI skills. This was a two-day 26 of 130 6/13/2017

27 session, one training was on leading effective meetings the other training was on testing change ideas and Plan, Do, Study, Act (PDSA s). It was a well-attended and well-reviewed training for the provider network. Hospital Quality Symposium planned for August 8 th in American Canyon and August 10 th in Redding. We are marketing this heavily to our Hospital QIP participants. Part of the focus of the hospital QIP team over the next year is more engagement with hospitals as well as building relationships with them, this is one way we will be working on that, we will also be providing training and sharing opportunities. Quality Improvement Programs Under the umbrella of our Quality Improvement Programs there is a lot of work underway, especially with the primary care QIP. There are some strategic changes to the program that we want to make fairly quickly to try to help improve our HEDIS scores. Changes to the payment methodology, changes to the relative improvement criteria, changes based on the ruling of San Mateo HealthPlan and subsequent guidance that we receive from DHCS around the types of measures that Federally Qualified Health Centers (FQHC) can exclude from their PPS Payment. Changes will come through in August and September. HEDIS Score Improvement The draft of our HEDIS Score Improvement Strategic Plan has been completed. It has been sent out to people who were on the HEDIS improvement goal team, as well as people who have attended various feedback sessions. If anyone from PHC did not receive a copy of the draft and would like to look at it, they are welcome to let Jessica Thacher or Nancy Steffen know and they will send a copy over. The final input is due back by Friday, June 16, HEDIS results Results are looking good, improvement from last year. Measures under the MPL are; Please note, first year reporting measures are BCS and AMR which DHCS does not hold MCP s accountable for year one performance. Measure SE SW NE NW Asthma Medication Ratio X X (AMR)* Annual Monitoring for Patients X X X on Persistent Medications (MPM) - ACE/ARB Annual Monitoring for Patients X X on Persistent Medications (MPM) - Diuretics Breast Cancer Screening X X X (BCS)* Comprehensive Diabetes Care X X (CDC) - Nephropathy Childhood Immunizations X X Status (CIS)- Combo 3 27 of 130

28 III. Presentations Managing Pain Safely (MPS) Managing Patients on Persistent Medications (MPM) There are also some new measures that we are first year reporting on this year that we have our eye on; Breast Cancer Screening, based on the initial rates, we are under the MPL in 3 of the 4 regions. Next year is the year that counts so we may be doing a push to increase those rates as well as the Asthma Medication Ratio. We have a team that is already getting into Asthma Medication Ration; however, we are under the MPL in the Northern region for Asthma medications. More to come, we will be bringing a full report to committee at a later date. Danielle Carter presented on Managing Pain Safely. This is an overview of what has been happening over the last year. This project is now in the closeout stage of the project. This project started in 2014, in which time; Partnership HealthPlan knew that the state of California was in a state of crisis with the opioid epidemic. The ultimate goal was By December 31, 2016, decrease the total number of initial prescriptions by 75% for opioids. Be December 31, 2016, decrease the total number of inappropriate prescription escalation by 90% Decrease the total number of patients on inappropriate high dose opioids by 75% The overall project data update shows Members on opioids on unsafe dose reached its goal and surpassed it by 4%. The target goal was a 75% decrease, the project ended with a 79% decrease. The average MED s prescribed by county showed that there has been a drastic decrease in each county. There will be a continued coalition support. Support to US Davis will continue. The hospitalization feedback pilot support will continue. Also, continued support for the substance use treatment with the roll out of drug Medi-cal. These are the next steps in the opioid work that we have not yet had a chance to fully address for MPS. Danielle Carter presented on Managing Patients on Persistent Medications. This was a staff incentive program that really focused on targeting the HEDIS measure that is below the MPL; Annual Monitoring for Patients on Persistent Medications (MPM); ACE/ARBs and Diuretics. Program Description The MPM measure is divided into two sub-measures. ACE s ARB s is one, Diuretics is the second. Historically we have been below the MPL. This was designed as a staff incentive program to motivate clinic staff to recruit members to complete needed labs by December 31, The thought was, if we engage staff, will that help change the way clinics engage in the program. Strategic Use Reserve (SUR) funds approved were used to support this pilot. We have three different tiers of incentives; A full incentive for acheiving above the 90 th percentile for ACE s ARB s and Diuretic. A partial incentive for acheiving 30 % relative improvement based on 2016 HEDIS rates. Engagement incentive was for those sites that sent 40% of their non-compliant labs. This was added because we have quite a few really large sites with a lot of 28 of 130 6/13/2017 6/13/2017

29 IV. Old Business labs but did not qualify for the other incentives. Who participated 86 sites voluntarily enrolled. That equated to 49% of the total MPM eligibile population. The Northwest had the highest participation rate. The Northwest had 70% of their sites enroll that were in the MPM denominator, 38.57% of those sites received an incentive. Outcome 31% received full incentive (27 provider sites) 11% received partial incentive (10 provider sites) 10% received engagement incentive (9 provider sites) A total of $75,000 dollars 2017 HEDIS Performance scores on MPM PHC remains below the MPL for ACE s and ARB s in 3 of the 4 regions but the MPL threshold did increase from last year. If it did not increase, based on last year s target we would have been above the MPL. Performance scores did improve in 3 of the 4 regions and were higher than any prior year. PHC remains below the MPL for Diuretics sub-measure in 2 of the 4 regions. Performance scores remained consistent or improved with significant improvement. If the MPL threshold had not increased, we would have met our goal. Some Challenges in the program were Short turn around, the program started in October and ended in December Timing- it was done in the holiday season We struggled engaging large provider sites Successes Improvement was seen across the regions and clinics We are still hearing about the program to this day, one clinic even stated they will use some of the same practices on different projects. Adapt, Adopt, or Abandon the incentive program pilot? We have chosen to ADAPT this program. We want to pilot this program again with another measure, potentially Breast Cancer Screening. We want to think through and take more time to develop what that would look like and get provider input from the start. There was no old business discussed. V. New Business (Committee Members as Applicable) Consent Calendar Delegation Reports Utilization Management / Care Coordination MCUG3008 Bathroom Equipment Guidelines MCUG3011 Criteria for Home Health Services MCUP3003 Rehabilitation Guidelines for Acute Skilled Nursing Inpatient Services (previously: Acute Inpatient or Long Term Care Rehabilitation Institution Services) Provider Relations MP CR 4B Identification of HIV/AIDS Specialists MP CR 6 Non-Physician Medical Practitioner Credentialing Criteria MP CR 8 Non-Physician Medical Practitioner Re-credentialing Criteria MP CR 9 Fair Hearing Process for Adverse Decisions 29 of 130 Motion: Peggy Hoover Second: Dr. Cotter Approved without changes 6/13/2017

30 MP CR 11 Delegation of Credentialing and RE-credentialing Activities MP CR 17 Standards for Contracted Primary Care Providers MP PR 200 PHC Provider Contracts MP PR 201 PCP Availability and Capacity Policy and Procedure MP PR 201A Network Availability Standards Policy and Procedure MP PR 202 Monitoring of PHC Specialist Physician Network Availability Policy and Procedure MP PR 202A Network Availability Standards Policy and Procedure MP PR 203 Provider Enrollment Status Guidelines MP PR 205 Monitoring of PCP Accessibility of Services Policy and Procedure MP PR 207 PHC Annual Physician Satisfaction Survey MP PR-GR 210 Provider Grievance Quality MPQP1003 Physician Advisory Committee Archived MCUP3122 Palliative Care CGA 001 Evaluating and Reporting Data on Complaints and Appeals CGA 002 Member Grievance Review Committee CGA 003 Medi-Cal Member Grievance System CGA 014 Clinical vs. Non-Clinical Grievances CGA 021 Aid Paid Pending Process 1. MP CR 10 Mary Kerlin presented on MP CR 10 Organizational Providers Assessment Criteria. As of July 1, 2017 it is mandated per the DHCS contract that HealthPlans are required to contract with birthing centers if they meet the HealthPlans credentialing criteria. Traditionally the HealthPlan has never contracted with birthing centers because of the conflict with the credentialing committee membership so a policy and procedure has been developed to define the criteria. Once it is approved by our credentialing committee, we will then reach out to the few birthing centers in our network to see if they want to contract with us and ensure they meet our credentialing criteria. It is stated in the policy that there is an initial site review. This is a PHC requirement, not a DHCS requirement. We have developed our own site review tool and did it to ensure we were meeting NCQA requirements. Action - Remove VI, H, 3, Comprehensive Perinatal Services Provider (CPSP). In section VI, A, add if the case is potentially greater than P2 or S2, this case should be referred to the peer review committee. 2. MPQP1016 Rose Santos presented on MPQP1016 Potential Quality Issue (PQI) Investigation and Resolution. Under the definition, section e this was updated which now gives the name of attachment B that is tied to the definition. Language stating that VSP is not delegated for grievances was added. Within the policy, language around the PQI review process was updated. Action - Remove VSP in section VI, A, e. Add P2, S2 to state, the CMO is the final stop to approve the P2 S2 s. Record retention, change from 3 years to 10 years keeping records, per DHCS requirements. 3. MCCP2023 This policy was pulled. This is a new policy that needs some revisions per the states feedback MCCP2023 New Member Needs Assessment (New Policy) PULLED until August 30 of 130 Motion: Peggy Hoover Second: Dr. Cotter Approved with changes Motion: Dr. Cotter Second: Dr. Vovakes Approved with changes Pulled from agenda until August 6/13/2017 6/13/2017 6/13/2017

31 4. MPCD2013 Rebecca Boyd-Anderson presented on the Care Coordination Program Description. This policy was brought through committee last month and needed some revisions after the committee input. The Program Description was reorganized to better reflect what is happening in both the Northern and Southern regions to be in compliance with the new Final Rule as well as the departmental changes that have been happening over the last year. It is heavily redlined, basically it was rewritten. The program descriptions were taken as they are and created sub-program descriptions; Included was also the new maternal child unit, what the pediatric case management model is going to look like, as well as the internal child-maternity care and how that rolls together. There is a previous policy; MCCP2023, New Member Needs Assessment, that is being updated to state - a new regulation is going live July 1 st, that is now being required by DHCS. This states all members new to the health plan will be using the Health Information Form. This has been referenced the Health Information Form process will be one of the ways we identify members for Care Coordination. The other primary change is, it was clarified and leaves room for doing either, telephonic or fetal-based programs across the board. 5. MPUP3126 Katherine Barresi presented on policy MPUP3126 Autism Spectrum Disorder (ASD) Behavioral Health Treatment (BHT). The changes made were to reflect the last DHCS audit. The APL was updated to the 2015-released version from the 2014 version. There are a lot of redlines regarding two criteria. In the new cited APL, 1525, DHCS included that there is certain treatment information that has to be included in the BHT treatment TARS that are submitted by providers, specifically that the transition plan, a crisis plan and an exit plan have to be included along with measurable goals and measurable outcomes. This policy has been updated to reflect those changes. Committee Discussion: Joan Russell made suggestion to add H2012 Behavioral Health Day Treatment, to the definition portion of this policy. Further review and research will be done. 6. MCUG3010 Peggy Hoover presented on policy MCUG3010 Chiropractor Services 24 visits per year were added instead of 12 per year. PHC did not want to put a monthly limit on chiropractic services so made the changes to state the yearly maximum is now MCUP3020 Peggy Hoover presented on policy MCUP3020 Hospice Services Guidelines. Definitions of terminal illness was updated. Life expectancy was changed from 12 months to 6 months. 8. MCUP3137 This is a new policy that Dr. Robert Moore presented on; MCUP3137 Palliative Care: Intensive Program. This is an expanded pilot program that is not quite a benefit but is being treated like a benefit. It is going through utilization management for TAR s. It will be paid through the claims system. The contracts have started going out, the sites are going live on July 1 st. The terms are defined, attachments and eligibility assessment as well as what the definition of terminal illness is. The two different types of billings that occur; one is for engagement, one is for intensive home-based palliative care and lastly the application to be a provider. Many of our IQI committee members have gone through the all-day palliative care training; this is the policy behind that. This policy is trying to anticipate what the state policy will end up being based on an early draft of what they have come up with. 9. MPQP1023 Jessica Thacher presented on policy MPQP1023 Access Standards. This policy was updated to reflect NCQA standards as well as the States wishes. Policy withdrawn for further discussion;. 31 of 130 Motion: Peggy Hoover Second: Jessica Thacher Approved with no changes Motion: Dr. Vovakes Second: Peggy Hoover Approved pending changes to the definition portion of this policy. Motion: Peggy Hoover Second: Dr. Cotter Approved without changes Motion: Dr. Cotter Second: Dr. Vovakes Approved without changes Motion: Dr. Cotter Second: Dr. Vovakes Approved without changes Pulled from agenda until August 6/13/2017 6/13/2017 6/13/2017 6/13/2017 6/13/2017

32 10. MPXG5003 Dr. Robert Moore presented on policy MPXG5003 Major Depression in Adults Clinical Practice Guidelines. Weblinks were updated as well as the medication list. 11. CGA024 Dina Cuellar presented on policy CGA 024 Medi-Cal Member Grievance System. 6 policies that are being archived that this policy is replacing. This policy is lengthy which is now reflecting some of the major changes coming down the pipe line that are going into effect July 1, 2017 as it relates to the APL, the final rule changes with DHCS. Timeframes for grievances; there are two different types of grievances, there are complaints and appeals. The are no time frames for complaints for a member to be able to file a complaint. Previously it was 180 days and now there is no time limit. Appeals have gone from 90days from the to 60 days. The time frame is being tightened in which a member can file an appeal. The member must exhaust the plans appeal process before going to the state. Appeals can still be deferred out. There is a 72 hours All complaints and appeals must be reported by the plan to DHCS. There were changes around Health Services ability to defer out 14 days or 10 on complaints. You cannot defer out the complaints 10 or 14 days as was previously allowable, now it has to be resolved in 30 days. Acknowledgement is required upon receipt within 5 days unless it is otherwise resolved. There is a 72 hour time frame for expedited appeals. VI. Presentations Motion: Dr. Cotter Second: Dr. Vovakes Approved without changes Motion: Dr. Cotter Second: Dr. Vovakes Approved without changes 6/13/2017 6/13/2017 Potential Quality Issue (PQI) Annual Report VII. Additional Business Rose Santos presented on the 2016 Potential Quality Issue Annual Report. There were 915 PQI referrals received last year, which is much higher than previous years. In 2016, 2 nd quarter there was a spike in referrals, the reason is, there was a pilot program done by member services, grievance and appeals, with regards to the end of next business day for all PQI s were generated for that report. This year there should be a decrease of those referrals since the pilot program is no longer generated to the quality department. We are no longer processing service issues, so the referrals that come to us are reviewed by the CMO and the nurses. The PQI counts by referral source, the two top sources remain from member services and the complaints grievances and appeals department. The two top referral types are assessments and treatment diagnosis. There were 572 referrals. 151 complaints about access and availability. 6/13/2017 Respectfully submitted by Sara Stamps, Quality Improvement Project Coordinator Signature of Approval: Date: Robert Moore, MD, MPH, Chairman 32 of 130

33 QI Department Update August 2017 Prepared by Jess Liu, Manager of Quality Incentive Programs Quality Improvement Programs (QIPs) Wrap up for the Primary Care Provider Quality Improvement Program Measurement Year is in process. Providers will have until 7/31/17 to submit data and, as part of a new process to minimize post payment dispute, 8/8/17 to validate their final clinical rates. Mercy Maternity Redding and NorthBay s ABC Clinic have signed the agreement to participate in the Perinatal QIP pilot, which begins on 7/1/17 and 8/1/17 respectively. Learnings from the pilot which runs through 12/31/17 will help inform PHC s decision to launch a plan wide program in Ten PCP organizations (close to 40 sites) will pilot the Partnership Quality Dashboard Module 1 QIP Non Clinical Measures from 8/7/17 to 9/1/17. A demo webinar will be hosted on 7/31/17 for the pilot sites and we will have weekly check ins with individual sites to log and resolve issues. PHC is hosting its first Hospital Quality Symposium in American Canyon on 8/8/17 and Anderson on 8/10/17, with the objectives to build relationships with Hospital QIP participants and to share peer sharing. So far there are 86 registrants in total. Registration will close on 8/1/17. Sixteen people attended the Hospital QIP Kick Off Webinar on 7/19/17. In the program s sixth year, the HQIP has expanded to five more hospitals; in total, the program has 25 hospital participants from all counties but Del Norte. QI Trainings PHC will be hosting an ABCs of Quality Improvement training in Ukiah on 7/25/17 and had 38 people registered. The same training is planned in Eureka on 9/19/17 and in Napa on 10/24/17. In July the ADVANCE program hosted a webinar on understanding variation and using data for improvement. Most ADVANCE teams started testing changes to improve rates in their HEDIS improvement focus area. Focus areas include: Annual Monitoring for Patients on Persistent Medications (MPM), Childhood Immunization Status Combo 3 (CIS 3), Cervical Cancer Screening (CCS), and Controlling Blood Pressure (CBP). PHC s internal performance improvement training program, QI EX, will run August through December. Participants will include QI and Pharmacy staff (21 trainees). Goals of the training include learning performance improvement methods and applying skills to specific HEDIS improvement projects; developing cross functional/multi disciplinary teams to help break down silos; building capacity/supporting personal growth and development. The training will focus on four HEDIS measures: Asthma Medication Ratio; Childhood Immunization Status Combo 3; Immunizations for Adolescents Combination 2; Annual Monitoring for Patients on Persistent Medications. A training by the American Society of Addiction Medicine (ASAM) was held on 6/30/17 having 105 attendees. ASAM training series B and C are planned for 7/28/17 and 8/30/17. HEDIS Score Improvement Diabetic Retinopathy Screening (CDC E): The installation of the two available cameras was completed on 6/14/17 at Fairchild Medical Clinic and 6/15/17 at Mountain Valleys Health Centers Burney. Bi weekly follow up will occur to assure appropriate ramp up of camera use. The existing four clinics continuing in the EyePACs project started the second measurement year in June and will report baseline data for diabetic eye exam rates and complete project year one evaluations. 33 of 130

34 The recent and final submission of state mandated PDSAs (cycle 2) demonstrated success in HEDIS improvement work in the Northern Region: o Timeliness of Postpartum Care (PPC Pst): Fairchild Medical Clinic reported a 73% rate of postpartum appointment completion for cycle 2, versus the pre PDSA baseline of 60%. This PDSA s success was attributed to timely communication via outreach calls, provider validation of postpartum visit importance, and mailing appointment reminders. o Timeliness of Prenatal Care (PPC Pre): Shasta Community Health Center (SCHC) reported consistently high performance (92%) in capturing detailed medical record documentation whenever pregnant patients are encountered. This PDSA s success was the result of optimizing use of EHR templates, assuring providers and scribes are prompted during the visit to cover and document all components of the measure. Cycle 2 is a significant improvement over the pre PDSA baseline of 47%. Healthcare Effectiveness Data Information Set (HEDIS) On June 15, we submitted final HEDIS rates to HSAG and NCQA. Preliminary data show improvements in plan wide performance relative to last year with sustained or improved performance across each region. A detailed summary of our HEDIS 2017 Performance will be posted to our HEDIS webpage. DHCS has revised the measurement set for HEDIS 2018 by replacing the Screening for Clinical Depression and follow up plan (CDF) measure to a new NCQA Electronic Clinical Data Systems (ECDS) measure, Depression Screening and Follow Up for Adolescents and Adults (DSF). Quality Compliance and Accreditation The NCQA team has finalized a global project plan which captures all NCQA requirements at the Element and Factor level for Interim and First survey accreditation. In addition, the NCQA team identified key stakeholders, business owners, target start/end dates, and current progress. QI is currently drafting key reporting metrics to support on going oversight of NCQA program management. An executive dashboard is presented monthly to our NCQA Steering Committee highlighting progress and potential risks. QI has launched our 17/18 NCQA Operations Workgroup and established a set of team goals in support of plan wide interim survey compliant by 6/30/18. Patient Safety During the period of 6/26/17 and 7/23/17, 46 Potential Quality Issue (PQI) referrals were received (31 South and 15 North), and 31 PQI cases were completed and closed (25 South and 6 North). All closed PQI cases were processed timely within 120 days. There are currently 69 open PQI cases (60 South and 9 North). During the same period, 12 Facility Site Reviews (10 South and 2 North) and 13 Medical Record Reviews (10 South and 3 North) were conducted. A total of 6 Corrective Action Plans were issued from the reviews conducted (3 South and 3 North). Sara Nopwaskey, PICS RN, completed her certification in June to conduct Site Reviews on behalf of PHC, as part of the team based in the Northern Region. A Palliative Care Site Review tool was developed and will be piloted with three current contracted providers in July. The Patient Safety team completed final User Acceptance Testing for the esite Review tool in June. Enhancements for the next release of the tool will open a new development cycle on 10/1/ of 130

35 PHC System Updates August 2017 Policy/Procedures/Guidelines Old Number New Assigned Number Comments Provider Manual Health Services Utilization Management Hearing Aid Guidelines MCUG3019 Regular review; no changes to policy content X Discharge Planning (Non-capitated Members MCUP3012 Regular review; minor language clarifications made X Emergency Services MCUP3014 Regular review; reference to old Dept. of Health Care Services (DHCS) Policy Letter removed; no other changes to policy content X Wheelchair Mobility, Seating and Positional Components MCUP3133 Regular review; no changes to policy content X Screening and Treatment for Substance Use Disorders Attachments: A. SBIRT Training Resources B. Sample PCP Policy/Procedure for SBIRT C. Pocket Screening & Brief Intervention (BI) for Alcohol Use Disorders D. Application to be a Contracted BI/Referral to Treatment Provider E. Review Documentation for Applicants to be Contracted BI/Referral to Treatment Provider MCUP3101 Regular review; language added that medical specialists treating SUD must be credentialed as buprenorphine prescribers by PHC; code F10.2x added for non- Referral Authorization X Appeals/ Expedited Appeals of UM Decisions for Medical Necessity Determination (Non Administrative) Attachments: A. Provider Request for Appeal of UM Decision for Medical Necessity Determination B. Member Auth. For Provider Appeal C. UM Appeal Acknowledgement Letter MCUP3037 Regular review; updated vs. contractual changes; provider appeal of non-admin. UM decision to occur within 30 calendar (vs. business) days; member and provider to receive acknowledgement of appeal receipt; language updated - decision notification to include verbal, along with mailed written notification no later than 72 hours (vs. two business days) after receipt of expedited appeal X Genetic Testing Attachments: A. Genetic Testing Requirements B. Quest Diagnostics BRCAvantage Patient & Family Clinical History Form MCUP3131 Regular review; no changes to policy content; Reference link updated Attachment A updated to reflect no Treatment Authorization Request (TAR) required for CPT Codes ; requirements for Codes 81400, 81401, 81403, 81405, 81420, 81470, & updated X 35 of 130

36 Policy/Procedures/Guidelines Old Number New Assigned Number Comments Provider Manual TAR Requirements List Attachment to policies: TAR Review Process Pain Management Specialty Services Authorization of Ambulatory Procedures MCUP3041-A MCUP3049-A MCUG3007-B Cardiac MRI (75561 only effective 8/1/17) added under Diagnostic Studies X Health Services Care Coordination Continuity of Care (Medi-Cal) MCCP2014 Regular review; definition of Risk of Harm added; reference to children changed to individuals; policy verbiage revised and restructured for clarity; DHCS References updated to current Regulations X EPSDT Supplemental Shift Nursing Services Attachments: A. EPSDT Supplemental Services Review of Request B. EPSDT Shift Nursing Services Indiv. Nurse Agreeement C. EPSDT Shift Nursing Services Family/ Primary Caregiver Agrmt MCCP2005 Regular review; Definitions added; verbiage updated to reflect contractual obligations and clarified to reflect current processes and authorization of requests; services to be prescribed by the member s (not beneficiary s) PCP; section added for beneficiaries referred to CCS residing in one of PHC s carved out counties; DHCS All Plan Letter (APL) added to References X Transportation Guidelines for Non- Emergency Medical (NEMT) and Non- Medical Transportation (NMT) MCCP2016 Regular review; Definitions updated; policy rewritten for clarification and to reflect contractual obligations; References updated and new DHCS APL added X Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services MCCP2022 Regular review; Definitions added; reference to children changed to individuals; sections added due to contractual obligations; DHCS APL added to References X New Member Needs Assessment Attachments: F. HIF/MET Form G. HRA Form MCCP2023 New versus contractual obligations X Health Services Quality Non-Physician Medical Practitioners & Medical Assistants Practice Guidelines Attachment: A. Sample Non-Physician Medical Practitioners Agreement MPQG1011 Regular review; no changes to policy content X Provider Relations Credentials Committee Review MP PR-PL- CR #201 Regular review; no changes to policy content X Member Services Notification of Provider Termination or Change in Location MP 300 Regular review; Purpose expanded to include Specialist or Hospital (Pharmacy removed) relative to transition for member; references to Healthy Kids removed; processes updated and those specific to pharmacies removed X 36 of 130

37 Policy/Procedures/Guidelines Old Number New Assigned Number Comments Provider Manual Weight Management Program Attachment: A. Website Summary MP 350 Regular review; no changes to policy content X Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior Attachments: A. Form #6 (Provider Request for Discharge/Assistance with Inappropriate Behavior) B. Letter #MS10a (Member Services Notifies PCP of decision) C. Letter #MS10c (Assistance with Inappropriate Behavior at Provider s Office) D. Letter #MS10b (Type U) (Notification of PCP Discharge Request Approved) MP 316 Regular review; Definitions updated; language clarifications added; processes updated to reflect current intra and interdepartmental practices; section added to address Incomplete Requests 37 of 130

38 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE Policy/Procedure Number: MCCP2005 (previously CP100205) Policy/Procedure Title: EPSDT Supplemental Shift Nursing Services Original Date: 04/18/2001 Lead Department: Health Services External Policy Internal Policy Next Review Date: 09/21/201708/16/2018 Last Review Date: 09/21/201608/16/2017 Applies to: Medi-Cal Healthy Kids Employees Reviewing Entities: Approving Entities: IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT BOARD COMPLIANCE FINANCE PAC CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 09/21/201608/16/2017 I. RELATED POLICIES: A. MCUP3065 MCCP Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services B. CR #12 - Credentialing of Independent Nurses under EPSDT C. MCUP TAR Review Process C.D. MPCP2002 California Children s Services II. III. IV. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services DEFINITIONS: A. N/ACCS: California Children Services B. EPSDT: Early and Periodic Screening, Diagnostic and Treatment C. FFS: Fee-for-Service D. LEA: Local Education Agency E. PHC: Partnership HealthPlan of California A.F. TCM: Targeted Case Management ATTACHMENTS: A. EPSDT Supplemental Services Review of Request B. EPSDT Shift Nursing Services Individual Nurse Agreement C. EPSDT Shift Nursing Services Family / Primary Caregiver Agreement V. PURPOSE: To define Partnership HealthPlan of California s (PHC s) responsibility to provide Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental Service Benefit for shift nursing to appropriate members under the age of 21. Under the Federal EPSDT Supplemental Services Program, Federal law [(Title 42, USC, Section 1396(a)(43) and 1396d(r)] requires that state Medicaid plans provide coverage for any service that is medically necessary to correct or ameliorate a defect, physical and mental illness, or a condition for beneficiaries under 21 years of age even if the service or item is not otherwise included in the state s Medicaid plan. VI. POLICY / PROCEDURE: A. PHC will provide or arrange for health care servicesshift nursing services under EPSDT Supplemental Services as identified in Title 22, CCR, Division 3, Subdivision 1, Chapter 3:3. 38 of 130 Page 1 of 3

39 Policy/Procedure Number: MCCP2005 (previously CP100205) Lead Department: Health Services Policy/Procedure Title: EPSDT Supplemental Shift Nursing Services External Policy Internal Policy Original Date: 04/18/2001 Next Review Date: 09/21/201708/16/2018 Last Review Date: 09/21/201608/16/2017 Applies to: Medi-Cal Healthy Kids Employees 1. All requests are subject to current Prior Authorization requirements. The services must be prescribed by the beneficiary s member s primary care provider in accordance with EPSDT regulatory requirements for medical necessity, CCR, Title 22, section 51340(e). B. Requests for services are authorized through Licensed and Medi-Cal certified home health agencies or individually enrolled supplemental service providers acting within their scope of practice (registered nurses and/or vocational/practical nurses). B.C. PHC will review and authorize requests fromif independent service providers if services are not available through a licensed agency. are Prior to approval, to be utilized, PHC Health Services staff must verify that the services are not available through a home health agency and that the provider meets all State and Federal practice and regulatory guidelines. PHC authorizes if, and only if, services are not available through a licensed agency. The approval is contingent upon the active participation of the family and/or primary caregiver in the program and appropriate level of direct patient care to ensure the continued health and safety of the beneficiary.member. PHC does not reimburse families for care. C.D. A family member and/or a primary caregiver should be proficient in the tasks necessary to care for the beneficiary member at home to ensure care is not interrupted should an unforeseen event occur. This proficiency may be satisfied by active participation and training as necessary to safely carry out the plan of treatment, and by caregiver providing four or more hours of direct care to the member per week. In keeping with this requirement, PHC reserves the right to limit skilled care to a maximum of 221 hours/day to enable primary caregiver(s) to maintain their skills. D.E. Beneficiary must have FULL SCOPE Medi-Cal benefits. E.F. Respite services are not included in this service.. F.G. The services must be provided in the home, which has been assessed to be a safe, healthy environment. G.H. Treatment Authorization Requests (TARs) and applicable documentation are reviewed by PHC Health Services (HS) staff. H.I. The total cost of providing services and all other medically necessary Medi-Cal services to the beneficiary is not greater than the costs incurred in providing medically equivalent services at the appropriate institutional level of care. I.J. The following documentation is required at the time of the request for services and/or with request for a renewal of services: 1. Completed TAR Form 2. Current Nursing Plan of Care 3. Home safety assessment 4. Emergency Plan 5. Report(s) of initial assessment J.K. Other documentation may be requested to clarify specific issues related to appropriate determination of care needs, such as: 1. Current History and Physical with full systems review 2. Social Worker Assessment 3. Regional Center Assessment 4. Current Physician Progress Notes 5. A needs assessment completed by an independent nurse consultant 6. Staff timesheets L. Authorization period for initial requests will be 90 days. Subsequent authorizations will be 180 days, as appropriate. K.M. For beneficiaries who reside in one of PHC s carved out counties who have been referred to CCS, providers must refer requests for supplemental shift nursing services to the appropriate California Children Services (CCS) program for authorization and case management. The TAR for these beneficiaries will be submitted directly to the EPSDT unit of DHCS. 39 of 130 Page 2 of 3

40 Policy/Procedure Number: MCCP2005 (previously CP100205) Lead Department: Health Services Policy/Procedure Title: EPSDT Supplemental Shift Nursing Services External Policy Internal Policy Original Date: 04/18/2001 Next Review Date: 09/21/201708/16/2018 Last Review Date: 09/21/201608/16/2017 Applies to: Medi-Cal Healthy Kids Employees L.N. Independent Services Providers - Additional Requirements: 1. AThe family member and/or primary caregiver, / beneficiary, independent nurses and nurse case manager must read and acknowledge their understanding of the provision of independent nursing as described in the EPSDT Supplemental Nursing Services Family/Primary Caregiver Agreement (Attachment B) and the EPSDT Supplemental Nursing Services Individual Nurse Agreement (Attachment C) prior to PHC s approval of services. 2. See credentialing policy if services are requested by an individually enrolled supplemental service provider not associated with a home health agency. (Policy CR #12 Credentialing of Independent Nurses under EPSDT) VII. VIII. REFERENCES: A. Title 42 U.S. Code (USC) Sections 1396(a)(43) and 1396d(r) B. Title 22 California Code of Regulations (CCR) Division 3, Subdivision 1, Chapter 3 C. Title 22 California Code of Regulations (CCR) Section 51340(e) C.D. Department of Health Care Services All Plan Letter : Requirements for Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Beneficiaries Under the Age of Twenty One. DISTRIBUTION: A. PHC Department Directors B. PHC Provider Manual IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services X. REVISION DATES: 04/17/02; 08/20/03; 04/20/05; 01/18/06; 01/16/08; 09/19/12; 01/20/16; 09/21/16; 08/16/17 PREVIOUSLY APPLIED TO: N/A *********************************** In accordance with the California Health and Safety Code, Section , this policy was developed with involvement from actively practicing health care providers and meets these provisions: Consistent with sound clinical principles and processes Evaluated and updated at least annually If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC. 40 of 130 Page 3 of 3

41 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE Policy/Procedure Number: MCCP2005 (previously CP100205) Policy/Procedure Title: EPSDT Supplemental Shift Nursing Services Original Date: 04/18/2001 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: Medi-Cal Employees Reviewing Entities: Approving Entities: Lead Department: Health Services External Policy Internal Policy IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT BOARD COMPLIANCE FINANCE PAC CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 08/16/2017 I. RELATED POLICIES: A. MCCP Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services B. CR #12 - Credentialing of Independent Nurses under EPSDT C. MCUP TAR Review Process D. MPCP2002 California Children s Services II. III. IV. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services DEFINITIONS: A. CCS: California Children Services B. EPSDT: Early and Periodic Screening, Diagnostic and Treatment C. FFS: Fee-for-Service D. LEA: Local Education Agency E. PHC: Partnership HealthPlan of California F. TCM: Targeted Case Management ATTACHMENTS: A. EPSDT Supplemental Services Review of Request B. EPSDT Shift Nursing Services Individual Nurse Agreement C. EPSDT Shift Nursing Services Family / Primary Caregiver Agreement V. PURPOSE: To define Partnership HealthPlan of California s (PHC s) responsibility to provide Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental Service Benefit for shift nursing to appropriate members under the age of 21. Under the Federal EPSDT Supplemental Services Program, Federal law [(Title 42, USC, Section 1396(a)(43) and 1396d(r)] requires that state Medicaid plans provide coverage for any service that is medically necessary to correct or ameliorate a defect, physical and mental illness, or a condition for beneficiaries under 21 years of age even if the service or item is not otherwise included in the state s Medicaid plan. VI. POLICY / PROCEDURE: A. PHC will provide or arrange for shift nursing services under EPSDT Supplemental Services as identified in Title 22, CCR, Division 3, Subdivision 1, Chapter 3: 41 of 130 Page 1 of 3

42 Policy/Procedure Number: MCCP2005 (previously CP100205) Lead Department: Health Services Policy/Procedure Title: EPSDT Supplemental Shift Nursing Services External Policy Internal Policy Original Date: 04/18/2001 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: Medi-Cal Employees 1. All requests are subject to current Prior Authorization requirements. The services must be prescribed by the member s primary care provider in accordance with EPSDT regulatory requirements for medical necessity, CCR, Title 22, section 51340(e). B. Requests for services are authorized through Licensed and Medi-Cal certified home health agencies or individually enrolled supplemental service providers acting within their scope of practice (registered nurses and/or vocational/practical nurses). C. PHC will review and authorize requests from independent service providers if services are not available through a licensed agency. Prior to approval, PHC Health Services staff must verify that the services are not available through a home health agency and that the provider meets all State and Federal practice and regulatory guidelines. The approval is contingent upon the active participation of the family and/or primary caregiver in the program and appropriate level of direct patient care to ensure the continued health and safety of the member. PHC does not reimburse families for care. D. A family member and/or a primary caregiver should be proficient in the tasks necessary to care for the member at home to ensure care is not interrupted should an unforeseen event occur. This proficiency may be satisfied by active participation and training as necessary to safely carry out the plan of treatment, and by caregiver providing four or more hours of direct care to the member per week. In keeping with this requirement, PHC reserves the right to limit skilled care to a maximum of 22 hours/day to enable primary caregiver(s) to maintain their skills. E. Beneficiary must have FULL SCOPE Medi-Cal benefits. F. Respite services are not included in this service. G. The services must be provided in the home, which has been assessed to be a safe, healthy environment. H. Treatment Authorization Requests (TARs) and applicable documentation are reviewed by PHC Health Services (HS) staff. I. The total cost of providing services and all other medically necessary Medi-Cal services to the beneficiary is not greater than the costs incurred in providing medically equivalent services at the appropriate institutional level of care. J. The following documentation is required at the time of the request for services and/or with request for a renewal of services: 1. Completed TAR Form 2. Current Nursing Plan of Care 3. Home safety assessment 4. Emergency Plan 5. Report(s) of initial assessment K. Other documentation may be requested to clarify specific issues related to appropriate determination of care needs, such as: 1. Current History and Physical with full systems review 2. Social Worker Assessment 3. Regional Center Assessment 4. Current Physician Progress Notes 5. A needs assessment completed by an independent nurse consultant 6. Staff timesheets L. Authorization period for initial requests will be 90 days. Subsequent authorizations will be 180 days, as appropriate. M. For beneficiaries who reside in one of PHC s carved out counties who have been referred to CCS, providers must refer requests for supplemental shift nursing services to the appropriate California Children Services (CCS) program for authorization and case management. The TAR for these beneficiaries will be submitted directly to the EPSDT unit of DHCS. N. Independent Services Providers - Additional Requirements: 1. A family member and/or primary caregiver, independent nurses and nurse case manager must read 42 of 130 Page 2 of 3

43 Policy/Procedure Number: MCCP2005 (previously CP100205) Lead Department: Health Services Policy/Procedure Title: EPSDT Supplemental Shift Nursing Services External Policy Internal Policy Original Date: 04/18/2001 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: Medi-Cal Employees and acknowledge their understanding of the provision of independent nursing as described in the EPSDT Supplemental Nursing Services Family/Primary Caregiver Agreement (Attachment B) and the EPSDT Supplemental Nursing Services Individual Nurse Agreement (Attachment C) prior to PHC s approval of services. 2. See credentialing policy if services are requested by an individually enrolled supplemental service provider not associated with a home health agency. (Policy CR #12 Credentialing of Independent Nurses under EPSDT) VII. VIII. REFERENCES: A. Title 42 U.S. Code (USC) Sections 1396(a)(43) and 1396d(r) B. Title 22 California Code of Regulations (CCR) Division 3, Subdivision 1, Chapter 3 C. Title 22 California Code of Regulations (CCR) Section 51340(e) D. Department of Health Care Services All Plan Letter : Requirements for Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Beneficiaries Under the Age of Twenty One. DISTRIBUTION: A. PHC Department Directors B. PHC Provider Manual IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services X. REVISION DATES: 04/17/02; 08/20/03; 04/20/05; 01/18/06; 01/16/08; 09/19/12; 01/20/16; 09/21/16; 08/16/17 PREVIOUSLY APPLIED TO: N/A *********************************** In accordance with the California Health and Safety Code, Section , this policy was developed with involvement from actively practicing health care providers and meets these provisions: Consistent with sound clinical principles and processes Evaluated and updated at least annually If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC. 43 of 130 Page 3 of 3

44 Policy/Procedure Number: MCCP2016 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/ PROCEDURE Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Healthy Kids Employees Reviewing Entities: Approving Entities: IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT BOARD COMPLIANCE FINANCE PAC CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 01/20/201608/17/2016 I. RELATED POLICIES: A. MCUP TAR Review Process B. MCUP3065 MCCP Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services C. MCUG Prenatal & Perinatal Care II. III. IV. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services D. Grievance E. Finance F. Provider Relations DEFINITIONS: A. NEMT: Non-Emergency Medical Transportation B. NMT: Non-Medical Transportation C. EPSDT: Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services D.C. GTPP: PHC s Growing Together Perinatal Program E.D. CMO: Chief Medical Officer F.E. Paratransit: Public or group transportation as by van or bus. F. Missed appointment: No notification of cancellation within 48 hours of the scheduled transportation. G. PCS: Physician Certification Statement prescribing the level of transportation necessary based upon the functional and medical limitations of the member H. Delegated transportation delivery vendor: Tthe vendor responsible for determining eligibility and mode of transportation as well as scheduling G.I. Transportation provider: the entity that will actually be transporting the member ATTACHMENTS: N/A V. PURPOSE: To outline the circumstances by which PHC will pay for and/or facilitate transportation services to members and to provide guidelines guidance for the transportation specialist when reviewing TAR requests for transportation services or approving and arranging transportation that exceeds the standard Medi-Cal benefit. VI. POLICY / PROCEDURE: 44 of 130 Page 1 of 12

45 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Employees A. EMERGENCY MEDICAL TRANSPORTATION (EMT) AND NON-EMERGENCY TRANSPORTATION (NEMT) B.A. 1. EMERGENCY TRANSPORTATION FOR ALL AGES 1. Emergency medical transportation (EMT) is provided for emergency medical conditions as defined in the Federal Statute (420.5.C.S 1396b[V]). The term emergency medical condition is defined in federal statute to mean a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: a. Placing the patient s health in serious jeopardy b. Serious impairment to bodily functions c. Serious dysfunction of any bodily organ or part 2. AIR emergency transportation is covered when medically necessary and when other forms of transportation are not practical or feasible for the patient s condition. 3. GROUND emergency transportation is covered when ordinary public or private medical transportation is medically contraindicated and transportation is needed to obtain care. 4. TAR is not required for emergency air or ground transportation. 5. Emergency transportation must be to the nearest hospital capable of meeting the medical needs of the patient. 6. Medical transportation which represents a continuation of an original emergency transport (such as transfer from an emergency room of one hospital to an emergency room of another hospital for treatment or admission) is considered a continuation of the initial emergency transport. 7. Emergency transportation provided for the purposes of evaluating a psychiatric crisis and/or for admission to a psychiatric facility is a covered service without a TAR. Counties directly performing this service are eligible providers, and the mode of transportation should be appropriate to the patient s medical and psychiatric needs. The continuation of an original emergency transport from an emergency room to another facility that can meet the medical and psychiatric needs of the patient is an appropriate emergency transport. B. 2. NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) 1. FOR ADULTS AGE (21) OR OVER 2. NEMT services are a covered Medi-Cal benefit when a member needs to obtain medically necessary covered services and when prescribed in writing by a physician, podiatrist, or mild to moderate mental health, or substance use disorder provider have who has identified that transport by ordinary means of public or private conveyance is medically contraindicated and transportation is required for obtaining medically necessary services [(22CCR Section (a)]). NEMT services are subject to a prior authorization, except when a member is transferred from an acute care hospital, immediately following an inpatient stay at the acute level of care, to a skilled nursing facility or an intermediate care facility licensed pursuant to Health and Safety Code (HSC) Section 1250.Non-emergency transportation is covered when the member s medical and physical condition is such that transport by ordinary means of public or private conveyance is contraindicated and transportation is required for the purpose of obtaining services that are necessary to protect life, prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury for members age 21 or over. Where applicable, PHC will make a good faith effort to refer and coordinate NEMT services for members when those services are carved out of the Hhealth Pplan. 45 of 130 Page 2 of 12

46 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Employees PHC will not provide transportation services for Medi-Cal services that are carved-out of the plan including dental services. 4. Transportation is covered from a medical facility to the same or lower level of care, including the member s documented address of record. 5. Transportation is covered when the member s needs are such that a Skilled Nursing Facility (SNF)/LTC must obtain specialty medical services not outlined as the responsibility of the facility as per CCR Title 22 Section and the service to be obtained is a Medi-Cal carved-in benefit Both aa TAR and a Physician Certification Statement (PCS) AREis required for all NEMTall NEMT (the only exception is transportation upon discharge non-emergency transportation except for transport, upon discharge, from an acute care facility, inpatient bed or Emergency Department directly to a Long Term Care (LTC) facility or to another acute care facility). Once submitted to PHC, prescribed NEMT services and the corresponding PCS form cannot be changed or altered. a. The TAR or Physician Certification (PCS) must include, at minimum, the function limitations justification, dates of services needed, and the mode of transportation appropriate based on the member s physician identified limitations. b. PHC collects information from the PCS form to submit to DHCS. a. the nature of the medical condition and verification that the attending physician ordered the service. b.c. The provider has 15 business days from date of service to submit a TAR. Refer to policy MCUP3041 for TAR Review Process. c.d. Untimely TARS will receive an administrative denial and a fax is sent to the provider with justification of the denial. d.e. PHC reviews the TAR request to determine the appropriate level of transport at the lowest level of cost based on medical necessity and reviews the case with the ordering physician as indicated. e.f. If the TAR does not appear to meet medical necessity, it is sent to the Care Coordination Manager for a decision and, if appropriate, forwarded to the CMO or physician designee for review. 3. PHC will provide transportation for a minor and a parent or legal guardian along with any travel related expenses such as meals and lodging if the medical appointment is too far distant from patient s home to reasonably allow for same day travel. 4. A minor may travel unaccompanied with written consent from the parent or legal guardian if the transportation provider s policy allows. 3. Types Of Non-Emergency Medical Transportation 4.5. AMBULANCE service may be used for: a..transport from hospital to long-term care facility or to home when the medical/physical condition requires recumbence and the use of medical supportive devices (such as IV fluids, suction, oxygen) a) Chronic respiratory distress patient who requires continuous oxygen and cannot utilize self-portable oxygen or who cannot otherwise sit upright b) Chronic cardiac conditions which requires monitoring during transport Transfers between facilities for members who require continuous intravenous medication, medical monitoring or observation. a. Transfers from an acute care facility to another acute care facility b. Transport for members who have recently been placed on oxygen (does not apply to 46 of 130 Page 3 of 12

47 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Employees members with chronic emphysema who carry their own oxygen for continuous use). c. Transport for members with chronic conditions who require oxygen if monitoring is required. d. Transfers between facilities for members who require continuous intravenous medication, medical monitoring or observation LITTER VAN service may be used forwhen the member s medical and physical condition does not meet the need for NEMT ambulance services, but meets both of the following: a. Medically necessary transport of member for special testing, radiation therapy or transfer to a lower level of care or to home when a member s medical/physical condition is stable but requires recumbence and does not require medical supportive devices a) Cases where a medical/physical condition precludes sitting upright for any period of time but no medical supportive devices are required b) Hospital transfer to a long-term care facility or home when the medical/physical condition requires recumbence but no supportive medical devices are required a. Requires that the member be transported in a prone or supine position, because the member is incapable of sitting for the period of time needed to transport. [(22CCR Section 51323(2)(A)(1))]. b. Requires specialized safety equipment over and above that normally available in passenger cars, taxicabs or other forms of public conveyance [(22 CCR Section (2)(B)]). 7. WHEELCHAIR VAN service may be used when the member s medical and physical condition does not meet the need for litter van services, but meets any of the following for: a. Members who are wheelchair bound and unable to travel by public or private conveyance a) Members who require attendant supervision door-to-door while ambulating, even with the assistance of a walker or crutches b) Members who are mentally challenged where transport requires attendant supervision a. Renders the member incapable of sitting in a private vehicle, taxi or other form of public transportation for the period of time needed to transport ([22CCR Section (3)(A)]). b. Requires that the member be transported in a wheelchair or assisted to and from a residence, vehicle and place of treatment because of a disabling physical or mental limitation (22CCR Section (3)(B)). c. Requires specialized safety equipment over and above that normally available in passenger cars, taxicabs or other forms of public conveyance (22 CCR Section 51323(3)(C) d. Members with the following conditions may qualify for wheelchair van transport when their providers submit a signed Physician Certification Statement (PCS) form 1) a.members who suffer from severe mental confusion 2) b. Members with paraplegia 3) c. Dialysis recipients. 4) d. Members with chronic conditions who require oxygen but do not require monitoring. 8. Air Transport for NEMT will be provided only when transportation by air is necessary because 47 of 130 Page 4 of 12

48 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Employees of the member s medical condition or because practical considerations render ground transportation not feasible. The necessity for transportation by air shall be substantiated in a written order of a physician, dentist, podiatrist, or mental health or substance use disorder provider. 9. 6) PHC reserves the right to review any TAR or claims for non-emergency transport and, based on medical necessity, will pay for the appropriate type of transport if that service is available within the county NON-EMERGENCY MEDICAL TRANSPORTATION OF A CHILD UNDER AGE (21) (EPSDT) 11. Members under age 21 (EPSDT) are eligible for transportation when medically necessary for screenings, diagnosis and or treatment services to correct or ameliorate defects. This includes physical and mental illnesses and conditions discovered by the screening services, whether or not such services or items are covered under PHC. (APL ) 12. Types of transportation under the EPSDT benefit include all types described above in section VI. A. 2. f. as well as taxi, bus or other carrier. It can also include reimbursing for mileage. As with other services covered through EPSDT, PHC may cover the least expensive means of transportation if it is actually available, accessible and appropriate. A TAR is required for all Non-Emergency Medical Transportation requests excluding mileage reimbursement as this is up to the discretion of PHC. PHC will provide transportation for the child and a parent or legal guardian BILLING FOR NON-EMERGENCY MEDICAL TRANSPORTATION OF ALL AGES a. The cost of an ambulance, litter van, or wheelchair transport of an inpatient between acute care facilities for services that cannot be performed at the facility, such as special testing, diagnostic procedures, or radiation therapy is included in the hospital per diem rate and the provider is to bill the hospital directly. b. Services included in the base rate and not separately reimbursable are as follows: backboards, flat/scoop stretcher, long boards, disposable O2 masks/tubing, disposable IV tubing, childbirth, assistance, restraints, suction/suction equipment, resuscitations, respirator/intermittent Positive Pressure Breathing (IPPB), crew of 3 (air) or 2 (ground), pick-up off paved road, or overweight or difficult patients, linens/blankets. c. Wait time up to 3 units is reimbursable (1 unit equals 30 minutes). d. The provider must bill Medicare and/or private insurance payers first for all emergency transports of PHC members who have other coverage. e. It is PHC policy to cover all transportation services per Medi-Cal guidelines. See Medi- Cal Guidelines for more specific information and rates. Medi-Cal References and 55, , Manual of Medi-Cal Criteria 6.1 CB. ENHANCED SERVICE: NON-MEDICAL TRANSPORTATION (NMT) Effective July 1, 2017, Non- Medical Ttransportation (NMT) is a benefit when a member is to obtain medically necessary Managed Care Plan (MCP)-covered services or services that are considered carved-in to the HhealthPplan. When and where applicable, PHC will make a good faith effort to refer and coordinate NMT for Medi-Cal services that are considered to be carved-out of the HhealthPplan. Effective October 1, 2017, unless otherwise instructed by DHCS, the NMT benefit will include medically-necessary Medi-Cal services that are considered carved-out to the HhealthPplan. (NMT) does not include transportation of the sick, injured, invalid, convalescent, infirm, or otherwise incapacitated members who need to be transported by ambulances, litter vans, or wheelchair vans licensed, operated, and equipped in accordance with state and local statutes, ordinances, or regulations. Physicians may authorize NMT for members if they are currently using a wheelchair but the limitation is such that the member is able to ambulate without assistance form the driver. The NMT requested must 48 of 130 Page 5 of 12

49 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Employees be the least costly method of transportation that meets the member s needs. Please refer to the Member Services handbook for further details. Partnership HealthPlan of California (PHC) offers a limited enhanced transportation service, in addition to what is covered through the Medi-Cal program. This service is not available if medical transportation such as ambulance or litter van is medically indicated. It is usually provided through paratransit (local public transit service) or a taxi service. Due to the nature of this enhanced service, the cases are reviewed on a case by case basis for carved-in services that are necessary to protect life, prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury for members age 21 or over. Members under age 21 may be eligible for transportation when medically necessary for screenings, diagnosis and or treatment services. See section VI. A. 3. a. for details regarding transportation for members under age 21. Gas reimbursement is not offered for this service. This enhancement is not a Medical Benefit and therefore those members not meeting PHC criteria will not receive a notice of action and are not eligible to file an appeal. This service may be discontinued when a member has a history of three (3) or more missed appointments (see III. G) in a calendar year. If discontinued, the member will not be eligible to receive this enhanced service for 12 months from the date of third missed appointment. 1. CONDITIONS FOR NON-MEDICAL TRANSPORTATION SERVICES ELIGIBILITY CRITERIA a. PRENATAL CARE a. Non PHC members are not eligible for transportation services. b. All PHC members requesting NMT will receive an assessment performed by PHC s contracted vendor to determine the most appropriate mode of transport. c. NMT coverage includes transportation costs for the member and one attendant. The attendant can be a parent, guardian, or spouse, to accompany the member in a vehicle or on public transportation which is subject to prior authorization at the time of the initial NMT authorization request. 1) The level of transportation accommodation needed will be based upon the limitations of the member being transported. Any attendants must be able to safely accompany the member and not require additional assistance. With the written consent of a parent or guardian, a minor may receive transportation unaccompanied as long as the vendor accepts the necessary written consent forms and agrees to provide unaccompanied transport. d. Certain appointments will not require written consent to travel unaccompanied such as: 1) Appointments resulting from sexual assault, abuse, rape or incest 2) Appointments related to drug or alcohol abuse 3) Family Planning/Pregnancy or abortion services 4) STD or HIV/AIDS related testing e. NMT does not cover trips to a non-medical location s or for appointments that are not medically necessary. f. The member must attest either in person, electronically, or over the phone that other transportation resources have been reasonably exhausted. The attestation may include confirmation that the member: 1) Has no valid driver s license. 2) Has no working vehicle available in the household. 3) Is unable to travel or wait for medical or dental services alone. 4) Has a physical, cognitive, mental or developmental limitation. g. Transportation from an emergency room to home or other housing resource is not included in the benefit h. PHCNMT transportation services include roundtrip transportation from consideration is typically based on the member s home of record, which is provided from the state, to the scheduled appointment s address and back. NMT services This includes passenger car, taxi 49 of 130 Page 6 of 12

50 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Employees cab, public/private conveyance, or mileage reimbursement. Limited exceptions may apply if there are safety concerns with the identified address or the member is homeless. 2. NON-MEDICAL TRANSPORTATION PRIVATE VEHICLE AUTHORIZATION REQUIREMENTS a. PHC s delegated transportation delivery vendor will authorize the use of private vehicle through the use of mileage reimbursement when no other methods of transportation are reasonably available to the member and the member verbally or in writing states they have the following: 1) Valid driver s license 2) Valid vehicle registration 3) Valid vehicle insurance b. Mileage reimbursement for gas is consistent with the Internal Revenue Service standard mileage rate for medical transportation when conveyance is in a private vehicle arranged by the member.. For the purpose of this policy, prenatal care transportation is defined as rides to and/or from OB offices, hospitals providing medical benefitted procedures (if directed by the provider), diagnostic procedures related to pregnancy, diabetes education programs, substance abuse programs, abortions and any other pregnancy related appointment. Transportation may be provided if the member meets all of the criteria below: 1) Eligible PHC member 2) Does not have Medicare Part A or Other Health Carrier (OHC) that covers inpatient hospitalizations 3) Enrolled in the Growing Together Perinatal Program (GTPP) and meets PHC s eligibility questionnaire criteria 4) Considered high risk due to a medical condition that makes transportation critical to the well- being of both the member and the fetus 5) The destination is to an out-of-county provider or to a provider that is at or over 30 miles away from the patient s residence b. RENAL DIALYSIS Transportation is provided if the member meets the following: 1) Is eligible for PHC full scope Medi-Cal or is a PHC Member that has met his/her share of cost (SOC) 2) Does not have Part A Medicare or OHC that covers inpatient hospitalizations 3) Is in a long term care facility regardless of Medicare or OHC status 4) Meets criteria after completion of transportation questionnaire c. OTHER Transportation for outpatient surgery, radiation, chemotherapy, specialty consults in or out-of-county may be provided if the member: 1. Is a PHC eligible member 2. Does not have Part A Medicare or OHC that covers inpatient hospitalizations 3. Needs medical treatment that, if left untreated, may lead to death or poor medical outcome 2. PROCESS 2.3. a. SUBMITTING NMT TRANSPORTATION REQUESTS a. Requests for transportation can be made by the member, the member s representative, or the member s provider by calling PHC s delegated NMT transportation delivery vendor or the HealthPlan. If the Health Plan is contacted, the member will be given the appropriate contact number for the vendor and will also be connected to the delegated transportation delivery vendor 50 of 130 Page 7 of 12

51 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Employees to be screened for services. The delegated transportation delivery vendor will assess the eligibility and the available modes of transportation available within the member s county of record.the PHC Care Coordination Department. 1) Non urgent/planned appointments requests are to be made a minimum of 5 business days prior to the scheduled appointment or risk being instructed to reschedule 1)2) Urgent transportation requests for unplanned appointments are considered but not guaranteed; the member may be instructed to reschedule the appointment 3. The delegated ttransportation delivery vendor will assess the eligibility and the available modes of transportation available within the member s county of record. Specialist in the Care Coordination department checks the member s eligibility and reviews remarks or notes to determine if the member has an authorization for the ride. 4. State eligible pregnant members who live in a PHC county are transferred to a coordinator with the Growing Together Perinatal Program (GTPP). 5. For eligible PHC members with an authorization, the Transportation Specialist completes the Transportation Sheet and approves transportation if criteria is met. 6. Non PHC members are not eligible for transportation. 7. Community transportation resources are discussed with all non-qualifying members and resource lists are mailed to members upon request. 8. RENAL DIALYSIS/OTHER 9. Transportation Specialist completes the Transportation Questionnaire. See processes below for members who meet criteria for transportation service at the appropriate levels of transportation described. 10. Taxi 11. The Transportation Specialist completes the Transportation Sheet and forwards it to the appropriate vendor. 12. The Transportation Specialist enters a remark in PHC s member management system (Call Center) using a GN remark code and notates the pick-up and destination addresses, frequency of appointments, and the effective and end dates of the authorization PARATRANSIT SERVICES WHERE AVAILABLE a. The Transportation Specialist confirms paratransit enrollment. a. b. For Members who are enrolled in a paratransit program, the Transportation Specialist sends an to the designated Member Services (MS) Staff requesting vouchers for paratransit services. The includes the member s pick up and destination addresses, estimated frequency of use, and where and to whom the vouchers are to be mailed. The Transportation Specialist enters a remark in PHC s member management system (Call Center) using a GN remark code and notates the information provided in the to the designated MS staff b.. c. Members who are not enrolled in a paratransit program are considered for taxi services. The member is referred to the local paratransit office to apply for the paratransit program. c. d. ARRANGING TRANSPORTATION Taxi Services The Transportation Specialist will fax the Transportation Sheets to the appropriate transportation providers. Assigned staff maintains the Transportation Sheets for invoice processing. Taxi vendors are determined based upon the pick-up location or the member s special needs. PHC delegates the assessment and scheduling of NMT to a transportation delivery vendor for this service. Paratransit Services Where Available e.d. PHC may purchases paratransit tickets where available for members who need assistance and 51 of 130 Page 8 of 12

52 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Employees meet the transportation criteria. Care Coordination Staff notifies the designated MS Staff of members who have been approved for paratransit tickets. Based on the information provided by Care Coordination, the designated MS Staff will: 1) Send up to a four (4) month supply of paratransit tickets through certified mail to the member or other designee. 2) Enter the member s information into a log, noting the date, address and number of tickets mailed. D. RECONCILING TAXI INVOICES E. Taxi vendors submit an invoice and transportation receipts (signed by members) biweekly. The designated Care Coordination staff will: F. Match the invoiced amount to the Transportation Sheets - Charges listed on the invoice that do not have a matching Transportation Sheet are issued a correction request with approved payment amount. G. Manager of Care Coordination or designee shall approve invoices prior to submitting to finance H. Forward the invoice and vouchers to the Finance Department for payment I. COMMUNITY ORGANIZED TRANSPORTATION SERVICE (COTS) J. Subject to the approval of the CEO or designee, the Director of Health Services or the Northern Region Executive Director may designate an area as one of high transportation need based upon limited transportation options and significant access issues. The community organized transportation service (COTS) is available to members only in areas designated as high transportation need. This enhancement is available to members designated as high transportation need only and is based on the availability of a PHC contracted community organized service. Those not qualifying for this enhanced service will not receive a notice of action and are not eligible to file an appeal. K. Designation of Area of High Transportation Need - An area may be designated as one of high transportation need if all of these criteria are met: 52 of 130 Page 9 of 12

53 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Employees M. There is no local public transportation system or the system has a limited number of routes and transports N. The distance between PHC primary care sites and the local hospitals is generally more than ten miles or 30 minutes O. When transportation requests pursuant to the rest of this policy would result in excessive delay of services. P. The area shall be defined in terms that are easy to understand (i.e., zip codes, city or county boundaries; etc.) Q. Definition of Community Organized Transportation R. The service is administered by a community agency such as a clinic, local nonprofit, or similar entity. S. The administering entity is responsible for arranging the transportation for PHC members which might include support for the cost of gas, use of volunteers, and payment for overnight stays for drivers for trips far out of the area, van services, or bus or train tickets. T. PHC will determine when the COTS will be utilized. The COTS will be notified and is responsible for verifying the member s eligibility per their process and also verifying that the purpose of the trip is for a health care service that has been recommended or referred by a PHC provider. Note that the health care service does not have to be a benefit provided by PHC (e.g., dental care). U. Eligibility for Community Organized Transportation V. In order to receive a community organized transportation service, the individual: W. Must be a PHC primary insured member at the time of the proposed transportation X. Be seeking health care services recommended or referred by a PHC provider Y. Meet the criteria of need established by the administering community entity Z. Must not have a history of three (3) or more missed appointments (see III. G.) in a calendar year. (If discontinued, the member will not be eligible to receive this enhanced service for 12 months from the date of third missed appointment.) AA. Payment for Community Organized Transportation Services BB. PHC shall pay the community agency a total amount for a given number of trips, with the agency agreeing to meet all PHC auditing and contracting requirements. CC. The agency shall establish its criteria for providing the service, except that it shall include in its criteria, approval of transportation for members referred to the agency by PHC. DD. Members eligible for services may include CCS clients who have exhausted their State funded transportation benefit. EE. EXCEPTIONS FF. Members who are identified as exceptions to our transportation policy are reviewed by the Care Coordination Lead, Healthcare Guide III, or Manager. GG. The Care Coordination Lead or Healthcare Guide III is the first line of review and is authorized to deny exception requests per PHC process. HH. The Care Coordination Manager consults with the treating physician or his/her office to determine eligibility for the non-emergency transportation service. II. If the Care Coordination Manager recommends the transportation for approval, the Care Coordination Manager completes the Transportation Exception Review form and forwards it to the CMO or physician designee for review. JJ. If the CMO or physician designee is not available, the Care Coordination Manager can authorize one ride. All subsequent rides need to be approved by the CMO or physician designee. The Care Coordination Manager will notify the member of the status/outcome of the request. 53 of 130 Page 10 of 12

54 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Lead Department: Health Services External Policy Internal Policy Next Review Date: 01/20/201708/16/2018 Last Review Date: 01/20/201607/07/201708/16/2017 Applies to: Medi-Cal Employees LL. The Care Coordination Transportation Specialist prepares a monthly summary report detailing: MM. The number of transportation requests NN. Total number of requests received under the exception criteria OO. The number of exception criteria rides that were approved. Other special exceptions may be considered on a case by case basis if there are compelling circumstances where lack of access to transportation not covered by the Medi-Cal program would materially compromise the member s life or health. Exceptions are approved by the CMO or physician designee. D. REGULATORY REQUIREMENTs a. PHC will establish a mechanism to capture and submit data from the PCS form to DHCS as instructed and is obligated to meet the contractually required timely access standards. E. COMPLAINTS AND GRIEVANCES 1. PHC will direct all member complaints and grievances regarding mistreatment and/or motor vehicle accidents to the individual vendor for investigation and resolution. 2. All accidents or damage to property while utilizing a PHC approved gas card are not the responsibility of the HealthPlan.. FCOMPLAINTS AND GRIEVANCES: PHC will direct all member complaints and grievances regarding mistreatment and/or motor vehicle accidents to the individual vendor for investigation and resolution. All accidents or damage to property while utilizing a PHC approved gas card are not the responsibility of the HealthPlan. VI.VII. REFERENCES: A. Title 22 California Code of Regulations (CCR) Section B. APL Requirements for Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Beneficiaries Under the Age of Twenty One (dated 6/201712/12/2014) B.C. APL Non-Emergency Medical and Non-Medical Transportation Services (dated 6/29/2017) VII.VIII. DISTRIBUTION: 1. PHC Departmental Directors 2. PHC Provider Manual VIII.IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services IX.X. REVISION DATES: 01/20/16; 08/16/17 PREVIOUSLY APPLIED TO: N/A *********************************** In accordance with the California Health and Safety Code, Section , this policy was developed with involvement from actively practicing health care providers and meets these provisions: Consistent with sound clinical principles and processes Evaluated and updated at least annually 54 of 130 Page 11 of 12

55 Policy/Procedure Number: MCCP2016 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/ PROCEDURE Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Lead Department: Health Services External Policy Internal Policy Applies to: Medi-Cal Employees Reviewing IQI P & T QUAC Entities: OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT Approving Entities: BOARD COMPLIANCE FINANCE PAC CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 08/17/2016 I. RELATED POLICIES: A. MCUP TAR Review Process B. MCCP Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services C. MCUG Prenatal & Perinatal Care II. III. IV. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services D. Grievance E. Finance F. Provider Relations DEFINITIONS: A. NEMT: Non-Emergency Medical Transportation B. NMT: Non-Medical Transportation C. GTPP: PHC s Growing Together Perinatal Program D. CMO: Chief Medical Officer E. Paratransit: Public or group transportation as by van or bus F. Missed appointment: No notification of cancellation within 48 hours of the scheduled transportation G. PCS: Physician Certification Statement prescribing the level of transportation necessary based upon the functional and medical limitations of the member H. Delegated transportation delivery vendor: The vendor responsible for determining eligibility and mode of transportation as well as scheduling I. Transportation provider: the entity that will actually be transporting the member ATTACHMENTS: N/A V. PURPOSE: To outline the circumstances by which PHC will pay for and/or facilitate transportation services to members and to provide guidance for the transportation specialist when reviewing TAR requests for transportation services. VI. POLICY / PROCEDURE: 55 of 130 Page 1 of 7

56 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Lead Department: Health Services External Policy Internal Policy Applies to: Medi-Cal Employees A. EMERGENCY MEDICAL TRANSPORTATION (EMT) 1. Emergency medical transportation (EMT) is provided for emergency medical conditions as defined in the Federal Statute (420.5.C.S 1396b[V]). The term emergency medical condition is defined in federal statute to mean a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: a. Placing the patient s health in serious jeopardy b. Serious impairment to bodily functions c. Serious dysfunction of any bodily organ or part 2. AIR emergency transportation is covered when medically necessary and when other forms of transportation are not practical or feasible for the patient s condition. 3. GROUND emergency transportation is covered when ordinary public or private medical transportation is medically contraindicated and transportation is needed to obtain care. 4. TAR is not required for emergency air or ground transportation. 5. Emergency transportation must be to the nearest hospital capable of meeting the medical needs of the patient. 6. Medical transportation which represents a continuation of an original emergency transport (such as transfer from an emergency room of one hospital to an emergency room of another hospital for treatment or admission) is considered a continuation of the initial emergency transport. 7. Emergency transportation provided for the purposes of evaluating a psychiatric crisis and/or for admission to a psychiatric facility is a covered service without a TAR. Counties directly performing this service are eligible providers, and the mode of transportation should be appropriate to the patient s medical and psychiatric needs. The continuation of an original emergency transport from an emergency room to another facility that can meet the medical and psychiatric needs of the patient is an appropriate emergency transport. B. NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) 1. NEMT services are a covered Medi-Cal benefit when a member needs to obtain medically necessary covered services and when prescribed in writing by a physician, podiatrist, or mild to moderate mental health or substance use disorder provider who has identified that transport by ordinary means of public or private conveyance is medically contraindicated and transportation is required for obtaining medically necessary services [22CCR Section (a)]. NEMT services are subject to a prior authorization, except when a member is transferred from an acute care hospital, immediately following an inpatient stay at the acute level of care, to a skilled nursing facility or an intermediate care facility licensed pursuant to Health and Safety Code (HSC) Section Where applicable, PHC will make a good faith effort to refer and coordinate NEMT services for members when those services are carved out of the Health Plan. 2. Both a TAR and a Physician Certification Statement (PCS) ARE required for all NEMT (the only exception is transportation upon discharge from an acute care facility, inpatient bed or Emergency Department directly to a Long Term Care (LTC) facility or to another acute care facility). Once submitted to PHC, prescribed NEMT services and the corresponding PCS form cannot be changed or altered. a. The TAR or Physician Certification (PCS) must include, at minimum, the function limitations justification, dates of services needed, and the mode of transportation appropriate based on the member s physician identified limitations. b. PHC collects information from the PCS form to submit to DHCS. 56 of 130 Page 2 of 7

57 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Lead Department: Health Services External Policy Internal Policy Applies to: Medi-Cal Employees c. The provider has 15 business days from date of service to submit a TAR. Refer to policy MCUP3041 for TAR Review Process. d. Untimely TARS will receive an administrative denial and a fax is sent to the provider with justification of the denial. e. PHC reviews the TAR request to determine the appropriate level of transport at the lowest level of cost based on medical necessity and reviews the case with the ordering physician as indicated. f. If the TAR does not appear to meet medical necessity, it is sent to the Care Coordination Manager for a decision and, if appropriate, forwarded to the CMO or physician designee for review. 3. PHC will provide transportation for a minor and a parent or legal guardian along with any travel related expenses such as meals and lodging if the medical appointment is too far distant from patient s home to reasonably allow for same day travel. 4. A minor may travel unaccompanied with written consent from the parent or legal guardian if the transportation provider s policy allows. 5. AMBULANCE service may be used for: a. Transfers from an acute care facility to another acute care facility b. Transport for members who have recently been placed on oxygen (does not apply to members with chronic emphysema who carry their own oxygen for continuous use). c. Transport for members with chronic conditions who require oxygen if monitoring is required. d. Transfers between facilities for members who require continuous intravenous medication, medical monitoring or observation. 6. LITTER VAN service may be used when the member s medical and physical condition does not meet the need for NEMT ambulance services, but meets both of the following: a. Requires that the member be transported in a prone or supine position, because the member is incapable of sitting for the period of time needed to transport. [22CCR Section 51323(2)(A)(1)]. b. Requires specialized safety equipment over and above that normally available in passenger cars, taxicabs or other forms of public conveyance [22 CCR Section (2)(B)]. 7. WHEELCHAIR VAN service may be used when the member s medical and physical condition does not meet the need for litter van services, but meets any of the following: a. Renders the member incapable of sitting in a private vehicle, taxi or other form of public transportation for the period of time needed to transport [22CCR Section (3)(A)]. b. Requires that the member be transported in a wheelchair or assisted to and from a residence, vehicle and place of treatment because of a disabling physical or mental limitation (22CCR Section (3)(B)). c. Requires specialized safety equipment over and above that normally available in passenger cars, taxicabs or other forms of public conveyance (22 CCR Section 51323(3)(C) d. Members with the following conditions may qualify for wheelchair van transport when their providers submit a signed Physician Certification Statement (PCS) form 1) Members who suffer from severe mental confusion 2) Members with paraplegia 3) Dialysis recipients 4) Members with chronic conditions who require oxygen but do not require monitoring. 57 of 130 Page 3 of 7

58 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Lead Department: Health Services External Policy Internal Policy Applies to: Medi-Cal Employees 8. Air Transport for NEMT will be provided only when transportation by air is necessary because of the member s medical condition or because practical considerations render ground transportation not feasible. The necessity for transportation by air shall be substantiated in a written order of a physician, dentist, podiatrist, or mental health or substance use disorder provider. 9. PHC reserves the right to review any TAR or claims for non-emergency transport and, based on medical necessity, will pay for the appropriate type of transport if that service is available within the county. 10. BILLING FOR NON-EMERGENCY MEDICAL TRANSPORTATION a. The cost of an ambulance, litter van, or wheelchair transport of an inpatient between acute care facilities for services that cannot be performed at the facility, such as special testing, diagnostic procedures, or radiation therapy is included in the hospital per diem rate and the provider is to bill the hospital directly. b. Services included in the base rate and not separately reimbursable are as follows: backboards, flat/scoop stretcher, long boards, disposable O2 masks/tubing, disposable IV tubing, childbirth, assistance, restraints, suction/suction equipment, resuscitations, respirator/intermittent Positive Pressure Breathing (IPPB), crew of 3 (air) or 2 (ground), pick-up off paved road, or overweight or difficult patients, linens/blankets. c. Wait time up to 3 units is reimbursable (1 unit equals 30 minutes). d. The provider must bill Medicare and/or private insurance payers first for all emergency transports of PHC members who have other coverage. e. It is PHC policy to cover all transportation services per Medi-Cal guidelines. See Medi- Cal Guidelines for more specific information and rates. C. NON-MEDICAL TRANSPORTATION (NMT) Effective July 1, 2017, Non-Medical Transportation (NMT) is a benefit when a member is to obtain medically necessary Managed Care Plan (MCP)-covered services or services that are considered carved-in to the HealthPlan. When and where applicable, PHC will make a good faith effort to refer and coordinate NMT for Medi-Cal services that are considered to be carved-out of the HealthPlan. Effective October 1, 2017, unless otherwise instructed by DHCS, the NMT benefit will include medically-necessary Medi-Cal services that are considered carved-out to the HealthPlan. NMT does not include transportation of the sick, injured, invalid, convalescent, infirm, or otherwise incapacitated members who need to be transported by ambulances, litter vans, or wheelchair vans licensed, operated, and equipped in accordance with state and local statutes, ordinances, or regulations. Physicians may authorize NMT for members if they are currently using a wheelchair but the limitation is such that the member is able to ambulate without assistance form the driver. The NMT requested must be the least costly method of transportation that meets the member s needs. Please refer to the Member Services handbook for further details. 1. CONDITIONS FOR NON-MEDICAL TRANSPORTATION SERVICES a. Non PHC members are not eligible for transportation services. b. All PHC members requesting NMT will receive an assessment performed by PHC s contracted vendor to determine the most appropriate mode of transport. c. NMT coverage includes transportation costs for the member and one attendant. The attendant can be a parent, guardian, or spouse to accompany the member in a vehicle or on public transportation which is subject to prior authorization at the time of the initial NMT authorization request. 1) The level of transportation accommodation needed will be based upon the limitations of the member being transported. Any attendants must be able to safely accompany the member and not require additional assistance. d. With the written consent of a parent or guardian, a minor may receive transportation unaccompanied as long as the vendor accepts the necessary written consent forms and agrees to 58 of 130 Page 4 of 7

59 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Lead Department: Health Services External Policy Internal Policy Applies to: Medi-Cal Employees provide unaccompanied transport. Certain appointments will not require written consent to travel unaccompanied such as: 1) Appointments resulting from sexual assault, abuse, rape or incest 2) Appointments related to drug or alcohol abuse 3) Family Planning/Pregnancy or abortion services 4) STD or HIV/AIDS related testing e. NMT does not cover trips to a non-medical location or for appointments that are not medically necessary. f. The member must attest either in person, electronically, or over the phone that other transportation resources have been reasonably exhausted. The attestation may include confirmation that the member: 1) Has no valid driver s license 2) Has no working vehicle available in the household 3) Is unable to travel or wait for medical or dental services alone 4) Has a physical, cognitive, mental or developmental limitation g. Transportation from an emergency room to home or other housing resource is not included in the benefit h. NMT transportation services include roundtrip transportation from the member s home of record, which is provided from the state, to the scheduled appointment s address and back. NMT services include passenger car, taxi cab, public/private conveyance, or mileage reimbursement. Limited exceptions may apply if there are safety concerns with the identified address or the member is homeless. 2. NON-MEDICAL TRANSPORTATION PRIVATE VEHICLE AUTHORIZATION REQUIREMENTS a. PHC s delegated transportation delivery vendor will authorize the use of private vehicle through the use of mileage reimbursement when no other methods of transportation are reasonably available to the member and the member verbally or in writing states they have the following: 1) Valid driver s license 2) Valid vehicle registration 3) Valid vehicle insurance b. Mileage reimbursement for gas is consistent with the Internal Revenue Service standard mileage rate for medical transportation when conveyance is in a private vehicle arranged by the member. 3. SUBMITTING NMT TRANSPORTATION REQUESTS a. Requests for transportation can be made by the member, the member s representative, or the member s provider by calling PHC s delegated NMT transportation delivery vendor or the HealthPlan. If the HealthPlan is contacted, the member will be given the appropriate contact number for the vendor and will also be connected to the delegated transportation delivery vendor to be screened for services. The delegated transportation delivery vendor will assess the eligibility and the available modes of transportation available within the member s county of record. 1) Non urgent/planned appointments requests are to be made a minimum of 5 business days prior to the scheduled appointment or risk being instructed to reschedule 2) Urgent transportation requests for unplanned appointments are considered but not guaranteed; the member may be instructed to reschedule the appointment 4. PARATRANSIT SERVICES WHERE AVAILABLE a. The Transportation Specialist confirms paratransit enrollment. b. For Members who are enrolled in a paratransit program, the Transportation Specialist sends an to the designated Member Services (MS) Staff requesting vouchers for paratransit services. The includes the member s pick up and destination addresses, estimated frequency of use, and where and to whom the vouchers are to be mailed. The Transportation 59 of 130 Page 5 of 7

60 Policy/Procedure Number: MCCP2016 Policy/Procedure Title: Transportation Guidelines for Non- Emergency Medical (NEMT) and Non-Medical Transportation (NMT) Original Date: 10/21/2015 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Lead Department: Health Services External Policy Internal Policy Applies to: Medi-Cal Employees Specialist enters a remark in PHC s member management system (Call Center) using a GN remark code and notates the information provided in the to the designated MS staff c. Members who are not enrolled in a paratransit program are considered for taxi services. The member is referred to the local paratransit office to apply for the paratransit program. d. PHC may purchase paratransit tickets where available for members who meet the transportation criteria. Care Coordination Staff notifies the designated MS Staff of members who have been approved for paratransit tickets. Based on the information provided by Care Coordination, the designated MS Staff will: 1) Send up to a four (4) month supply of paratransit tickets through certified mail to the member or other designee. 2) Enter the member s information into a log, noting the date, address and number of tickets mailed. D. REGULATORY REQUIREMENT PHC will establish a mechanism to capture and submit data from the PCS form to DHCS as instructed and is obligated to meet the contractually required timely access standards. E. COMPLAINTS AND GRIEVANCES 1. PHC will direct all member complaints and grievances regarding mistreatment and/or motor vehicle accidents to the individual vendor for investigation and resolution. 2. All accidents or damage to property while utilizing a PHC approved gas card are not the responsibility of the HealthPlan. VII. VIII. IX. REFERENCES: A. Title 22 California Code of Regulations (CCR) Section B. APL Requirements for Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Beneficiaries Under the Age of Twenty One (dated 6/2017) C. APL Non-Emergency Medical and Non-Medical Transportation Services (dated 6/29/2017) DISTRIBUTION: 1. PHC Departmental Directors 2. PHC Provider Manual POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services X. REVISION DATES: 01/20/16; 08/16/17 PREVIOUSLY APPLIED TO: N/A *********************************** In accordance with the California Health and Safety Code, Section , this policy was developed with involvement from actively practicing health care providers and meets these provisions: Consistent with sound clinical principles and processes Evaluated and updated at least annually If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request 60 of 130 Page 6 of 7

61 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/ PROCEDURE Policy/Procedure Number: MCCP2022 (previously MCUP3065; UP100365) Policy/Procedure Title: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services Original Date: 03/16/2005 (MCUP3065) Lead Department: Health Services External Policy Internal Policy Next Review Date: 02/15/201808/16/2018 Last Review Date: 02/15/201708/16/2017 Applies to: Medi-Cal Employees Reviewing Entities: Approving Entities: IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT BOARD COMPLIANCE FINANCE PAC CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 02/15/201708/16/2017 I. RELATED POLICIES: A. MCUP3041 TAR Review Process B. MPCP2002 California Children s Services C. MCCP2005 EPSDT Supplemental Shift Nursing Services D. MPCP2006 Coordination of Services for Members with Special Health Care Needs (MSHCNs) and Persons with Developmental Disabilities E. MCQG1015 Pediatric Preventive Health II. III. IV. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services DEFINITIONS: A. N/ACCS: California Children s Services B. : FFS: Fee-for-Service C. LEA: Local Education Agency D. TCM: Targeted Case Management ATTACHMENTS: A. N/A V. PURPOSE: To define Partnership HealthPlan of California s (PHC s) responsibility to cover medically necessary services not covered under the Medi-Cal Program for children individuals under the age of 21 under the Early and Periodic Screening Diagnosis and Treatment (EPSDT) supplemental services benefit. VI. POLICY / PROCEDURE: A. For services to be approved by PHC under this section, services requested must satisfy the criteria in Title 22 California Code of Regulation (CCR) Section and Section 1905(a) of the Social Security Act. B. EPSDT services that shall be covered by PHC may be subject to prior authorization and must meet the standards set forth in Section 1905(a) of the Social Security Act within the categories of mandatory and optional services and Sections and in Title 22 CCR, and any specific requirements 61 of 130 Page 1 of 4

62 Policy/Procedure Number: MCCP2022 (previously MCUP3065; UP100365) Lead Department: Health Services Policy/Procedure Title: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services External Policy Internal Policy Original Date: 03/16/2005 (MCUP3065) Next Review Date: 02/15/201808/16/2018 Last Review Date: 02/15/201708/16/2017 Applies to: Medi-Cal Employees applicable to a specific service that are based on the standards and requirements of those sections other than the service-specific requirements set forth in Title 22 CCR Section C. PHC has the primary responsibility to provide all carved in medically necessary services which exceed the amount provided by Local Education Agency (LEA), Regional Centers or local government health programs. However, these entities must continue to meet their own requirements regarding provisions of services. C.D. Prior authorization procedures may not be required for any all EPSDT screening services. D.E. The service-specific requirements as set forth in Title 22 CCR Section must meet all of the following criteria, where applicable: 1. The services are necessary to screen, diagnose, correct or ameliorate defects in physical illnesses and mental illnesses and conditions. Mental health services for those children with serious and persistent mental health issues and conditions are the responsibility of the local Mental Health Department. 2. Children with mild to moderate mental health issues or conditions are the responsibility of PHC and services for them are available through Beacon Health Strategies as PHC s subcontractor. If a member is assigned to Kaiser Permanente as his/her Primary Care Provider (PCP), mental health services are available through Kaiser Permanente. 3. The supplies, items, or equipment to be provided are medical in nature. 4. The services are not requested solely for the convenience of the beneficiary, family, physician or another provider of services. 5. The services are not unsafe for the individual EPSDT-eligible beneficiary, and are not experimental. 6. The services are neither primarily cosmetic in nature nor primarily for the purpose of improving the beneficiary s appearance. The correction of severe or disabling disfigurement shall not be considered to be primarily cosmetic nor primarily for the purpose of improving the beneficiary s appearance. 7. Where alternative medically accepted modes of treatment are available, the services are the most cost-effective. E.F. In addition to the items listed under VI.ED, the services to be provided must meet all of the following criteria, where applicable: 1. Must be generally accepted by the professional medical community as effective and proven treatments for the conditions for which they are proposed to be used. Such acceptance shall be demonstrated by scientific evidence, consisting of well-designed and well-conducted investigations published in peer-review journals and have opinions and evaluations published by national medical and dental organizations, consensus panels, and other technology evaluation bodies. Such evidence shall demonstrate that the services can screen, diagnose, correct or ameliorate the conditions for which they are prescribed. 2. Are within the authorized scope of practice of the provider, and are an appropriate mode of treatment for the health condition of the beneficiary. 3. The predicted beneficial outcome of the services outweighs potential harmful effects. 4. Available scientific evidence demonstrates that the services improve the overall health outcomes as much as, or more than, established alternatives. G. Case Management & Targeted Case Management Services 1. When identified, PHC will determine whether a member requires Case Management or Targeted Case Management (TCM) services under EPSDT. For members who are eligible for these services, PHC will refer the member to the Regional Center or local government health program where applicable. 2. For members less than 21 year old, for whom the Regional Center or local government health program is not able to provide necessary TCM services for the eligible PHC member, PHC shall ensure that the member has access to comparable TCM services. 3. If a member is currently receiving TCM services, PHC will coordinate the member s health care 62 of 130 Page 2 of 4

63 Policy/Procedure Number: MCCP2022 (previously MCUP3065; UP100365) Lead Department: Health Services Policy/Procedure Title: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services External Policy Internal Policy Original Date: 03/16/2005 (MCUP3065) Next Review Date: 02/15/201808/16/2018 Last Review Date: 02/15/201708/16/2017 Applies to: Medi-Cal Employees with the TCM provider. 4. PHC s Care Coordination Department will provide appointment scheduling assistance and coordinate any necessary transportation to and from any medically necessary covered EPSDT appointments. H. Excluded Services: 1. Dental Services provided by providers covered by the Medi-Cal Denti-Cal program. 2. Non-medical services provided by Regional Centers to individuals with developmental disabilities, including but not limited to, respite, out-of-home placement, and supportive living. 3. Alcohol and substance use disorder treatment services available under the Drug Medi-Cal Program and outpatient heroin detoxification services including all medication used for the treatment of alcohol and substance use disorders covered by the Department of Health Care Services (DHCS), as well as specific medications not currently covered by DHCS, but reimbursed through Medi-Cal feefor-service (FFS). 4. Specialty mental health services listed in Title 9, CCR, Section for individuals who meet medical necessity criteria as specified in Title 9, CCR, Sections , or ; for which services must be provided by the individual s county Mental Health Plan. 5. California Children Services (CCS) that are carved out to the state, including private duty nursing related to a CCS-eligible condition, must be case managed and have obtained prior authorization by the CCS Program (on a FFS basis) per Title 22, CCR, Section Pediatric Day Health Care Services I. Prior Authorization Process 1. For services to be considered under the EPSDT benefit, a Treatment Authorization Request (TAR) must be, and shall be, accompanied by the following information: a. The principal diagnosis and significant associated diagnoses b. Prognosis c. Date of onset of the illness or condition, and etiology if known d. Clinical significance or functional impairment caused by the illness or condition e. Specific types of services to be rendered by each discipline with physician's prescription where applicable f. The therapeutic goals to be achieved by each discipline, and anticipated time for achievement of goals g. The extent to which health care services have been previously provided to address the illness or condition, and results demonstrated by prior care h. Any other documentation available which may assist the Department in making the determinations required by this section 2. The TAR will be reviewed by PHC using current EPSDT criteria. VII. VIII. REFERENCES: A. Title 22 California Code of Regulation (CCR) Sections 51003, 51184, 51303, 51340, B. Mental Health Parity and Addiction Equity Act C. Social Security Act Section 1905 (a) D. Department of Health Care Services All Plan Letter : Requirements for Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Beneficiaries Under the Age of Twenty One. DISTRIBUTION: A. Provider Manual B. PHC Directors 63 of 130 Page 3 of 4

64 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/ PROCEDURE Policy/Procedure Number: MCCP2022 (previously MCUP3065; UP100365) Policy/Procedure Title: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services Original Date: 03/16/2005 (MCUP3065) Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Lead Department: Health Services External Policy Internal Policy Applies to: Medi-Cal Employees Reviewing Entities: Approving Entities: IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT BOARD COMPLIANCE FINANCE PAC CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 08/16/2017 I. RELATED POLICIES: A. MCUP3041 TAR Review Process B. MPCP2002 California Children s Services C. MCCP2005 EPSDT Supplemental Shift Nursing Services D. MPCP2006 Coordination of Services for Members with Special Health Care Needs (MSHCNs) and Persons with Developmental Disabilities E. MCQG1015 Pediatric Preventive Health II. III. IV. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services DEFINITIONS: A. CCS: California Children s Services B. FFS: Fee-for-Service C. LEA: Local Education Agency D. TCM: Targeted Case Management ATTACHMENTS: A. N/A V. PURPOSE: To define Partnership HealthPlan of California s (PHC s) responsibility to cover medically necessary services not covered under the Medi-Cal Program for individuals under the age of 21 under the Early and Periodic Screening Diagnosis and Treatment (EPSDT) supplemental services benefit. VI. POLICY / PROCEDURE: A. For services to be approved by PHC under this section, services requested must satisfy the criteria in Title 22 California Code of Regulation (CCR) Section and Section 1905(a) of the Social Security Act. B. EPSDT services that shall be covered by PHC may be subject to prior authorization and must meet the standards set forth in Section 1905(a) of the Social Security Act within the categories of mandatory and optional services and Sections and in Title 22 CCR, and any specific requirements applicable to a specific service that are based on the standards and requirements of those sections other 64 of 130 Page 1 of 4

65 Policy/Procedure Number: MCCP2022 (previously MCUP3065; UP100365) Lead Department: Health Services Policy/Procedure Title: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services External Policy Internal Policy Original Date: 03/16/2005 (MCUP3065) Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: Medi-Cal Employees than the service-specific requirements set forth in Title 22 CCR Section C. PHC has the primary responsibility to provide all carved in medically necessary services which exceed the amount provided by Local Education Agency (LEA), Regional Centers or local government health programs. However, these entities must continue to meet their own requirements regarding provisions of services. D. Prior authorization procedures may not be required for all EPSDT screening services. E. The service-specific requirements as set forth in Title 22 CCR Section must meet all of the following criteria, where applicable: 1. The services are necessary to screen, diagnose, correct or ameliorate defects in physical illnesses and mental illnesses and conditions. Mental health services for those children with serious and persistent mental health issues and conditions are the responsibility of the local Mental Health Department. 2. Children with mild to moderate mental health issues or conditions are the responsibility of PHC and services for them are available through Beacon Health Strategies as PHC s subcontractor. If a member is assigned to Kaiser Permanente as his/her Primary Care Provider (PCP), mental health services are available through Kaiser Permanente. 3. The supplies, items, or equipment to be provided are medical in nature. 4. The services are not requested solely for the convenience of the beneficiary, family, physician or another provider of services. 5. The services are not unsafe for the individual EPSDT-eligible beneficiary, and are not experimental. 6. The services are neither primarily cosmetic in nature nor primarily for the purpose of improving the beneficiary s appearance. The correction of severe or disabling disfigurement shall not be considered to be primarily cosmetic nor primarily for the purpose of improving the beneficiary s appearance. 7. Where alternative medically accepted modes of treatment are available, the services are the most cost-effective. F. In addition to the items listed under VI.E, the services to be provided must meet all of the following criteria, where applicable: 1. Must be generally accepted by the professional medical community as effective and proven treatments for the conditions for which they are proposed to be used. Such acceptance shall be demonstrated by scientific evidence, consisting of well-designed and well-conducted investigations published in peer-review journals and have opinions and evaluations published by national medical and dental organizations, consensus panels, and other technology evaluation bodies. Such evidence shall demonstrate that the services can screen, diagnose, correct or ameliorate the conditions for which they are prescribed. 2. Are within the authorized scope of practice of the provider, and are an appropriate mode of treatment for the health condition of the beneficiary. 3. The predicted beneficial outcome of the services outweighs potential harmful effects. 4. Available scientific evidence demonstrates that the services improve the overall health outcomes as much as, or more than, established alternatives. G. Case Management & Targeted Case Management Services 1. When identified, PHC will determine whether a member requires Case Management or Targeted Case Management (TCM) services under EPSDT. For members who are eligible for these services, PHC will refer the member to the Regional Center or local government health program where applicable. 2. For members less than 21 year old, for whom the Regional Center or local government health program is not able to provide necessary TCM services for the eligible PHC member, PHC shall ensure that the member has access to comparable TCM services. 3. If a member is currently receiving TCM services, PHC will coordinate the member s health care with the TCM provider. 65 of 130 Page 2 of 4

66 Policy/Procedure Number: MCCP2022 (previously MCUP3065; UP100365) Lead Department: Health Services Policy/Procedure Title: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services External Policy Internal Policy Original Date: 03/16/2005 (MCUP3065) Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: Medi-Cal Employees 4. PHC s Care Coordination Department will provide appointment scheduling assistance and coordinate any necessary transportation to and from any medically necessary covered EPSDT appointments. H. Excluded Services: 1. Dental Services provided by providers covered by the Medi-Cal Denti-Cal program. 2. Non-medical services provided by Regional Centers to individuals with developmental disabilities, including but not limited to, respite, out-of-home placement, and supportive living. 3. Alcohol and substance use disorder treatment services available under the Drug Medi-Cal Program and outpatient heroin detoxification services including all medication used for the treatment of alcohol and substance use disorders covered by the Department of Health Care Services (DHCS), as well as specific medications not currently covered by DHCS, but reimbursed through Medi-Cal feefor-service (FFS). 4. Specialty mental health services listed in Title 9, CCR, Section for individuals who meet medical necessity criteria as specified in Title 9, CCR, Sections , or ; for which services must be provided by the individual s county Mental Health Plan. 5. California Children Services (CCS) that are carved out to the state, including private duty nursing related to a CCS-eligible condition, must be case managed and have obtained prior authorization by the CCS Program (on a FFS basis) per Title 22, CCR, Section Pediatric Day Health Care Services I. Prior Authorization Process 1. For services to be considered under the EPSDT benefit, a Treatment Authorization Request (TAR) must be, and shall be, accompanied by the following information: a. The principal diagnosis and significant associated diagnoses b. Prognosis c. Date of onset of the illness or condition, and etiology if known d. Clinical significance or functional impairment caused by the illness or condition e. Specific types of services to be rendered by each discipline with physician's prescription where applicable f. The therapeutic goals to be achieved by each discipline, and anticipated time for achievement of goals g. The extent to which health care services have been previously provided to address the illness or condition, and results demonstrated by prior care h. Any other documentation available which may assist the Department in making the determinations required by this section 2. The TAR will be reviewed by PHC using current EPSDT criteria. VII. VIII. IX. REFERENCES: A. Title 22 California Code of Regulation (CCR) Sections 51003, 51184, 51303, 51340, B. Mental Health Parity and Addiction Equity Act C. Social Security Act Section 1905 (a) D. Department of Health Care Services All Plan Letter : Requirements for Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Beneficiaries Under the Age of Twenty One. DISTRIBUTION: A. Provider Manual B. PHC Directors POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services 66 of 130 Page 3 of 4

67 Policy/Procedure Number: MCCP2023 PARTNERSHIP HEALTHPLAN OF CALIFORNIA Policy/Procedure Title: New Member Needs Assessment Original Date: 08/16/2017 POLICY/ PROCEDURE Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Lead Department: Health Services External Policy Internal Policy Applies to: Medi-Cal Employees Reviewing Entities: Approving Entities: IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT BOARD COMPLIANCE FINANCE PAC CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 08/16/2017 I. RELATED POLICIES: A. MPCD2013 Care Coordination Program Description B. MCCP2019 Identification and Care Coordination for Seniors and Persons with Disabilities II. III. IV. IMPACTED DEPTS: A. Health Services B. Information Technology C. Member Services DEFINITIONS: A. Health Information Form (HIF)/Member Evaluation Tool (MET): Screening tool sent to newly enrolled members to identify members needing expedited care. B. Health Risk Assessment (HRA): Tool utilized to evaluate newly enrolled members with corresponding Senior and Persons with Disabilities (SPD) aid codes. C. Care Coordination Staff: PHC s Care Coordination staff members have either experience in health care fields (i.e. Medical Assistant, Emergency Medical Technician, etc.) or are licensed and possess the appropriate skills and training to assist members. All staff are trained in care coordination and motivational interviewing. ATTACHMENTS: A. HIF/MET Form B. HRA Form V. PURPOSE: This policy describes the process Partnership HealthPlan of California (PHC) will follow to assess new plan enrollees in order to identify those members who may need expedited services. VI. POLICY / PROCEDURE: A. New Member Outreach Process 1. All newly enrolled members who are designated with an SPD aid code are sent the HRA form (Attachment B) via mail within 10 days of enrollment into the plan along with a postage-paid envelope for response. The HRA includes both questions from the HIF tool and additional questions appropriate for assessing the need for expedited services for SPD members. (See policy MCCP2019 for the full process of SPD screening and risk assignment.) 2. All newly enrolled members who are not designated with an SPD aid code are sent the HIF/MET form (Attachment A) via mail within 10 days of enrollment into the plan along with a postage- 67 of 130 Page 1 of 2

68 Policy/Procedure Number: MCCP2023 Lead Department: Health Services External Policy Policy/Procedure Title: New Member Needs Assessment Internal Policy Next Review Date: 08/16/2018 Original Date: 08/16/2017 Last Review Date: 08/16/2017 Applies to: Medi-Cal Employees paid envelope for response. 3. Members who have not returned the HRA or the HIF/MET within 30 days of the initial mailing are contacted by phone. This outreach can be made to head of household for Members under the care of parents or other authorized representatives. At least two attempts will be made to contact the member within a 14 day period. The purpose of the call is to: a. Confirm the receipt of the HRA or HIF/MET b. Encourage the member to complete the HRA or HIF/MET c. Offer assistance in completing the HRA or HIF/MET with the member over the phone d. Offer to send a second HRA or HIF/MET if it was either lost or not received B. Initial Screening 1. Within 45 days of enrollment and receipt of the HRA (for high risk SPDs) or within 90 days of enrollment and receipt of the HIF/MET for all other newly enrolled members, PHC will review the screening tool to determine if the member requires expedited care. If the member is found to require expedited care, a Care Coordination staff member will contact the member or member s authorized representative. a. The role of Care Coordination staff member in the HRA or HIF/MET process is to expedite access to care for new members. Examples include, but are not limited to: 1) Contact durable medical equipment vendors to facilitate timely delivery of appropriate medical equipment 2) Work with the primary care provider and/or specialists offices to coordinate appointments 3) Arrange transportation as appropriate 4) Provide support and encouragement to the member and caregiver 5) Identify members who may benefit from mental health services and refer to appropriate agencies for services 6) Work with member to identify any psychosocial needs and refer to community-based organizations as appropriate 7) Assist with facilitating referrals to appropriate resources and/ or services outside of the Plan s benefits (i.e. personal care, housing, meal delivery programs, and/or energy assistance programs) 8) Screen and refer new members who may benefit from Basic Case Management or Complex Case Management Services C. Disenrollment 1. Upon disenrollment from PHC and when requested, PHC will make the results of the HRA or HIF/MET assessment available to the new Medi-Cal Managed Care Health Plan. REFERENCES: B. DHCS Contract July 2017 C. Title 42 Code of Federal Regulations (CFR) (b) VII. VIII. IX. DISTRIBUTION: A. PHC Department Directors B. PHC Provider Manual POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services REVISION DATES: N/A PREVIOUSLY APPLIED TO: N/A 68 of 130 Page 2 of 2

69 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE Policy/Procedure Number: MP316 Policy/Procedure Title: Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior Original Date: 07/27/1994 Lead Department: Member Services External Policy Internal Policy Next Review Date: 08/16/ /14/2015 Last Review Date: 08/16/ /14/2014 Applies to: Medi-Cal Healthy Kids Employees Reviewing Entities: IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT Approving BOARD COMPLIANCE FINANCE PAC Entities: CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Date: Approval Signature: Kevin Spencer / Kelley Sewell 08/16/ /14/2014 I. RELATED POLICIES: A. MP 301 Assisting Providers with Missed Appointments B. MP 312 Processing PCP Selections and Transfers Requests II. III. IV. IMPACTED DEPTS.: DEFINITIONS: A. Provider Request to Discharge: A provider s request to discharge a member from his/her practice. B. Re-assignment: A member is transferred to the care of another Primary Care Provider or Special Case Managed category, if applicable. C. Member Type U: For the purpose of this policy, members are defined as Type U Members if they have been discharged for reasons other than fraud, threats of violence and/or violent behavior. D. Member Type V: For the purpose of this policy, members are defined as Type V Members if they have been discharged for fraud, threats of violence t and/or violent behavior. Threats of violence includes menacing body language and/or verbal threats of physical violence. D.E. Medical Home: The provider identified as the member s medical home or PCP is responsible for managing the member s primary care needs. ATTACHMENTS: A. Form #6 (Provider Request for Discharge/Assistance with Inappropriate Behavior) B. Letter #MS10a (Member Services Notifies PCP of decision) C. Letter #MS10c (Assistance with Inappropriate Behavior at Provider s Office) D. Letter #MS10d (Notice of PCP Discharged Request Denied) E.D. Letter #MS10b (Type U) (Notification of PCP Discharge Request Approved) F. Letter #MS10e (Type V) (Notification of PCP Discharge Request Approved Special Member) V. PURPOSE: To clarify the circumstances in which a medical provider may discharge a PHC member from his/her practice and the process of member and provider notification. Additional clarification of questions about this process areis directed to the PHC Provider Relations (PR) Department. VI. POLICY / PROCEDURE: A. Assistance with Inappropriate Behavior 1. Prior to requesting discharge, providers may request assistance from PHC when a patient and/or patient representative displays verbally abusive and/or disruptive behavior in a physician s office. 2. Examples of verbal abuse and/or disruptive behavior: 69 of 130 Page 1 of 6

70 Policy/Procedure Number: MP316 Lead Department: Member Services Policy/Procedure Title: Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior External Policy Internal Policy Original Date: 07/27/1994 Next Review Date: 08/16/ /14/2015 Last Review Date: 08/16/ /14/2014 Applies to: Medi-Cal Healthy Kids Employees a. Yelling and/or screaming b. Ethnic slurs c. Foul language d. Physical or verbal threats of violence 3. If the provider requests PHC assistance, the following procedure is followed: a. The provider must notify PHC s Member Services (MS) Department in writing to request assistance with inappropriate behavior. The provider must provide complete documentation outlining the nature of the problem, including Form #6 titled Provider Request for Discharge/Assistance with Inappropriate Behavior (Attachment A) for each member included in the request. If additional information is needed from the provider, the MS Department will request the additional information through PHC s Provider Relations Department. b. The Provider faxes a request for assistance to PHC s MS Department at the fax number on Form #6specified on the Provider Request for Discharge/Assistance with Inappropriate Behavior form, (Attachment A). MS staff documents the request in Amisys or the Call Center System and sends letter #10c (Attachment C) to the member, copying the requesting provider. c. Incomplete requests: If additional information is needed from the provider, the MS Department requests the information through PHC s PR Department. The request for assistance with inappropriate behavior will beis pended for five (5) business days. If the information is not received within the five (5) business days the request is closed. MS notifies the provider that not enough information was received timely to process the request. B. Discharge Requests 1. PHC s uses its best effort is used to provide members the opportunity to be cared for by medical providers with whom a collaborative physician/patient relationship can be developed. Because the relationship is personal in nature, circumstances may arise under which the relationship between a member and a provider becomes non-collaborative. Medical providers are permitted to request that a member be discharged from his/her practice in certain circumstances, but it is the sole responsibility of PHC to determine if the request meets PHC s discharge criteria. Providers are expected to have procedures in place that provide guidance to practitioners and staff when dealing with challenging patients. Providers can request sample procedures through PHC s PRrovider Relations Department. C. Discharge Criteria 1. Using the written documentation provided by the provider and the discharge criteria listed below, appropriate PHC staff determines if the request for discharge meets PHC s discharge criteria. Designated MS staff consults the Care Coordination (CC) designee, PHC Chief Medical Officer or designee as needed. 2. The following behaviors are generally considered appropriate criteria for discharge: a. Fraudulently receiving benefits under a health plan contract. b. Fraudulently receiving and/or altering prescriptions, theft of prescription pads, or photocopying prescriptions. c. Physically abusive behavior exhibited to the provider or office personnel. d. Threatening behavior exhibited in the course of needing or receiving care. e. Credible threat of thereceipt of a notice of a member s intent to initiate or pursue legal action (not including a state fair hearing) against the provider and/or his/her associates. f. Refusal by the member to follow recommended medical treatment where the provider believes there is no alternative treatment, and that refusal will severely endangers the health of the member. This situation cannot be ameliorated improved by repeated attempts by PHC s CC case managerdesignee to intervene, and in the judgment of the designated MS Management staff or the Chief Medical Officer or designee, a change in provider would clearly benefit the member s 70 of 130 Page 2 of 6

71 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE g. health status. h. A determination by PHC s CC designee designated MS Management Staff andor the Chief Medical Officer or designee that deterioration in the doctor/patient relationship has occurred to the point where continuation might result in adverse consequences to the member s health or to the safety of the provider or provider s staff. i. Documented evidence that the member had been discharged from the practice site in the past before the member became PHC eligible. If a member has been previously discharged from a practice, it is the responsibility of the practice to notify PHC within sixty (60) days of the member s initial assignment. Exceptions to the sixty (60) day period can be made on a case-bycase basis. The provider s capitation payment is recouped. j. Disruptive or verbally inappropriate behavior to the provider, office staff or other patients if counseling and corrective action by the provider has been ineffective. For assistance with inappropriate behavior refer to the section above titled Assistance with Inappropriate Behavior. k. Three (3) or more missed appointments within the previous six (6) month period or four (4) or more missed appointments within the previous twelve (12) month period, if the provider has made a good faith effort to correct the member s behavior. Good faith effort is defined as at least one verbal and one written warning or at least two written warnings. All verbal and/or written warnings must informing the member that continued missed appointments will result in discharge. When requesting discharge, Pprovider offices must provide documentation of the verbal warning and one written warningand or two (2) or more written warnings. a copy of the letter sent advising the member that continuing to miss appointments will result in discharge. The verbal and/or written warnings must be within the specified timeframes of the missed appointments. Exceptions: Missed appointments due to an inpatient hospital stay or appointments cancelled 24 hours in advance are not considered missed appointments for the purpose of this policy. l. If the provider has multiple locations and/or practices, the that provider must specify on the Discharge Request Form if the discharge applies to all locations and/or practices or specific locations and/or practices. D. Requesting Discharge Process 1. The provider must notify PHC s MS Department in writing to request a member discharge. The provider must provide complete documentation outlining the nature of the problem, including Form #6 titled Provider Request for Discharge/Assistance with Inappropriate Behavior (Attachment A) for each member included in the discharge request. The request must also indicate if the member is or is not in active care for an acute medical condition and/or if the member has diagnostic testing or surgeries scheduled. If additional information is needed from the provider, the MS Department will request the additional information through PHC s PRrovider Relations Department. 2. By the end of the second business day from the date of receipt, the designated MS staff documents the date the discharge request was received using the DE Remark Code. 3. If the provider does not provide the supporting documentation needed, MS forwards the request to the PRrovider Relations Help Desk with a scanned copy attached noting what additional information is needed. To ensure that the is forwarded appropriately, the word Discharge must be included in the subject field of the . PRrovider Relations forwards the additional information to MS upon request. The request is pended for five (5) business days. If the documentation requested is not received within the five (5) business days, the request is denied. E. Provider Notification of Decisions 1. MS sends lusing letter #MS10a (Attachment B), MS to notify notifies providers of the discharge decision. in writing. 2. The provider can call the the MSember Services at Department at (800) to check the status of a request. Direct extensions of MS staff are not provided. F. Member Notification - Approved Requests 1. Member Type V - For the purpose of this policy, members are defined as Type V Members if they 71 of 130 Page 3 of 6

72 Policy/Procedure Number: MP316 Lead Department: Member Services Policy/Procedure Title: Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior External Policy Internal Policy Original Date: 07/27/1994 Next Review Date: 08/16/ /14/2015 Last Review Date: 08/16/ /14/2014 Applies to: Medi-Cal Healthy Kids Employees have been Ddischarged for fraud, threatening and/or violent behavior. a. The copy of the provider s discharge submission and documentation is sent to the CC designee. a.b. The CC designee determines if the relationship between the provider and member can be repaired. If the relationship cannot be repaired, CC designee identifiesassists the member in selecting a new medical home or PCP. A list of PCP s that have agreed in advance to accept Type V Members is maintained by the PHC MS Department. However, before a Type V Member is assigned to a PCP, the Regional Medical Director CC designee must get approval by the accepting PCP before the assignment is made. The CC designee Regional Medical Director informs the new PCP of the reason the member was discharged and the assignment date to his or her practice. If the CC designee and/or the member needs more time to select a new medical home or PCPcannot find an accepting PCP, the member is placed in a limited Special Case Managed (SCM) status for a minimum of thirty (30) to a maximum of sixty (60) days. During this time, the member and can be seen by any Medi-Cal provider willing to see the member and bill PHC. If at the end of the limited SCM period, the member has not informed PHC of their new medical home or PCP, PHC assigns the member to the next closest open PCP. b. If the member is discharged and meets the definition of a Type V Member, the designated MS staff sends the appropriate MS10e (Attachment F) notification letter to the member within ten (10) business days from the date the request was received, or sooner, upon approval of the provider request. The letter explains the reason for the discharge and the effective date of the reassignment to the new PCP or Special Case Managed status. The member is re-assigned to a PCP in their service area that has agreed to accept Typethe member V Members. If there is more than one PCP in the member s service area that accepts Type V Members, the member is given a choice of PCP s to choose from. Members will remain assigned to this PCP, unless the member requests a PCP transfer and there is another PCP in the member s service area that accepts Type V Members. c. If PHC isn t able to locate a PCP to accept the member, the member is placed in a Special Case Managed Status and can be seen by any Medi-Cal provider that is willing to see the member and bill PHC. The mmember notification letter #MS10e (Attachment F) is sent and instructs the member to call PHC s MS Department if they are unable to find a provider. 2. Member Type U - For the purpose of this policy, members are defined as Type U Members if they have been Ddischarged for reasons other than fraud, threats of violence and/or violent behavior. a. Members are placed in a limited SCM status for a minimum of thirty (30) days to a maximum of sixty (60) days. b. Referrals are sent to Care CoordinationCC if the Provider Request for Discharge/Assistance with Inappropriate Behavior form, (Attachment A) indicates any current treatments and/or if the member has any open TARSs/RAFs. Member notification letter #MS10b (Attachment E) is sent to the member within ten (10) business days from the date the request was received. The letter explains the reason for the discharge and the effective date of the re-assignment to the new PCP. The letter also advises the member to choose a new PCP from the PHC Provider Directory if they don t like the PCP that was assigned to them.member notifications Letter #MS10b (Attachment D) is sent to the member within ten (10) business days from the date the request was received. The letter explains the reason for the discharge and the effective date of the new PCP or medical home or PCP. The letter advises the member; how to choose a new medical home or PCP, to contact Member ServicesMS Department if they need assistance or have questions and, if applicable, how to receive care during the SCM period. Enclosures include: provider directory, selection form, business reply envelope, Your Rights, Non Discrimination and Language Assistance notices. 72 of 130 Page 4 of 6

73 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE a. G. Member Notification - Denied Requests 1. Within ten (10) business days from the date the request was received, designated MS staff sends member notification letter MS10d (Attachment D) informing the member of PHC s denial of the request and a statement that advises the member of the importance of maintaining a good patient/ physician relationship. 3. H.G. Transition of Care (applies to both Type U and Type V Members) 1. If the member has diagnostic testing, specialty referrals and/or surgeries scheduled for conditions that could adversely affect the member s health if delayed, designated MS Staff requests that the CC are Coordination Department work with the member and appropriate providers to ensure that needed medical care is provided. The member may be assigned to Special Case Managed status, depending on the timing of the discharge. 2. If the member is medically unstable, as defined in MS Policy MP312, Processing PCP Selections and Transfer Requests, the PCP will continue to provide care to the member until PHC is able to change the member s PCP for a period not to exceed two (2) months. I.H. Processing Approved Requests in Amisys 1. To prevent discharged members from relinking or auto assigning to the discharging PCP, the AX remark code is entered in Amisys. The member is also placed On Review to alert staff of the discharge should the member request this PCP at a later date. Refer to Job Aid (JA) 103-Amisys- Member on Review for instructions on how to place a member on review. J.I. Discharge of Special Case Managed Members 1. A provider can terminate care of a Special Case Managed Member when the patient/physician relationship becomes non-collaborative, by notifying the member in writing that he/she will no longer be able to provide care for that member. If the member is unstable, the provider should care for the member until the member selects another provider, and the provider provides emergency care for at least 30 days. 2. Primary Care Providers should notify PHC of their intent to discharge a Special Case Managed Member from their practice so that PHC can document the reason for discharge and assist with transition of care, as described above in the section of this policy titled Transition of Care. K.J. Discharge Requests from Specialists 1. A specialist physician can cease providing care for any member when the physician/patient relationship becomes non-collaborative. In these cases, the specialist physician must notify both the PCP and the patient that they will no longer provide care to the patient. The PCP should refer the member to another specialist for treatment, if specialist care is still necessary. 2. In all cases, the provider discharging a member should assist with continuity of care by transferring appropriate medical records to the new provider. L.K. Request for Grievance 1. Members may request a grievance or a State Hearing. M.L. Reporting Violent and/or Fraudulent Behavior 1. Providers are encouraged to report violent and/or fraudulent behavior to the appropriate authorities MS notifies thephc s Regulatory Affairs Compliance Department of suspected fraudulent behavior. VII. VIII. REFERENCES: N/A DISTRIBUTION: 73 of 130 Page 5 of 6

74 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE Policy/Procedure Number: MP316 Policy/Procedure Title: Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior Original Date: 07/27/1994 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: Medi-Cal Employees Reviewing Entities: Approving Entities: Lead Department: Member Services External Policy Internal Policy IQI P & T QUAC OPERATIONS EXECUTIVE COMPLIANCE DEPARTMENT BOARD COMPLIANCE FINANCE PAC CEO COO CREDENTIALING DEPT. DIRECTOR/OFFICER Approval Signature: Kevin Spencer / Kelley Sewell Approval Date: 08/16/2017 I. RELATED POLICIES: A. MP 301 Assisting Providers with Missed Appointments B. MP 312 Processing PCP Selections and Transfers Requests II. III. IV. IMPACTED DEPTS.: DEFINITIONS: A. Provider Request to Discharge: A provider s request to discharge a member from his/her practice. B. Re-assignment: A member is transferred to the care of another Primary Care Provider or Special Case Managed category, if applicable. C. Member Type U: For the purpose of this policy, members are defined as Type U Members if they have been discharged for reasons other than fraud, threats of violence and/or violent behavior. D. Member Type V: For the purpose of this policy, members are defined as Type V Members if they have been discharged for fraud, threats of violence and/or violent behavior. Threats of violence includes menacing body language and/or verbal threats of physical violence. E. Medical Home: The provider identified as the member s medical home or PCP is responsible for managing the member s primary care needs. ATTACHMENTS: A. Form #6 (Provider Request for Discharge/Assistance with Inappropriate Behavior) B. Letter #MS10a (Member Services Notifies PCP of decision) C. Letter #MS10c (Assistance with Inappropriate Behavior at Provider s Office) D. Letter #MS10b (Notification of PCP Discharge Request Approved) V. PURPOSE: To clarify the circumstances in which a medical provider may discharge a PHC member from his/her practice and the process of member and provider notification. Additional clarification of questions about this process are directed to the PHC Provider Relations (PR) Department. VI. POLICY / PROCEDURE: A. Assistance with Inappropriate Behavior 1. Prior to requesting discharge, providers may request assistance from PHC when a patient and/or patient representative displays verbally abusive and/or disruptive behavior in a physician s office. 2. Examples of verbal abuse and/or disruptive behavior: a. Yelling and/or screaming b. Ethnic slurs c. Foul language d. Physical or verbal threats of violence 74 of 130 Page 1 of 6

75 Policy/Procedure Number: MP316 Lead Department: Member Services Policy/Procedure Title: Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior External Policy Internal Policy Original Date: 07/27/1994 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: Medi-Cal Employees 3. If the provider requests PHC assistance, the following procedure is followed: a. The provider must notify PHC s Member Services (MS) Department in writing to request assistance with inappropriate behavior. The provider must provide complete documentation outlining the nature of the problem, including Form #6 titled Provider Request for Discharge/Assistance with Inappropriate Behavior (Attachment A) for each member included in the request. b. The Provider faxes a request for assistance to PHC s MS Department at the fax number on Form #6, (Attachment A). MS staff documents the request in Amisys or the Call Center System and sends letter #10c (Attachment C) to the member, copying the requesting provider. c. Incomplete requests: If additional information is needed from the provider, the MS Department requests the information through PHC s PR Department. The request for assistance with inappropriate behavior is pended for five (5) business days. If the information is not received within the five (5) business days the request is closed. MS notifies the provider that not enough information was received timely to process the request. B. Discharge Requests 1. PHC s best effort is used to provide members the opportunity to be cared for by medical providers with whom a collaborative physician/patient relationship can be developed. Because the relationship is personal in nature, circumstances may arise under which the relationship between a member and a provider becomes non-collaborative. Medical providers are permitted to request that a member be discharged from his/her practice in certain circumstances, but it is the sole responsibility of PHC to determine if the request meets PHC s discharge criteria. Providers are expected to have procedures in place that provide guidance to practitioners and staff when dealing with challenging patients. C. Discharge Criteria 1. Using the written documentation provided by the provider and the discharge criteria listed below, appropriate PHC staff determines if the request for discharge meets PHC s discharge criteria. Designated MS staff consults the Care Coordination (CC) designee, PHC Chief Medical Officer or designee as needed. 2. The following behaviors are generally considered appropriate criteria for discharge: a. Fraudulently receiving benefits under a health plan contract. b. Fraudulently receiving and/or altering prescriptions, theft of prescription pads, or photocopying prescriptions. c. Physically abusive behavior exhibited to the provider or office personnel. d. Threatening behavior exhibited in the course of needing or receiving care. e. Credible threat of the member s intent to initiate or pursue legal action (not including a state hearing) against the provider and/or his/her associates. f. Refusal by the member to follow recommended medical treatment where the provider believes there is no alternative treatment, and that refusal will severely endanger the health of the member. This situation cannot be improved by repeated attempts by PHC s CC designee to intervene, and in the judgment of the Chief Medical Officer or designee, a change in provider would clearly benefit the member s 75 of 130 Page 2 of 6

76 PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE g. health status. h. A determination by PHC s CC designee and the Chief Medical Officer or designee that deterioration in the doctor/patient relationship has occurred to the point where continuation might result in adverse consequences to the member s health or to the safety of the provider or provider s staff. i. Documented evidence that the member had been discharged from the practice site before the member became PHC eligible. If a member has been previously discharged from a practice, it is the responsibility of the practice to notify PHC within sixty (60) days of the member s initial assignment. Exceptions to the sixty (60) day period can be made on a case-by-case basis. The provider s capitation payment is recouped. j. Disruptive or verbally inappropriate behavior to the provider, office staff or other patients if counseling and corrective action by the provider has been ineffective. For assistance with inappropriate behavior refer to the section above titled Assistance with Inappropriate Behavior. k. Three (3) or more missed appointments within the previous six (6) month period or four (4) or more missed appointments within the previous twelve (12) month period, if the provider has made a good faith effort to correct the member s behavior. Good faith effort is defined as at least one verbal and one written warning or at least two written warnings. All verbal and/or written warnings must inform the member that continued missed appointments will result in discharge. Provider offices must provide documentation of the verbal warning and one written warning or two (2) or more written warnings. The verbal and/or written warnings must be within the specified timeframes of the missed appointments. Exceptions: Missed appointments due to an inpatient hospital stay or appointments cancelled 24 hours in advance are not considered missed appointments for the purpose of this policy. l. If the provider has multiple locations and/or practices, the provider must specify on the Discharge Request Form if the discharge applies to all locations and/or practices or specific locations and/or practices. D. Requesting Discharge Process 1. The provider must notify PHC s MS Department in writing to request a member discharge. The provider must provide complete documentation outlining the nature of the problem, including Form #6 titled Provider Request for Discharge/Assistance with Inappropriate Behavior (Attachment A) for each member included in the discharge request. The request must indicate if the member is or is not in active care for an acute medical condition and/or if the member has diagnostic testing or surgeries scheduled. If additional information is needed from the provider, the MS Department will request the additional information through PHC s PR Department. 2. By the end of the second business day from the date of receipt, the designated MS staff documents the date the discharge request was received using the DE Remark Code. 3. If the provider does not provide the supporting documentation needed, MS forwards the request to the PR Help Desk with a scanned copy noting what additional information is needed. To ensure that the is forwarded appropriately, the word Discharge must be included in the subject field of the . PR forwards the additional information to MS upon request. The request is pended for five (5) business days. If the documentation requested is not received within the five (5) business days, the request is denied. E. Provider Notification of Decisions 1. MS sends letter #MS10a (Attachment B) to notify providers of the discharge decision. 2. The provider can call the MS Department at (800) to check the status of a request. Direct extensions are not provided. F. Approved Requests 1. Member Type V - Discharged for fraud, threatening and/or violent behavior. a. The copy of the provider s discharge submission and documentation is sent to the CC designee. b. The CC designee determines if the relationship between the provider and member can be repaired. If the relationship cannot be repaired, CC designee assists the member in selecting a 76 of 130 Page 3 of 6

77 Policy/Procedure Number: MP316 Lead Department: Member Services Policy/Procedure Title: Provider Request to Discharge Member & Assistance with Inappropriate Member Behavior External Policy Internal Policy Original Date: 07/27/1994 Next Review Date: 08/16/2018 Last Review Date: 08/16/2017 Applies to: Medi-Cal Employees new medical home or PCP. If the CC designee and/or the member needs more time to select a new medical home or PCP, the member is placed in a limited Special Case Managed (SCM) status for a minimum of thirty (30) to a maximum of sixty (60) days. During this time, the member can be seen by any Medi-Cal provider willing to see the member and bill PHC. If at the end of the limited SCM period, the member has not informed PHC of their new medical home or PCP, PHC assigns the member to the next closest open PCP. 2. Member Type U - Discharged for reasons other than fraud, threats of violence and/or violent behavior. a. Members are placed in a limited SCM status for a minimum of thirty (30) days to a maximum of sixty (60) days. b. Referrals are sent to CC if the Provider Request for Discharge/Assistance with Inappropriate Behavior form, (Attachment A) indicates any current treatments and/or if the member has any open TARs/RAFs. Member notifications Letter #MS10b (Attachment D) is sent to the member within ten (10) business days from the date the request was received. The letter explains the reason for the discharge and the effective date of the new medical home or PCP. The letter advises the member; how to choose a new medical home or PCP, to contact MS Department if they need assistance or have questions and, if applicable, how to receive care during the SCM period. Enclosures include: provider directory, selection form, business reply envelope, Your Rights, Non Discrimination and Language Assistance notices. 77 of 130 Page 4 of 6

78 3. G. Transition of Care 1. If the member has diagnostic testing, specialty referrals and/or surgeries scheduled for conditions that could adversely affect the member s health if delayed, designated MS Staff requests that the CC Department work with the member and appropriate providers to ensure that needed medical care is provided. The member may be assigned to Special Case Managed status, depending on the timing of the discharge. 2. If the member is medically unstable, as defined in MS Policy MP312, Processing PCP Selections and Transfer Requests, the PCP will continue to provide care to the member until PHC is able to change the member s PCP for a period not to exceed two (2) months. H. Processing Approved Requests in Amisys 1. To prevent discharged members from relinking or auto assigning to the discharging PCP, the AX remark code is entered in Amisys. The member is also placed On Review to alert staff of the discharge should the member request this PCP at a later date. Refer to Job Aid (JA) 103-Amisys-Member on Review for instructions on how to place a member on review. I. Discharge of Special Case Managed Members 1. A provider can terminate care of a Special Case Managed Member when the patient/physician relationship becomes non-collaborative, by notifying the member in writing that he/she will no longer be able to provide care for that member. If the member is unstable, the provider should care for the member until the member selects another provider, and the provider provides emergency care for at least 30 days. 2. Primary Care Providers should notify PHC of their intent to discharge a Special Case Managed Member from their practice so that PHC can document the reason for discharge and assist with transition of care, as described above in the section of this policy titled Transition of Care. J. Discharge Requests from Specialists 1. A specialist physician can cease providing care for any member when the physician/patient relationship becomes non-collaborative. In these cases, the specialist physician must notify both the PCP and the patient that they will no longer provide care to the patient. The PCP should refer the member to another specialist for treatment, if specialist care is still necessary. 2. In all cases, the provider discharging a member should assist with continuity of care by transferring appropriate medical records to the new provider. K. Request for Grievance 1. Members may request a grievance or a State Hearing. L. Reporting Violent and/or Fraudulent Behavior 1. Providers are encouraged to report violent and/or fraudulent behavior to the appropriate authorities. 2. MS notifies PHC s Regulatory Affairs Department of suspected fraudulent behavior. VII. VIII. IX. REFERENCES: N/A DISTRIBUTION: A. SharePoint B. Provider Manual POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Associate Director of Enrollment Unit Member Services 78 of 130

79 4665 Business Center Drive Fairfield, CA Grievance Summary 2 nd Quarter: April June 2017 Presented To: IQI and QUAC Committee August 2017 Presented By: Eric Becerra Grievance and Appeals Resolution Manager Grievance Summary 2 nd Quarter 2017 (414) 2 nd Quarter grievances received. (Complaints/Appeals/State Hearings) Complaints (245) complaints were filed during the review period Top 3 complaints filed: 1. Denial of medication 2. Quality of care/services 3. Discrimination (73) Quality of Care/Quality of Service 1. Exam not completed 2. Disagreement with prescription/treatment plan 3. Inappropriate provider office conditions (35) Discrimination/Denial of Care 1. Members having issues in obtaining medicine 2. Member feel discriminated due to her race 3. Discriminated by an LTC facility (24) Access 1. Dissatisfaction with PCP 2. Appointment scheduling issues 3. New referrals: PCP, RAF, and TAR (20) Poor Provider/Staff Attitude 1. Rudeness issues 2. Dissatisfied with care 3. PHC review of TAR taking too long ( 2) HIPAA 1. Member feels HIPAA rights violated Appeals (122) appeals were filed during the review period Top 3 appeals filed: 1. Medication Denial (Oxycodone/Hydrocodone) 2. RAF to Stanford 3. Power wheel chair 79 of 130 Page 1 of 2

80 4665 Business Center Drive Fairfield, CA (109) UM Appeals 1. Norco 2. Hydrocodone Acetaminophen 3. PediaSure (10) Withdrawn 1. Group 3 power wheel chair 2. Oxycodone 3. Lidocane ( 3) Non UM Appeals State Hearings (47) State Hearings were filed during the review period Top 3 State Hearings filed: 1. Medication (Oxycodone/Hydrocodone) 2. RAF to Stanford 3. Group 3 power wheel chair (36) Withdrawn/Dismissed 1. Hydrocodone-Acetaminophen 2. Oxycodone 3. Incontinent supplies ( 5) Pending Hearing Date/Decision ( 3) Postponed ( 2) Non-Appearance to the Hearing ( 1) Upheld 1. PHC correctly denied RAF for an OON PCP 80 of 130 Page 2 of 2

81 Summary of inter-rater reviews of Clinical vs Non Clinical Cases (2 nd Quarter 2017) Date of Reviewer Case Agree Accuracy Comments review Number 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % Issue characterized as a Clinical issue instead of Non Clinical 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % Results: 10 inter-rater reviews by MD reviewer were completed. Overall 90.00% accuracy rate was noted for the 2 nd Quarter 2017 review. Per policy CGA024, 90% threshold was met. 81 of 130

82 Summary of inter-rater reviews of Non PQI Cases (2 nd Quarter 2017) Date of Reviewer Case Agree Accuracy Comments review Number 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % 7/17/2017 MD % Results: 10 inter-rater reviews by MD reviewer were completed. Overall % accuracy rate was noted for the 2 nd Quarter 2017 review. 82 of 130

83 PHC Quality Improvement Department s Staff Incentive Programs Overview In the fall of 2016, Partnership HealthPlan offered a unique staff incentive program to contracted primary care providers, focusing on the Monitoring Patients on Persistent Medications (MPM) measure. This measure was chosen because of its clinical importance, and it is also featured in both HEDIS and the Quality Improvement Program (PCP QIP). Practices participating in this program were asked to spend the incentive recognizing the front-line and other critical staff that work hard to ensure quality care is delivered to our members. The incentive was available to any eligible practice that achieved outstanding performance on their MPM rates by December 31, Below are details on the outcomes of this program as well as plans for a future program. Annual Monitoring Patients on Persistent Medications The Annual Monitoring Patients on Persistent Medications measure requires adults who are on certain blood pressure medications to receive an annual lab screening to monitor potentially harmful side effects of the medications, including reduced kidney function and heart arrhythmias. The measure is divided into two parts, for patients on medications that are called ACEs or ARBs, as well as Diuretics. The two rates are reported on separately. The denominator for this program was the number of PHC members 18+ years of age as of December 31, 2016 who during the course of the measurement year received at least 180 treatment days of ACE inhibitors or ARBs, or 180 treatment days of Diuretics. The numerator was the number of members within the denominator with at least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. In order to assist providers, participants were sent monthly gap lists to identify non-compliant members and then performance was calculated at the end of the program period. Performance Targets Outstanding Performance (full incentive: $1.60/ assigned adult member) Outstanding Improvement (partial incentive: $.80/assigned adult member) Engagement (partial incentive: $.40/assigned adult member) Target Details 92% This target was based on the MPM performance percentiles obtained from HEDIS national averages for Medicaid HMO plans. 30% relative (Current Performance - Baseline Performance)/(100 - improvement Baseline) Current Performance: 2016 MPM Score 40% of noncompliant patients Baseline Performance: 2015 MPM Score Providers who did not meet performance or RI targets but were actively engaged and sent in records for at least 40% of their non-compliant patients were eligible for a partial incentive Results A total of 86 unique provider sites enrolled in the program. Of those, 46 received at least a partial incentive. Performance improved in all four regions for the ACE/ARB measure, and in two out of the four regions for Diuretics. Overall, practices that enrolled in the program saw more improvement than clinics that did not enroll. The Northwest region also showed the most dramatic improvement across both submeasures. The total payout for the program was just over $75,000, ranging from $500 to over $6, of 130

84 Provider Feedback The program received a lot of attention and positive feedback from the network. According to the evaluation survey, 100% of participating providers either agreed or strongly agreed that the program was helpful in improving patient outreach and/or compliance on the MPM measure. Providers requested other similar programs with more time to get patients in for care. Below are a few excerpts from the program evaluation. This incentive program was great. I think that we should have similar programs for metrics that are also not meeting the standards The staff incentive was definitely more motivating as everyone gets to share in the reward and not just the business receiving the incentive as in regular QIP. Breast Cancer Screenings After the positive response from the MPM Staff Incentive Program, the Quality Improvement Department is proposing a similar program featuring the Breast Cancer Screening measure. Mammography is recognized as an effective tool in decreasing mortality associated with breast cancer, which is the most common cancer among women in California. Clinical recommendations encourage mammography screenings for women between years of age. As an added benefit, BCS will be a new clinical measure in 2018 PCP QIP, accounting for 5% of potential points earned for family and internal medicine practices. Some members in the denominator for this program will likely appear in the 2018 PCP QIP denominator list. For these members, the screenings performed during the program period will qualify for numerator compliance in both programs. Eligibility Minimum 100 assigned PHC adult members. Enrollment in the program by October 6, 2017 In good standing with PHC. Timeline PHC will reward staff from provider practices that achieve outstanding performance or outstanding improvement by December 31, Sites that reach the 90 th percentile target (71.5%) will earn the full incentive. Sites that do not meet this target, but achieve 25% relative improvement compared to calendar year 2016 scores, will be eligible for a partial incentive. In addition, there will be an extra reward for the highest performers in each of our four geographic regions. Task Due Date Clinic Leadership Engagement August 2017 Announce to PCP Network 09/01/2017 Introductory Webinar 09/19/2017 Last day to enroll 10/06/2017 Distribute October denominator lists to enrolled sites 10/04/ /06/2017 Distribute November denominator lists to enrolled sites 11/06/2017 Distribute December denominator lists (i.e. final denominators) to enrolled sites 12/06/2017 Last date of service that will be accepted for this project 12/31/2017 Last day to submit data 01/19/2018 Final payment disbursement 03/31/ of 130 2

85 4665 Business Center Dr. Fairfield, CA Quality Improvement Staff Incentive Program Communication Options Because of the life-saving value of mammography, the Primary Care Provider Quality Improvement Program (PCP QIP) has added Breast Cancer Screenings to the measurement set beginning in In order to get a jump start on managing the measure, the QIP team is offering a unique Staff Incentive Program focusing on increasing annual breast cancer screenings for Partnership members. The program is designed to reward critical front line staff members that have a direct impact on patients receiving the care they need as well as filling the data gaps for the HealthPlan. The Staff Incentive Program is separate and unique from the traditional QIP, and the financial rewards must be used to the benefit of provider site staff. If the executive director/ceo or practice owner chooses options B or C, please submit this completed form to the PCP QIP team at: PCPQIP@partnershiphp.org by August 23, Communication Options: A. The QIP team will reach out to our usual contacts at each provider site to describe the Staff Incentive Program. No action is needed to utilize this option. B. Site commits to participating in Breast Cancer QI sprint, but asks that communication go through the CEO/Executive Director/Practice owner, who will submit the proposal and ensure its implementation. C. Site declines to participate in the special incentive program. Reasoning for choice: Clinic Name(s): Clinic Location(s): Name and title of signee: Phone: We will always acknowledge receipt of communications; if you do not receive a receipt you should contact us directly. Requests for option B or C should be sent by midnight on August 23 rd to avoid the default communication strategies being used with your QI staff. If you have any questions, please contact us via PCPQIP@partnershiphp.org. Thank you! 3 85 of 130

86 PHC (PARTNERSHIP HEALTHPLAN OF CALIFORNIA) MEETING MINUTES PAC SUMMARY Pg. 1 of 14 * =by phone conference Committee: Credentialing Committee Date/Time: June 14, :00 a.m. 7:30 a.m. Members Present: M. Tracy Johnson, MD; Bradley Sandler, MD; Jeff Gaborko, MD; Steven Gwiazdowski, MD; Michael Stacey, MD PHC Staff: Robert Moore, MD MPH MBA, PHC Chief Medical Officer; Marshall Kubota, MD*, PHC Regional Medical Director; Mary Kerlin, PHC Senior Director Provider Relations; Michael Vovakes, MD*,PHC Northern Region Medical Director; Bettina Spiller, MD*, PHC Northern Region Medical Director; James Cotter, MD, PHC Associate Medical Director; Scott Endsley, MD, PHC Associate Medical Director of Quality; Cheryl Lockhart*, Performance Improvement Clinical Specialist II; Heidi Lee, Credentialing Supervisor; Jasmine Jones, Credentialing Specialist II AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE DATE RESOLVED I. Meeting called to order I. PHC Regional Medical Director Marshall Kubota, MD II. Review/Approval of previous minutes III. Old Business: None called the meeting to order. II. A. The Credentialing Committee meeting minutes for May 10, 2017 III. None II. A. Motion made and carried to approve the Minutes of May 10, 2017 III. None IV. New Business A. Review of Practitioner File IV. A. Please see approved list of Routine Providers on Pages 5-14 The Committee reviewed and discussed the list of Twenty seven (27) Physicians, thirteen (13) Non-Physician Medical Practitioners, one (1) Chiropractor, four (4) Behavioral Health Analysts, two (2) Physical Therapist, and one (Occupational Therapist) for Initial Credentialing, forty one (41) Physicians, twenty three (23) Non-Physician Medical Practitioners, two (2) Podiatrist, and one (1) Chiropractor for Re-Credentialing. A. The Committee reviewed and approved the list of Twenty seven (27) Physicians, thirteen (13) Non- Physician Medical Practitioners, one (1) Chiropractor, four (4) Behavioral Health Analysts, two (2) Physical Therapist, and one (Occupational Therapist) for Initial Credentialing, forty one (41) Physicians, twenty three (23) Non-Physician Medical Practitioners, two (2) Podiatrist, and one (1) Chiropractor for Re-Credentialing B. Exception: Family Medicine B. Provider does not meet the criteria of policy MP CR #17 Standards for Contracted Primary Care Providers. Charts have been ordered and not been received by PHC. Chart review will be presented upon completion at an upcoming meeting. B. This item is informational only C. MP CR #10: Organizational Providers Assessment Criteria. C.MP CR #10: Organizational Providers Assessment Criteria. This policy was updated to include Free- Standing Birthing Centers beginning July 1, C. Motion made and carried to approve the updated policy of 130

87 PHC Credentialing PAC Summary Page 2 of 14 AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE IV. New Business (cont.) IV. New Business (cont.) DATE RESOLVED V. Update of Ongoing Monitoring of Sanctions Two providers found. A. Chiropractor V. A. Chiropractor: Provider listed on the SAM (System for Award Management) and OIG (Officer of Inspector General) Exclusion reports. A. This item is informational only B. Hospitalist B. Hospitalist: Provider was listed on the Medi-Cal Suspended and Ineligible Provider List. Provider has been termed from PHC. B. Motion made and carried to approve based on the correction VI. Consent Calendar Items. A. Report of Long Term Care Facility, Hospital, and Ancillary Prov. List. VI. A. Report of Long Term Care Facility, Hospital, and Ancillary provider list. VI. Motion made and carried to approve all items in the Consent Calendar B. BayChildren s Physicians: 1 st Quarter 2017 Credentialing/ Re- Credentialing Activities. B. BayChildren s Physicians: 1 st Quarter 2017 Credentialing/ Re-Credentialing Activities. C. Beacon: 1 st Quarter 2017 Credentialing/ Re- Credentialing Activities. C. Beacon: 1 st Quarter 2017 Credentialing/ Re- Credentialing Activities. D. Sutter Medical Group of the Redwoods: 1 st Quarter 2017 Credentialing/ Re- Credentialing Activities. D. Sutter Medical Group of the Redwoods: 1 st Quarter 2017 Credentialing/ Re-Credentialing Activities. 87 of 130

88 PHC Credentialing PAC Summary Page 3 of 14 AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE VI. Consent Calendar VI. Consent Calendar Items (cont.) Items (cont.) DATE RESOLVED E. Sutter Pacific Medical Foundation/Physician Foundation Medical Associates/Marin Headlands: 1 st Quarter 2017 Credentialing/ Re- Credentialing Activities. F. UCSF: 1 st Quarter 2017 Credentialing/ Re- Credentialing Activities G. Woodland Clinic Medical Group: 1 st Quarter 2017 Re- Credentialing Activities. H st Quarter New Provider Orientation Verification: BHT Providers. I Beacon Annual Review Report. J. Sutter Medical Foundation Delegated Audit Report. K. MP CR #4B Identification of HIV/AIDS Specialist. L. MP CR #6: Non- Physician Medical Practitioner Credentialing Criteria. E. Sutter Pacific Medical Foundation/Physician Foundation Medical Associates/Marin Headlands: 1 st Quarter 2017 Credentialing/ Re-Credentialing Activities. F. UCSF: 1 st Quarter 2017 Credentialing/ Re- Credentialing Activities G. Woodland Clinic Medical Group: 1 st Quarter 2017 Credentialing/ Re-Credentialing Activities. H st Quarter New Provider Orientation Verification: BHT Providers. I Beacon Annual Review Report. J. Sutter Medical Foundation Delegated Audit Report. K. MP CR #4B Identification of HIV/AIDS Specialists. L. MP CR #6: Non-Physician Medical Practitioner Credentialing Criteria. 88 of 130

89 PHC Credentialing PAC Summary Page 4 of 14 AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE VI. Consent Calendar VI. Consent Calendar Items (cont.) Items (cont.) DATE RESOLVED M. MP CR #8: Non- Physician Medical and Allied Health Practitioner Re-Credentialing Criteria. N. MP CR #9: Fair Hearing Process for Adverse Decisions. O. MP CR #11: Delegation of Credentialing and Recredentialing Activities. P. MP CR #17: Standards for Contracted Primary Care Providers. Q. Review of Suboxone/ Buprenorphine credentialed primary care/ specialty providers. VII. Meeting Adjourned M. MP CR #8: Non-Physician Medical and Allied Health Practitioner Re-Credentialing Criteria. N. MP CR #9: Fair Hearing Process for Adverse Decisions. O. MP CR #11: Delegation of Credentialing and Recredentialing Activities. P. MP CR #17: Standards for Contracted Primary Care Providers. Q. Review of Suboxone/ Buprenorphine credentialed primary care/ specialty providers. With No further items for discussion, the meeting was adjourned Next Meeting Scheduled for August 9, PAC Summary Meeting Minutes for June 14, 2017, respectfully prepared and submitted by Skyler Bellmore - Credentialing Specialist II Chairman Signature of Approval Date Marshall Kubota M.D., PHC Credentialing Chairman 89 of 130

90 IC or RC Provider Name/Provider Group County Practice Specialty Board Certification Board Status Privileges Criteria Hospital Privileges Malpractice Claims & Payments (within 7 yrs.) 1 IC Allen, Anthony E. MD Skilled MD, Inc Alameda SFNist AMA verified four year residency in Internal Medicine Alta Bates Summit Medical Center - Active No Claims History 2 IC Allmeyer-Green, Rita M. PT Shasta Orthopedics & Sports Medicine Shasta Physical Therapy No Claims History 3 IC Alonzo, Natalie FNP Sonoma Valley Community Health Ctr Sonoma Family Nurse Practitioner Family Nurse Practitioner-2016 No Claims History 4 RC Ankenmann, Janice G. FNP Napa Valley Nephrology Napa Family Nurse Practitioner Family Nurse Practitioner-2002 No Claims History 5 IC Austin, Jeremy R. MD Shingletown Medical Center Shasta Family Medicine Family Medicine-2002 Hospitalist Coverage No Claims History 6 RC Bach, Philip M. MD Sacramento Heart & Vascular Medical Associates Yolo Cardiology Cardiovascular Disease-1983 Internal Medicine-1981 Group Coverage No Claims History 7 RC Bieselin, Ronald G. MD Solano Surgery Surgery-1990 Sutter Solano Medical Center-Active Open: 0 Closed w/pay: 1 w/o pay: 0 Total Cases: 1 8 RC Bly, KC CNM Communicare Health Centers Yolo Sacramento Certified Nurse Midwife Certified Nurse Midwife No Claims History 9 RC Bowen, Trina L. MD West County Health Centers Sonoma Family Medicine Family Medicine-1983 Hospitalist Coverage No Claims History 10 IC Brown, Jennifer K. PA-C Adv: Coon Joint Replacement Napa Physician Assistant Certified Physician Assistant Certified No Claims History 11 RC Cartwright, Wade R. MD Solano Otolaryngology Otolaryngology-1977 Children's Hospital of Oakland - Active No Claims History 12 RC Chahal, Resham S., MD Mission Hills Eye Center Contra Costa Ophthalmology Ophthalmology John Muir Medical Center - Active No Claims History 13 RC Chang, Margaret A. MD Retinal Consultants Medical Group Yolo Shasta Ophthalmology Retina Ophthalmology-2007 Sutter Medical Center Sacramento-Active No Claims History 90 Page of June 2017

91 IC or RC Provider Name/Provider Group County Practice Specialty Board Certification Board Status Privileges Criteria Hospital Privileges Malpractice Claims & Payments (within 7 yrs.) 14 IC 15 IC Chawla-Kondal, Bhani K. MD Sutter Coast Community Clinic Del Norte Surgery Surgery-2016 Hospitalist Coverage No Claims History Endocrinology, Diabetes, & Metabolism- Cheng, Mickie H. MD Endocrinology, Diabetes, 2007 Marin General Hospital- Marin Healthcare District - Endocrinology Marin & Metabolism Internal Medicine-2005 Courtesy No Claims History 16 RC Clair, Bradley T. MD Sutter Lakeside Family Medical Clinic Lake Cardiovascular Disease Cardiovascular Disease-1995 Sutter Lakeside Hospital- Active No Claims History 17 RC Cordes, Susan R. MD Adv: Ukiah Valley Rural Health Mendocino Otolaryngology Otolaryngology Ukiah Valley Medical Center - Active No Claims History 18 IC Coty, Paul C. MD Humboldt Medical Specialists Humboldt Medical Ongology Hematology Hematology Medical Oncology Group Coverage No Claims History 19 RC 20 RC De Pala Jr., Armando V. MD Annadel Medical Group Sonoma Pediatrics Pediatrics Deeik, Ramzi K. MD Northerna CA Minimally Invasive Sonoma Thoracic & Cardiothoracic Surgery Napa Cardiovascular Surgery Thoracic & Cardiovascular Surgery-2004 General Surgery-2001 Petaluma Valley Hospital-Active Queen of the Valley- Active No Claims History No Claims History 21 IC 22 IC Dellacort-Erickson, Laura M. OT Shasta Orthopedics & Sports Medicine Shasta Occupational Therapy No Claims History Family Medicine-2014 Dolbier, Candice M. DO Osteopathic Manipulative Therapy- Frank R. Howard Memorial Baechtel Creek Medical Clinic Mendocino Family Medicine 2014 Hospital-Active No Claims History 23 RC Eickhoff III, Leo E. MD Shasta Gastroenterology Gastroenterology-1995 Shasta Regional Medical Center-Active No Claims History 24 IC Ezra, Navid MD TeleMed2U Placer Dermatology Dermatology-2015 No Direct Patient Contact No Claims History 25 RC Feuerman, Neal E. MD Humboldt Pain Management Anesthesiology-1997 St. Joseph Hospital- Courtesy No Claims History 26 IC Fink, Lilo FNP North Coast Family Health Center Mendocino Family Nurse Practitioner Family Nurse Practitioner No Claims History 91 Page of June 2017

92 IC or RC Provider Name/Provider Group County Practice Specialty Board Certification Board Status Privileges Criteria Hospital Privileges Malpractice Claims & Payments (within 7 yrs.) 27 RC Finnegan, Maria CNM Mendocino Community Health Clinic Mendocino Lake Certified Nurse Midwife Certified Nurse Midwife No Claims History 28 RC Flaherty, James G. MD Consolidated Tribal Health Mendocino Pediatrics Pediatrics Hospitalist Coverage No Claims History 29 RC Gary, Erika D. FNP Mendocino Community Health Clinic Mendocino Family Nurse Practitioner Family Nurse Practitioner-2014 No Claims History 30 IC 31 RC Gaudiani, Linda M. MD Marin Healthcare District - Endocrinology Marin Endocrinology & Metabolism Endocrinology & Metabolism-1985 Internal Medicine-1984 Goltz, David H. MD Mt. Tam Orthopedics Marin Comm. Clinics Marin Orthopaedic Surgery Orthopaedic Surgery-2002 Marin General Hospital- Active Marin General Hospital- Active No Claims History Open: 0 Closed w/pay: 1 w/o pay: 0 Total Cases: 1 32 IC 33 RC Greene, David A. MD NCMA Sonoma SNFist Groppo, Eli R. MD Sacramento Ear Nose & Throat Sacramento Otolaryngology Otolaryngology-2012 Internal Medicine-1987 Geriatric Medicine-1992 Group Coverage No Claims History Open: 1 Mercy San Juan Hospital-Closed w/pay: 0 w/o pay: 0 Active Total Cases: 1 34 RC Hamblin, Basil C. MD Marin Healthcare District Marin Family Medicine Suboxone Family Medicine Geriatric Medicine Hospice & Palliative Medicine Petaluma Valley Hospital-Active No Claims History 35 IC Hao, Minghua A. MD Pediatric Cardiologists of No. CA Sacramento Shasta Pediatric Cardiology Pediatric Cardiology Pediatrics Group Coverage No Claims History 36 IC Harish, Gorli MD Women's Health Specialists Shasta Butte Family Planning Obstetrics & Gynecology-1982 Transfer Agreement No Claims History 37 IC Hernandez, Danielle BCBA Trumpet Behavioral Health Alameda Behavioral Health Behavioral Health Analyst No Claims History 38 IC Highland, Elizabeth M. FNP Adv: Ukiah Valley Rural Health Mendocino Family Nurse Practitioner Family Nurse Practitioner No Claims History 92 Page of June 2017

93 IC or RC Provider Name/Provider Group County Practice Specialty Board Certification Board Status Privileges Criteria Hospital Privileges Malpractice Claims & Payments (within 7 yrs.) 39 RC 40 IC Hofberg, Dawn B., PA Mendocino Coast Clinic Mendocino Physician Assistant No Claims History Hornberger, Paul W. MD SR Community Health Centers Sonoma Gastroenterology Gastroenterology-1991 Internal Medicine-1989 Sutter Santa Rosa Regional -Active No Claims History 41 RC James, Gregory D. PA-C Adventist Heart Institute Napa Physician Assistant Certified Physician Assistant Certified-2015 No Claims History 42 IC Johnson, David S. MD Sutter Coast Community Clinic Del Norte General Surgery General Surgery-2005 Hospitalist Coverage No Claims History 43 RC Jumper, James M. MD West Coast Retina Medical Group Marin Ophthalmology Ophthalmology-1997 St. Mary's Medical Center-Active No Claims History 44 RC Kako, Rony Y. MD Napa Internal Medicine Internal Medicine Katnik, Lori L. FNP SR Comm Hlth Centers: Vista Family 45 IC Health Center Sonoma Queen of the Valley- Active No Claims History Family Nurse Practitioner Family Nurse Practitioner-2015 No Claims History 46 IC 47 IC Kazi, Phiroze M. MD Southern Humboldt Comm Clinic Humboldt Family Medicine Kennedy, Abbey L. MD Mt. Tam Orthopedics Marin Orthopaedic Surgery Meet MP CR #17 - Previously Board Certified in Family Medicine Hospitalist Coverage No Claims History Marin General Hospital- Active Open: 0 Closed w/pay: 1 w/o pay: 0 Total Cases: 1 48 RC 49 RC Khaira, Herkanwal S. MD NBHG: Urology Solano/Napa Urology Urology-2008 Kim, Christian K. MD Marin Eyes Marin Ophthalmology Ophthalmology NorthBay Medical Center-Active Attending Marin General Hospital - Courtesy Open: 1 Closed w/pay: 0 w/o pay: 0 Total Cases: 1 No Claims History 50 IC Kim, Michael P. MD Live Well Medical Center Yolo Family Medicine Family Medicine-2001 Hospitalist Coverage No Claims History 93 Page of June 2017

94 IC or RC Provider Name/Provider Group County Practice Specialty Board Certification Board Status Privileges Criteria Hospital Privileges Malpractice Claims & Payments (within 7 yrs.) 51 IC Kim, Paul H. MD Mt. Tam Orthopedics Marin Orthopaedics Foot & Ankle Surgery Marin General Hospital- Provisional Active No Claims History 52 RC Klingman, Robert R., MD Napa Valley Cardiothoracic & Cardiovascular Surgery, Inc. Napa Solano Thoracic Surgery Thoracic & Cardiac Surgery Surgery Queen of the Valley- Active No Claims History 53 RC Korver, Keith F. MD Sonoma Marin Thoracic & Cardiovascular Surgery Thoracic & Cardiovascular Surgery-1991 Surgery-1988 Santa Rosa Memorial Hospital-Active No Claims History 54 RC 55 RC 56 IC 57 RC Kreger, Jonathan B. DPM Ukiah Podiatry Group Mendocino Podiatry Podiatry-1995 Ukiah Valley Medical Center - Active No Claims History Laughton, Frances A. NP Adv: Ukiah Valley Primary Care Adv: Ukiah Valley Rural Health Mendocino Nurse Practitioner No Claims History Leach, Tamara BCBA Trumpet Behavioral Health Contra Costa Behavioral Health Behavioral Health Analyst No Claims History Lefevre, Kathleen P. NP NBHG: Center for Primary Care Solano Nurse Practitioner No Claims History 58 RC Liana, Jennifer I. CNM Mendocino Community Health Mendocino/ Lake Certified Nurse Midwife Certified Nurse Midwife-2006 No Claims History 59 RC Loftus, John P. MD Bay Area Surgical Specialists Napa Vascular Surgery Vascular Surgery Surgery Queen of the Valley- Active No Claims History 60 IC Louwrens, Neil A. MD Tehama Wound Care Internal Medicine-2001 Lowe, Heather N. PA-C NCMA Sonoma 61 RC Santa Rosa Community Health Mendocino Mercy Medical Center Redding-Active No Claims History Physician Assistant Certified Physician Assistant Certified-2002 No Claims History 62 RC Lowry, Caroline A. PA-C ODCHC - North Country Clinic Humboldt Physician Assistant Certified Physician Assistant Certified-2014 No Claims History 94 Page of June 2017

95 IC or RC Provider Name/Provider Group County Practice Specialty Board Certification Board Status Privileges Criteria Hospital Privileges Malpractice Claims & Payments (within 7 yrs.) 63 RC Lundergan, Faye S. MD Sonoma Pediatrics Pediatrics-2003 Petaluma Valley Hospital-Active No Claims History 64 IC Mahon, Margaret J. FNP Planned Parenthood Humboldt Family Nurse Practitioner Family Nurse Practitioner-2015 No Claims History 65 IC Manske, Mary Claire B. MD Shriners Hospitals for Children Sacramento Orthopaedic Surgery Shriners Hospitals for Children-Active No Claims History 66 RC 67 RC Manulkin, Stephanie E. FNP Coastal Health Alliance Martinez, Alexis A. PA-C Napa Valley Orthopaedic Medical Group Marin Napa Family Nurse Practitioner Family Nurse Practitioner No Claims History Physician Assistant Open: 1 Closed w/pay: 0 w/o pay: 0 Certified Physician Assistant Certified-2012 Total Cases: 1 68 RC Matthews, Linnea M. FNP Mendocino Coast Clinic Mendocino Family Nurse Practitioner Family Nurse Practitioner No Claims History 69 RC McIntyre, Paige A. CNM Mendocino Community Health Mendocino/ Lake Certified Nurse Midwife Certified Nurse Midwife-2004 No Claims History 70 RC McLeod, Dennis M. MD Sonoma Otolaryngology Otolaryngology-1978 Petaluma Valley Hospital-Active No Claims History 71 RC Metzger, Alex S. MD Marin Cancer Care Inc Marin Medical Ongology Hematology Medical Oncology-2007 Hematology-2008 Internal Medicine-2003 Marin General Hospital- Active No Claims History 72 IC Miner, David J. DC Southshore Chiropractic Lake Chiropractic No Claims History 73 RC Mischiu, Oana M. MD Solano Diagnostics Imaging Solano Diagnostic Radiology Diagnostic Radiology-2006 No Direct Patient Contact No Claims History 95 Page of June 2017

96 74 RC IC or RC Provider Name/Provider Group County Mraz, Serena M. MD Solano Dermatology Associates, Inc. SR Comm Hlth Centers Practice Specialty Board Certification Board Status Solano Sonoma Dermatology Dermatology-2002 Privileges Criteria Hospital Privileges Sutter Solano Medical Center-Active Malpractice Claims & Payments (within 7 yrs.) No Claims History 75 RC Nunnally, Janet NP Marin Community Clinic Marin Nurse Practitioner No Claims History 76 IC Obispo, Nancy M. ANP Asante Physician Partners Oregon Adult Nurse Practitioner Adult Gerontology-2014 No Claims History 77 RC 78 IC 79 RC O'Loughlin, Terence J. MD Solano Diagnostics Imaging Solano Diagnostic Radiology Diagnostic Radiology Ordal, John C. MD Asante Physician Partners: Pulmonary Consultants Clinic Oregon Pulmonary Disease Patel, Arun C. MD Retinal Consultants Medical Group Retina Center of Chico Yolo Shasta butte Ophthalmology Retina Pulmonary Diseases-1980 Sleep Medicine-2009 Internal Medicine-1978 Ophthalmology-1988 No Direct Patient Contact Asante Rogue Regional Med Center-Courtesy Mercy General Hospital of Sacramento-Active No Claims History No Claims History Open: 0 Closed w/pay: 1 w/o pay: 0 Total Cases: 1 80 RC 81 RC Pearlman, Joel A. MD Retinal Consultants Medical Group Retina Center of Chico Piersol, Patricia E. CNM Alliance Medical Center Yolo Shasta butte Ophthalmology Ophthalmology-2001 Sonoma Certified Nurse Midwife Certified Nurse Midwife Mercy General Hospital of Sacramento-Active No Claims History Open: 0 Closed w/pay: 1 w/o pay: 0 Total Cases: 1 82 RC Quilala, Marlene Q. MD Lake County Tribal Health Center Lake Pediatrics Pediatrics-1999 Sutter Lakeside Hospital- Active No Claims History 83 IC 84 IC Randhawa Jr., Mohinder P. MD DHMG: North State Rawson, Debra J. FNP SR Comm Hlth Centers: Vista Family Health Center Shasta Sonoma Cardiovascular Surgery Surgery-1998 Thoracic & Cardiac Surgery-2000 Mercy Medical Center Redding-Active No Claims History Family Nurse Practitioner Family Nurse Practitioner-2014 No Claims History 85 IC Ridley, Courtney P. MD Sutter Coast Community Clinic Del Norte Obstetrics & Gynecology Obstetrics & Gynecology-1992 Sutter Coast Hospital- Provisional Active Open: 0 Closed w/pay: 2 w/o pay: 0 Total Cases: 1 96 Page of June 2017

97 IC or RC Provider Name/Provider Group County Practice Specialty Board Certification Board Status Privileges Criteria Hospital Privileges Malpractice Claims & Payments (within 7 yrs.) 86 RC Rudin, Guy J.A. MD Adv: Ukiah Valley Rural Health Mendocino Orthopaedic Surgery Orthopaedic Surgery Ukiah Valley Medical Center - Active No Claims History 87 IC Rudnick, Eric M. MD Tehama Wound Care Emergency Medicine-1994 Emergency Medical Services-2015 St. Elizabeth Community Hospital- Courtesy No Claims History 88 RC Rupnik, John K. MD Napa Valley Family Medical Group Napa Infectious Disease Internal Medicine-1976 Infectious Disease-1978 Queen of the Valley- Active No Claims History 89 IC Sandys, James M. MD North Coast Family Health Center Mendocino Family Medicine Family Medicine Mendocino Coast District Hospital-Active No Claims History 90 IC Sazmand, Takesh DO Health Diagnostics of California Marin Diagnostic Radiology Diagnostic Radiology-2015 No Direct Patient Contact No Claims History 91 IC Sharpe, Kathleen A. FNP Long Valley Health Center Mendocino Family Nurse Practitioner Family Nurse Practitioner No Claims History 92 RC Shaw, Amy E. MD Annadel Medical Group Sonoma Oncology Family Medicine Santa Rosa Memorial Hospital-Courtesy No Claims History 93 IC Simard, Jane K. PA-C Anderson Walk-In Clinic Shasta Physician Assistant Certified Physician Assistant Certified No Claims History 94 IC Smith, Holly B. MD TeleMed2U Placer Rheumatology Internal Medicine-2015 No Direct Patient Contact No Claims History 95 RC Smith, Larry A. DPM Sonoma Podiatry Group Coverage No Claims History 96 IC Souter, Stacia E. FNP Anderson Walk-In Medical Clinic Shasta 97 RC Stiles, Thomas E. MD Napa Endocrinology Family Nurse Practitioner Family Nurse Practitioner-2009 No Claims History St. Helena Hospital- Active Open: 0 Closed w/pay: 1 w/o pay: 0 Total Cases: 1 97 Page of June 2017

98 IC or RC Provider Name/Provider Group County Practice Specialty Board Certification Board Status Privileges Criteria Hospital Privileges Malpractice Claims & Payments (within 7 yrs.) 98 IC Strahm, Kathleen I. PA-C Mt. Tam Orthopedics Marin Physicial Assistant Certified Physician Assistant Certified-2015 No Claims History 99 RC Sugarman, Jeffrey L. MD Northern California Medical Associates Sonoma Mendocino Dermatology Pediatric Dermatology Dermatology-2002 Pediatric Dermatology-2008 Santa Rosa Memorial Hospital-Courtesy No Claims History 100 RC Tamarisk, Nancy K. NP Napa Valley Nephrology Napa Nurse Practitioner No Claims History 101 RC Taylor, Stephen J. DC Napa Chiropractic No Claims History 102 RC Thomas III, James A. PA-C Mendocino Coast Clinic Mendocino Physician Assistant Certified Physician Assistant Certified No Claims History 103 IC 104 IC 105 IC 106 RC 107 RC 108 RC Thompson, Zhanna BCBA Trumpet Behavioral Health Alameda Behavioral Health Behavioral Analyst-2017 No Claims History Thu, Ye MD Annadel Medical Group Sonoma Infectious Disease Internal Medicine-2015 Hospitalist Coverage No Claims History Thurman Woodruff, Hannorah O. BCBA Autism Intervention Professionals Sonoma Behavioral Health Behavioral Health No Claims History Velazquez, Kei J. CNM Mendocino Coast Clinic North Coast Family Health Vikstrom, Brian G. MD NBHG: NorthBay Cancer Center Mendocino Solano Certified Nurse Midwife Certified Nurse Midwife No Claims History Hematology/ Medical Oncology Internal Medicine-2001 Hematology-2005 Medical Oncology-2005 Weeks, Roger D. MD North Bay Eye Associates Petaluma Health Center Sonoma Opthalmology Opthalmology-1978 NorthBay Medical Center- Active Attending Petaluma Valley Hospital-Active No Claims History No Claims History 98 Page of 130 June 2017

99 IC or RC Provider Name/Provider Group County Wendel, Robert T. MD Yolo Retinal Consultants Medical Group Shasta 109 RC Retina Center of Chico butte Practice Specialty Ophthalmology Retina Board Certification Board Status Ophthalmology-1984 Privileges Criteria Hospital Privileges Mercy General Hospital of Sacramento-Active Malpractice Claims & Payments (within 7 yrs.) No Claims History 110 RC Wyatt, Carolyn M. NP Mendocino Community Health Clinics Mendocino Nurse Practitioner No Claims History 111 RC Wyble, Angela R. PA-C Northern California Medical Associates Sonoma Physician Assistant Certified Physician Assistant Certified-2003 No Claims History 112 IC Zauher, Ryan J. PA-C Redding Rancheria: Churn Creek Healthcare Shasta Physician Assistant Certified Physician Assistant Certified-2002 No Claims History 113 RC Ziady, Mary S. NP Mendocino Community Health Clinics Mendocino/ Lake Nurse Practitioner No Claims History 114 IC Zimmerman, Alisha F. PT NBHG: NorthBay Rehab Services Solano Physical Therapy No Claims History Medical Director/Physician Approval of Routine List Marshall Kubota M.D., PHC Credentialing Chairman 99 Page of June 2017

100 Healthcare Effectiveness Data Information Set (HEDIS) 2017 Summary of Performance Measuring quality of care and services provided to our members! Presented by: Megan D. Wilson, HEDIS Program Manager Nancy Steffen, Northern Region Associate Director of Quality, Analytics, and Project Management 100 of 130

101 Objectives HEDIS Overview 2017 Summary of Performance Regional and County Level Changes for HEDIS 2018 Planned Improvement Q&A Eureka Fairfield Redding Santa Rosa 101 of 130

102 Overview What is HEDIS? Healthcare Effectiveness Data Information Set Why is HEDIS Important? Evaluates clinical quality in a standardized way Identifies opportunities for improvement Regional level performance is publicly reported Regional level reporting is required by the State HEDIS/CAHPS equates to 50% of NCQA Accreditation Score Eureka Fairfield Redding Santa Rosa 102 of 130

103 HEDIS Overview Measure Reporting Methodology: Administrative Measures Measures the entire eligible population Data collected through transaction data or other administrative data used to identify the eligible population and numerator (i.e. Claims/encounter) Hybrid Measures Measures a statistically significant sample of the eligible population Data collected from transaction data or other administrative data and key data elements collected from the medical record chart Eureka Fairfield Redding Santa Rosa 103 of 130

104 Overview Southeast: Solano, Yolo, Napa Southwest: Sonoma, Marin, Mendocino, Lake Northeast: Lassen, Modoc, Siskiyou, Trinity, Shasta Northwest: Humboldt, Del Norte Eureka Fairfield Redding Santa Rosa 104 of 130

105 2017 Performance Summary Plan wide Scoring Methodology: 4 points for the 90 th percentile 3 points for the 75 th 89 th percentile 2 points for the 50 th 74 th percentile 1 point for the 25 th 49 th percentile NO points for below the 25 th percentile Eureka Fairfield Redding Santa Rosa 105 of 130

106 Composite HEDIS Performance % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% HEDIS RY 2016 HEDIS RY % 55.56% 23.61% 42% 31.94% 62.50% 55.56% 34.72% 48% 40.28% SE SW NE NW SE SW NE NW HEDIS 2016 HEDIS 2017 Total Points earned: 121 Points out of 288 Total Points Measures Reflected in Reporting: 18 Measures excluded due to not been held accountable for HEDIS RY2016: AMB, CAP, and ACR, and MPM Digoxin Measures excluded due to not been held accountable for HEDIS RY2017: IMA Combo 1 Measures excluded due to been removed from HEDIS RY2017: MMA (2 indicators), WCC BMI Measures Included: MPM (two indicators), AAB, CCS, CIS 3, CDC (6 indicators), CBP, PPC (2 indicators), LBP, WCC (2 indicators), W34 Total Points earned: 139 Points out of 288 Total Points Measures Reflected in Reporting: 18 Measures excluded due to not been held accountable for HEDIS RY2017: AMB, CAP, ACR, and CDF Measures excluded due to not been held accountable for HEDIS RY2017 new measures: AMR, BCS, and IMA Combo 2 Measures Included: MPM (two indicators), AAB, CCS, CIS 3, CDC (6 indicators), CBP, PPC (2 indicators), LBP, WCC (2 indicators), W34 Eureka Fairfield Redding Santa Rosa 106 of 130

107 2017 Performance Summary Review of HEDIS 2017 Performance Summary Report Eureka Fairfield Redding Santa Rosa 107 of 130

108 PartnershipHealthPlanofCalifornia HealthcareEfectivenessDataInformationSet(HEDIS) ReportYear2017;MeasurementYear2016 SummaryofPerformancebyRegion DelNorte Siskiyou Modoc Humboldt Shasta Trinity Lassen Northeast Mendocino Lake Yolo Sonoma Napa Solano Marin Northwest Southeast Southwest Distribution of Measures by Percentile Ranking (Includes first year measures BCS and AMR which DHCS does not hold plans accountable for MY 2016) Percentile Northeast Northwest Southeast Southwest 90th(HPL) th th th Below MPL MeasuresAtorAbovetheHighPerformanceLevel(HPL)-90thPercentile MeasureName Southeast Southwest AvoidanceofAntibioticTreatmentinAdultswithAcuteBronchitis(AAB)* UseofImagingStudiesforLow BackPain(LBP)* WeightAssessmentandCounselingforNutrition&PhysicalActivity(WCC)- CounselingforNutrition WeightAssessmentandCounselingforNutrition&PhysicalActivity(WCC)- CounselingforPhysicalActivity MeasureName Northeast Northwest Southwest AnnualMonitoringforPatientsonPersistentMedications(MPM)-ACEorARB* AnnualMonitoringforPatientsonPersistentMedications(MPM)-Diuretics* AsthmaMedicationRatio(AMR)*-New Measure BreastCancerScreening(BCS)*-New Measure ChildhoodImmunizationStatus(CIS-3)-Combo3 MeasuresBelow theminimum PerformanceLevel(MPL)-25thPercentile ComprehensiveDiabetesCare(CDC)-MedicalAtentionforNephropathy *AdministrativeMeasures.Theentireeligiblepopulationisusedincalculatingperformance(versusasystematicsampledrawnfrom theeligiblepopulationforthehybridmeasures). NOTES:ExcludesmeasuresreportedtoDHCSwhereDHCSdoesnotholdManagedCarePlansaccountableformeetingspecificperformancetargets(Al-Cause Readmissions,AmbulatoryCare,Children& AdolescentsAccesstoPrimaryCarePractitioners,ImmunizationforAdolescents-Combo2,ScreeningforClinicalDepression). DHCSremovedthefolowingmeasuresfrom thery2017externalaccontabilityset(eas):medicationmanagementforpeoplewithasthma,weightassessmentandcounselingfor NutritionandPhysicalActivity-BMI. BreastCancerScreening(BCS)andAsthmaMedicationRatio(AMR)arenewmeasuresaddedtotheEASduringRY2017.ManagedCarePlansarenotaccountablefor meetingspecificperformancetargetsduringthefirstyearreporting.planswilbeaccountableformeetingminumum PerformanceLevel(MPL)duringRY of 130

109 MeasureName Northeast Northwest Southeast Southwest AnnualMonitoringforPatientsonPersistent Medications(MPM)-ACEorARB* AnnualMonitoringforPatientsonPersistent Medications(MPM)-Diuretics* AsthmaMedicationRatio(AMR)*-New Measure AvoidanceofAntibioticTreatmentinAdultswith AcuteBronchitis(AAB)* BreastCancerScreening(BCS)*-New Measure CervicalCancerScreening(CCS) ChildhoodImmunizationStatus(CIS-3)-Combo3 ComprehensiveDiabetesCare(CDC)-BloodPressure Control(<140/90) ComprehensiveDiabetesCare(CDC)-EyeExams ComprehensiveDiabetesCare(CDC)-HbA1cControl (<8%) ComprehensiveDiabetesCare(CDC)-Medical AtentionforNephropathy ComprehensiveDiabetesCare(CDC)-PoorHbA1c Control(>9%) ComprehensiveDiabetesCare(CDC)-HbA1cTesting ControlingHighBloodPressure(CBP) PrenatalandPostpartum Care(PPC)-Postpartum Care PrenatalandPostpartum Care(PPC)-Timelinessof PrenatalCare UseofImagingStudiesforLow BackPain(LBP)* WeightAssessmentandCounselingforNutrition& PhysicalActivity(WCC)-CounselingforNutrition WeightAssessmentandCounselingforNutrition& PhysicalActivity(WCC)-CounselingforPhysical Activity Wel-ChildVisitsinthe3rd,4th,5th,and6thYearsof Life(W34) 84.67% 52.06% 84.85% 84.92% 87.83% 60.00% 46.04% 50.39% 85.55% 56.54% 50.67% 50.89% 84.77% 82.40% 72.07% 83.84% 44.06% 75.30% 80.18% 83.03% 42.55% 75.61% 76.56% 89.44% 69.17% 64.89% 89.29% 37.71% 51.34% 57.42% 68.61% 66.85% 59.06% 59.74% 78.04% 85.44% 72.51% 61.70% 84.35% 34.72% 90.46% 54.03% 59.41% 63.81% 74.56% 67.09% 57.20% 66.67% 86.20% 87.11% 71.65% 59.51% 63.41% 81.16% 84.42% 65.08% 48.10% 91.24% 40.15% 51.09% 47.93% 63.26% 49.15% 32.51% 86.06% 65.10% 51.82% 58.88% 76.30% 81.27% 61.56% 64.30% 85.89% 38.69% 89.78% 52.07% 49.64% 70.32% 52.07% 36.13% RegionalPerformance HEDIS2017RegionalPerformance PerformanceRelativetoNationalMedicaidBenchmarks AboveHPL(highperformancelevel,basedonNCQA'snationalMedicaid90thpercentile) Below MPL(minimum performancelevel,basedonncqa'snationalmedicaid25thpercentile) 25TH(MPL) 50TH 75TH 90TH(HPL) 82.97% 71.58% 79.52% 81.42% 91.00% 73.61% 70.69% 92.88% 29.23% 93.56% 58.39% 68.11% 75.73% 79.81% 69.95% 71.52% 38.91% 70.00% 92.28% 92.13% 77.57% 63.47% 70.88% 77.09% 87.56% 67.53% 63.99% 89.42% 36.87% 91.97% 52.55% 61.50% 68.61% 75.60% 63.88% 65.30% 32.51% 65.36% 90.00% 89.92% 71.42% 55.38% 62.65% 73.71% 82.25% 60.98% 54.78% 85.95% 43.80% 90.51% 46.76% 53.28% 59.73% 71.06% 55.94% 58.08% 26.17% 61.26% 87.52% 87.43% 64.72% 45.09% 51.84% 69.88% 74.21% 55.47% 46.87% 82.98% 52.31% 88.32% 39.80% 44.53% 52.26% 64.30% 48.18% 52.24% 22.12% 54.55% 85.18% 85.63% Benchmarks *AdministrativeMeasures.Theentireeligiblepopulationisusedincalculatingperformance(versusasystematicsampledrawnfrom theeligiblepopulationforthehybridmeasures). 109 of 130

110 HEDIS2017RegionalPerformance PercentageDiferencefrom ReportYear2016and2017 Measuresthatincreasedmorethan5.0% from HEDIS2016 Measuresthatdecreasedmorethan5.0% from HEDIS2016 MeasureName Northeast Northwest Southeast Southwest AnnualMonitoringforPatientsonPersistentMedications (MPM)-ACEorARB* 0.72% 6.73% 0.72% 1.52% AnnualMonitoringforPatientsonPersistentMedications (MPM)-Diuretics* 1.38% 5.61% 0.88% -0.18% AvoidanceofAntibioticTreatmentinAdultswithAcute Bronchitis(AAB)* 8.91% -1.92% 7.74% 2.91% CervicalCancerScreening(CCS) 9.98% 5.11% 6.99% 1.28% ChildhoodImmunizationStatus(CIS-3)-Combo3-0.07% 3.46% 2.89% 0.08% ComprehensiveDiabetesCare(CDC)-BloodPressure Control(<140/90) 6.08% 2.68% 0.16% -2.68% ComprehensiveDiabetesCare(CDC)-EyeExams 6.57% 5.11% -1.56% 3.41% ComprehensiveDiabetesCare(CDC)-HbA1cControl (<8%) 8.03% 2.68% -0.11% 2.43% ComprehensiveDiabetesCare(CDC)-MedicalAtention fornephropathy 2.43% 2.68% 2.90% -1.95% ComprehensiveDiabetesCare(CDC)-PoorHbA1c Control(>9%)* -8.27% 0.49% -0.89% -2.43% ComprehensiveDiabetesCare(CDC)-HbA1cTesting -0.97% 7.54% -0.77% 2.19% ControlingHighBloodPressure(CBP) 9.56% % -3.88% -0.63% PrenatalandPostpartum Care(PPC)-Postpartum Care 12.29% 5.71% 6.12% 0.83% PrenatalandPostpartum Care(PPC)-Timelinessof PrenatalCare 8.83% 3.89% 0.98% -2.50% UseofImagingStudiesforLow BackPain(LBP)* -5.33% -4.56% -3.24% -4.02% WeightAssessmentandCounselingforNutrition& PhysicalActivity(WCC)-CounselingforNutrition 0.24% 6.24% -1.22% 3.57% WeightAssessmentandCounselingforNutrition& PhysicalActivity(WCC)-CounselingforPhysicalActivity 0.24% 3.31% -0.98% 8.32% Wel-ChildVisitsinthe3rd,4th,5th,and6thYearsofLife (W34) 1.44% 11.59% 0.40% 2.48% *AdministrativeMeasures.Theentireeligiblepopulationisusedincalculatingperformance(versusasystematicsampledrawnfrom theeligiblepopulationforthehybridmeasures). **Decreaseindicatesperformanceimprovement 110 of 130

111 HEDIS2017RegionalPerformance PercentileRankingChangefrom HEDIS ReportYear2016to2017 MeasurepercentilerankingimprovedsinceHEDIS2016 MeasurepercentilerankingdecreasedsinceHEDIS2016 MeasureName Northeast Northwest Southeast Southwest AnnualMonitoringforPatientsonPersistent Medications(MPM)-ACEorARB* AnnualMonitoringforPatientsonPersistent Medications(MPM)-Diuretics* AvoidanceofAntibioticTreatmentinAdultswith AcuteBronchitis(AAB)* CervicalCancerScreening(CCS) ChildhoodImmunizationStatus(CIS-3)-Combo3 ComprehensiveDiabetesCare(CDC)-BloodPressure Control(<140/90) ComprehensiveDiabetesCare(CDC)-EyeExams ComprehensiveDiabetesCare(CDC)-HbA1cControl (<8%) ComprehensiveDiabetesCare(CDC)-Medical AtentionforNephropathy ComprehensiveDiabetesCare(CDC)-PoorHbA1c Control(>9%)* ComprehensiveDiabetesCare(CDC)-HbA1cTesting ControlingHighBloodPressure(CBP) PrenatalandPostpartum Care(PPC)-Postpartum Care PrenatalandPostpartum Care(PPC)-Timelinessof PrenatalCare UseofImagingStudiesforLow BackPain(LBP)* WeightAssessmentandCounselingforNutrition& PhysicalActivity(WCC)-CounselingforNutrition WeightAssessmentandCounselingforNutrition& PhysicalActivity(WCC)-CounselingforPhysicalAct. Wel-ChildVisitsinthe3rd,4th,5th,and6thYearsof Life(W34) 25th 25th 25th 50th 25th 50th 75th 25th 50th 25th 50th 25th 75th <25th 25th 75th <25th <25th <25th 25th 25th 75th <25th <25th 25th 50th 25th 75th 25th <25th 50th <25th <25th 50th <25th <25th 50th 50th 50th 75th 50th 50th 25th 75th 50th <25th 50th 25th 50th <25th 25th 75th 25th <25th <25th 50th 25th 90th 25th 25th 50th 25th 50th 75th 50th <25th 25th <25th <25th 75th <25th <25th 75th 90th 90th 90th 50th 75th 50th 25th 75th 25th 75th 50th 50th 50th 75th 90th 25th 25th 50th 90th 90th 90th 25th 50th 75th 25th 50th 75th 75th 50th 50th 50th 25th 75th 25th 25th 50th 90th 75th 90th 75th 75th 75th 50th 50th <25th 50th 50th 75th 25th 50th 90th <25th <25th 50th 50th 75th 90th 90th 50th 75th 50th 50th 75th 50th 25th 75th 25th 25th 90th 25th <25th *AdministrativeMeasures.Theentireeligiblepopulationisusedincalculatingperformance(versusasystematicsampledrawnfrom theeligiblepopulationforthehybridmeasures). 111 of 130

112 PartnershipHealthPlanofCalifornia HealthcareEfectivenessDataInformationSet(HEDIS) 2017SummaryofPerformancebyCounty DelNorte Siskiyou Modoc DelNorte Humboldt Trinity Shasta Lassen Humboldt Lake Lassen Marin Mendocino Modoc Mendocino Lake Yolo Sonoma Napa Solano Marin Napa Shasta Siskiyou Solano Sonoma Trinity Yolo DistributionofPercentileRankingsbyCounty Southeast Southwest Northeast Northwest Percentile Solano Yolo Napa Sonoma Mendoci. Marin Lake Shasta Siskiyou Lassen Trinity Modoc HumboldtDelNorte 90th(HPL) th th th Below MPL of 130

113 HEDIS2017PerformancebyCounty SoutheastRegion;(Solano,YoloandNapaCounties) 25TH(MPL) 50TH 75TH 90TH(HPL) 82.97% 71.58% 79.52% 81.42% 91.00% 73.61% 70.69% 92.88% 29.23% 93.56% 58.39% 68.11% 75.73% 79.81% 69.95% 71.52% 38.91% 70.00% 92.28% 92.13% 77.57% 63.47% 70.88% 77.09% 87.56% 67.53% 63.99% 89.42% 36.87% 91.97% 52.55% 61.50% 68.61% 75.60% 63.88% 65.30% 32.51% 65.36% 90.00% 89.92% 71.42% 55.38% 62.65% 73.71% 82.25% 60.98% 54.78% 85.95% 43.80% 90.51% 46.76% 53.28% 59.73% 71.06% 55.94% 58.08% 26.17% 61.26% 87.52% 87.43% 64.72% 45.09% 51.84% 69.88% 74.21% 55.47% 46.87% 82.98% 52.31% 88.32% 39.80% 44.53% 52.26% 64.30% 48.18% 52.24% 22.12% 54.55% 85.18% 85.63% Benchmarks AboveHPL(highperformancelevel,basedonNCQA'snationalMedicaid90thpercentile) Below MPL(minimum performancelevel,basedonncqa'snationalmedicaid25thpercentile) MeasureName Napa Solano Yolo AnnualMonitoringforPatientsonPersistentMedications (MPM)-ACEorARB* AnnualMonitoringforPatientsonPersistentMedications (MPM)-Diuretics* AsthmaMedicationRatio(AMR)*-New Measure AvoidanceofAntibioticTreatmentinAdultswithAcute Bronchitis(AAB)* BreastCancerScreening(BCS)*-New Measure CervicalCancerScreening(CCS) ChildhoodImmunizationStatus(CIS-3)-Combo3 ComprehensiveDiabetesCare(CDC)-BloodPressure Control(<140/90) ComprehensiveDiabetesCare(CDC)-EyeExams ComprehensiveDiabetesCare(CDC)-HbA1cControl (<8%) ComprehensiveDiabetesCare(CDC)-MedicalAtention fornephropathy ComprehensiveDiabetesCare(CDC)-PoorHbA1c Control(>9%) ComprehensiveDiabetesCare(CDC)-HbA1cTesting ControlingHighBloodPressure(CBP) PrenatalandPostpartum Care(PPC)-Postpartum Care PrenatalandPostpartum Care(PPC)-Timelinessof PrenatalCare UseofImagingStudiesforLow BackPain(LBP)* WeightAssessmentandCounselingforNutrition& PhysicalActivity(WCC)-CounselingforNutrition WeightAssessmentandCounselingforNutrition& PhysicalActivity(WCC)-CounselingforPhysicalActivity Wel-ChildVisitsinthe3rd,4th,5th,and6thYearsofLife (W34) 82.92% 87.50% 79.66% 76.25% 91.67% 96.36% 60.00% 82.80% 38.96% 83.52% 44.31% 89.04% 90.41% 86.85% 70.00% 41.67% 71.68% 72.09% 77.50% 80.45% 70.83% 59.38% 90.00% 30.00% 58.18% 63.64% 66.95% 53.55% 66.79% 87.12% 87.86% 78.57% 69.14% 77.14% 83.33% 72.97% 63.27% 35.42% 52.50% 61.25% 62.92% 70.33% 67.23% 58.85% 65.58% 85.96% 87.09% 82.00% 83.02% 73.58% 59.26% 40.68% 91.53% 49.15% 54.24% 67.80% 74.63% 57.00% 85.66% 85.75% SoutheastRegion *AdministrativeMeasures.Theentireeligiblepopulationisusedincalculatingperformance(versusasystematicsampledrawnfrom theeligiblepopulationforthehybridmeasures). 113 of 130

114 25TH(MPL) 50TH 75TH 90TH(HPL) 82.97% 71.58% 79.52% 81.42% 91.00% 73.61% 70.69% 92.88% 29.23% 93.56% 58.39% 68.11% 75.73% 79.81% 69.95% 71.52% 38.91% 70.00% 92.28% 92.13% 77.57% 63.47% 70.88% 77.09% 87.56% 67.53% 63.99% 89.42% 36.87% 91.97% 52.55% 61.50% 68.61% 75.60% 63.88% 65.30% 32.51% 65.36% 90.00% 89.92% 71.42% 55.38% 62.65% 73.71% 82.25% 60.98% 54.78% 85.95% 43.80% 90.51% 46.76% 53.28% 59.73% 71.06% 55.94% 58.08% 26.17% 61.26% 87.52% 87.43% 64.72% 45.09% 51.84% 69.88% 74.21% 55.47% 46.87% 82.98% 52.31% 88.32% 39.80% 44.53% 52.26% 64.30% 48.18% 52.24% 22.12% 54.55% 85.18% 85.63% Benchmarks MeasureName Lake Marin Mendocino Sonoma AnnualMonitoringforPatientsonPersistent Medications(MPM)-ACEorARB* AnnualMonitoringforPatientsonPersistent Medications(MPM)-Diuretics* AsthmaMedicationRatio(AMR)*-New Measure AvoidanceofAntibioticTreatmentinAdults withacutebronchitis(aab)* BreastCancerScreening(BCS)*-New Measure CervicalCancerScreening(CCS) ChildhoodImmunizationStatus(CIS-3)- Combo3 ComprehensiveDiabetesCare(CDC)-Blood PressureControl(<140/90) ComprehensiveDiabetesCare(CDC)-Eye Exams ComprehensiveDiabetesCare(CDC)-HbA1c Control(<8%) ComprehensiveDiabetesCare(CDC)- MedicalAtentionforNephropathy ComprehensiveDiabetesCare(CDC)-Poor HbA1cControl(>9%) ComprehensiveDiabetesCare(CDC)-HbA1c Testing ControlingHighBloodPressure(CBP) PrenatalandPostpartum Care(PPC)- Postpartum Care PrenatalandPostpartum Care(PPC)- TimelinessofPrenatalCare UseofImagingStudiesforLow BackPain (LBP)* WeightAssessmentandCounselingfor Nutrition&PhysicalActivity(WCC)- CounselingforNutrition WeightAssessmentandCounselingfor Nutrition&PhysicalActivity(WCC)- CounselingforPhysicalActivity Wel-ChildVisitsinthe3rd,4th,5th,and6th YearsofLife(W34) 86.96% 85.02% 84.94% 79.03% 43.55% 36.36% 40.85% 52.59% 88.00% 80.61% 83.68% 58.00% 47.17% 44.12% 58.67% 80.00% 37.33% 54.00% 40.74% 38.67% 47.30% 83.44% 81.65% 81.19% 84.77% 75.16% 71.02% 29.13% 49.40% 84.89% 92.31% 75.82% 39.22% 76.92% 86.15% 85.41% 74.00% 94.00% 74.00% 84.13% 50.00% 82.01% 89.44% 89.57% 55.65% 62.17% 70.43% 77.42% 64.32% 60.45% 64.47% 66.07% 53.85% 75.38% 59.52% 87.10% 48.39% 45.16% 66.13% 57.50% 87.43% 87.34% 78.00% 88.00% 61.67% 34.00% 58.00% 68.00% 60.00% 53.30% 62.63% 49.06% 78.57% 86.76% 57.14% 86.67% 45.33% 66.67% 32.89% 85.74% SouthwestRegion HEDIS2017PerformancebyCounty SouthwestRegion;(Lake,Marin,MendocinoandSonomaCounties) AboveHPL(highperformancelevel,basedonNCQA'snationalMedicaid90thpercentile) Below MPL(minimum performancelevel,basedonncqa'snationalmedicaid25thpercentile) *AdministrativeMeasures.Theentireeligiblepopulationisusedincalculatingperformance(versusasystematicsampledrawnfrom theeligiblepopulationforthehybridmeasures). 114 of 130

115 25TH(MPL) 50TH 75TH 90TH(HPL) 82.97% 71.58% 79.52% 81.42% 91.00% 73.61% 70.69% 92.88% 29.23% 93.56% 58.39% 68.11% 75.73% 79.81% 69.95% 71.52% 38.91% 70.00% 92.28% 92.13% 77.57% 63.47% 70.88% 77.09% 87.56% 67.53% 63.99% 89.42% 36.87% 91.97% 52.55% 61.50% 68.61% 75.60% 63.88% 65.30% 32.51% 65.36% 90.00% 89.92% 71.42% 55.38% 62.65% 73.71% 82.25% 60.98% 54.78% 85.95% 43.80% 90.51% 46.76% 53.28% 59.73% 71.06% 55.94% 58.08% 26.17% 61.26% 87.52% 87.43% 64.72% 45.09% 51.84% 69.88% 74.21% 55.47% 46.87% 82.98% 52.31% 88.32% 39.80% 44.53% 52.26% 64.30% 48.18% 52.24% 22.12% 54.55% 85.18% 85.63% Benchmarks MeasureName Modoc Trinity Siskiyou Shasta Lassen AnnualMonitoringforPatientsonPersistent Medications(MPM)-ACEorARB* AnnualMonitoringforPatientsonPersistent Medications(MPM)-Diuretics* AsthmaMedicationRatio(AMR)*-New Measure AvoidanceofAntibioticTreatmentinAdultswith AcuteBronchitis(AAB)* BreastCancerScreening(BCS)*-New Measure CervicalCancerScreening(CCS) ChildhoodImmunizationStatus(CIS-3)-Combo3 ComprehensiveDiabetesCare(CDC)-Blood PressureControl(<140/90) ComprehensiveDiabetesCare(CDC)-EyeExams ComprehensiveDiabetesCare(CDC)-HbA1c Control(<8%) ComprehensiveDiabetesCare(CDC)-Medical AtentionforNephropathy ComprehensiveDiabetesCare(CDC)-PoorHbA1c Control(>9%) ComprehensiveDiabetesCare(CDC)-HbA1c Testing ControlingHighBloodPressure(CBP) PrenatalandPostpartum Care(PPC)-Postpartum Care PrenatalandPostpartum Care(PPC)-Timeliness ofprenatalcare UseofImagingStudiesforLow BackPain(LBP)* WeightAssessmentandCounselingforNutrition& PhysicalActivity(WCC)-CounselingforNutrition WeightAssessmentandCounselingforNutrition& PhysicalActivity(WCC)-CounselingforPhysical Activity Wel-ChildVisitsinthe3rd,4th,5th,and6thYears oflife(w34) 30.00% 42.00% 52.00% 88.00% 34.00% 40.00% 40.00% 44.00% 44.35% 51.69% 75.52% 72.41% 57.44% 50.69% 84.46% 58.46% 82.72% 46.99% 42.99% 48.72% 80.85% 79.61% 62.00% 36.00% 69.81% 46.00% 54.00% 38.00% 38.00% 42.00% 44.00% 24.77% 76.35% 50.00% 72.41% 44.83% 46.00% 56.00% 42.00% 48.00% 46.00% 43.44% 47.83% 94.00% 64.00% 64.29% 95.38% 66.00% 72.45% 82.00% 52.00% 86.00% 46.00% 62.00% 32.81% 65.10% 53.21% 60.38% 77.07% 79.34% 63.10% 68.50% 84.53% 35.09% 92.08% 55.47% 53.58% 75.09% 55.04% 57.17% 33.87% 86.60% 65.71% 70.00% 77.55% 88.71% 62.90% 62.86% 87.65% 40.74% 49.38% 46.91% 69.14% 64.91% 35.79% 56.00% 85.42% 58.33% 88.00% 56.00% 61.36% 85.33% 50.00% 52.00% 74.19% 88.00% 90.00% 40.00% 64.58% 90.08% NortheastRegion HEDIS2017PerformancebyCounty NortheastRegion;(Modoc,Trinity,Siskiyou,ShastaandLassenCounties) AboveHPL(highperformancelevel,basedonNCQA'snationalMedicaid90thpercentile) Below MPL(minimum performancelevel,basedonncqa'snationalmedicaid25thpercentile) *AdministrativeMeasures.Theentireeligiblepopulationisusedincalculatingperformance(versusasystematicsampledrawnfrom theeligiblepopulationforthehybridmeasures). 115 of 130

116 25TH(MPL) 50TH 75TH 90TH(HPL) 82.97% 71.58% 79.52% 81.42% 91.00% 73.61% 70.69% 92.88% 29.23% 93.56% 58.39% 68.11% 75.73% 79.81% 69.95% 71.52% 38.91% 70.00% 92.28% 92.13% 77.57% 63.47% 70.88% 77.09% 87.56% 67.53% 63.99% 89.42% 36.87% 91.97% 52.55% 61.50% 68.61% 75.60% 63.88% 65.30% 32.51% 65.36% 90.00% 89.92% 71.42% 55.38% 62.65% 73.71% 82.25% 60.98% 54.78% 85.95% 43.80% 90.51% 46.76% 53.28% 59.73% 71.06% 55.94% 58.08% 26.17% 61.26% 87.52% 87.43% 64.72% 45.09% 51.84% 69.88% 74.21% 55.47% 46.87% 82.98% 52.31% 88.32% 39.80% 44.53% 52.26% 64.30% 48.18% 52.24% 22.12% 54.55% 85.18% 85.63% Benchmarks AboveHPL(highperformancelevel,basedonNCQA'snationalMedicaid90thpercentile) HEDIS2017PerformancebyCounty NorthwestRegion;(DelNorteandHumboldtCounties) Below MPL(minimum performancelevel,basedonncqa'snationalmedicaid25thpercentile) MeasureName DelNorte Humboldt AnnualMonitoringforPatientsonPersistent Medications(MPM)-ACEorARB* AnnualMonitoringforPatientsonPersistent Medications(MPM)-Diuretics* AsthmaMedicationRatio(AMR)*-New Measure AvoidanceofAntibioticTreatmentinAdults withacutebronchitis(aab)* BreastCancerScreening(BCS)*-New Measure CervicalCancerScreening(CCS) ChildhoodImmunizationStatus(CIS-3)- Combo3 ComprehensiveDiabetesCare(CDC)-Blood PressureControl(<140/90) ComprehensiveDiabetesCare(CDC)-Eye Exams ComprehensiveDiabetesCare(CDC)-HbA1c Control(<8%) ComprehensiveDiabetesCare(CDC)-Medical AtentionforNephropathy ComprehensiveDiabetesCare(CDC)-Poor HbA1cControl(>9%) ComprehensiveDiabetesCare(CDC)-HbA1c Testing ControlingHighBloodPressure(CBP) PrenatalandPostpartum Care(PPC)- Postpartum Care PrenatalandPostpartum Care(PPC)- TimelinessofPrenatalCare UseofImagingStudiesforLow BackPain (LBP)* WeightAssessmentandCounselingfor Nutrition&PhysicalActivity(WCC)- CounselingforNutrition WeightAssessmentandCounselingfor Nutrition&PhysicalActivity(WCC)- CounselingforPhysicalActivity Wel-ChildVisitsinthe3rd,4th,5th,and6th YearsofLife(W34) 87.54% 61.37% 46.57% 45.85% 50.73% 84.99% 84.47% 48.39% 42.86% 54.76% 46.65% 49.02% 82.53% 95.12% 69.85% 59.77% 62.39% 84.82% 68.15% 49.52% 90.27% 41.34% 51.37% 47.11% 65.96% 32.91% 80.00% 58.21% 68.66% 76.10% 82.26% 35.37% 89.02% 50.00% 51.22% 52.44% 63.93% 30.61% 89.36% 88.99% NorthwestRegion *AdministrativeMeasures.Theentireeligiblepopulationisusedincalculatingperformance(versusasystematicsampledrawnfrom theeligiblepopulationforthehybridmeasures). 116 of 130

117 Partnership HealthPlan of California Report Year 2017 Measurement Year 2016 Summary of Measures in the Primary Care Provider Quality Improvement Program (PCP QIP) included in the HEDIS 2017 External Accountability Set (EAS) Measure PCP QIP Measure 2017 Transition PCP QIP Measure Notes for PCP QIP Measures All-Cause Readmissions (ACR)* Ambulatory Care (AMBA) Annual Monitoring for Patients on Persistent Medications (MPM) Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) x x New measure for Family Practices in Thresholds are 50 th percentile for while 90 th percentile for 2017 Transition Period. Asthma Medication Ration (AMR) Will be added to 2018 measurement set for Pediatric practices Breast Cancer Screening (BCS) Will be added to 2018 measurement sets for Internal Medicine and Family Practices Cervical Cancer Screening (CCS) x x Childhood Immunization Status Combo 3 (CIS) x x Children and Adolescents Access to Primary Care Practitioners (CAP) x x Only DTap and MMR are measures in QIP. Family and Pediatric report on DTap. Only Pediatrics practices report on MMR. The average number of assigned members' visits to PCP per member per year. Comprehensive Diabetes Care (CDC) Eye Exam x x Comprehensive Diabetes Care (CDC) HbA1c Adequate Control (<8) Comprehensive Diabetes Care (CDC) HbA1c Poor Control (>9)* QIP measures Good Control, HbA1c <9. QIP measures Good Control, HbA1c <9. Comprehensive Diabetes Care (CDC) HbA1c Testing Comprehensive Diabetes Care (CDC) Medical Attention for Nephropathy x x Controlling High Blood Pressure (CBP) x x Immunizations for Adolescents (IMA) Combo 2 x x Prenatal and Postpartum Care (PPC) Timeliness of Postpartum Care Prenatal and Postpartum Care (PPC) Timeliness of Prenatal Care Screening for Clinical Depression and Follow-up Plan (CDF) Use of Imaging Studies for Low Back Pain (LBP) Weight Assessment and Counseling for Children/Adolescents (WCC) Physical Activity Weight Assessment and Counseling for Children/Adolescents (WCC) Nutrition Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34) Pediatric Practices only; will be added to 2018 measurement set for Family practices x x Pediatric Practices only; Family Practices do not report. x x Pediatric Practices only; Family Practices do not report. x x Family and Pediatric practices report. *Lower rate indicates better performance. 117 of 130

118 Measures under the MPL Comprehensive Diabetes Care (CDC) Medical Attention for Nephropathy HEDIS RY MPL Southeast Southwest Northeast Northwest % 25 th <MPL 25 th <MPL % 75 th 75 th 75 th 75 th Childhood Immunization Status, Combo 3 (CIS 3) Percentage of children 2 years of age who had a series of vaccinations by their second birthday HEDIS RY MPL Southeast Southwest Northeast Northwest % 50 th 25 th <MPL <MPL % 50 th 25 th <MPL <MPL Eureka Fairfield Redding Santa Rosa 118 of 130

119 Measures under the MPL Annual Monitoring for Patients on Persistent Medications (MPM) ACE/ARBs & Diuretics Annual therapeutic monitoring for members on ACE or ARB s HEDIS RY MPL Southeast Southwest Northeast Northwest % 25 th <MPL <MPL <MPL % 25 th <MPL <MPL <MPL Annual therapeutic monitoring for members on Diuretics HEDIS RY MPL Southeast Southwest Northeast Northwest % 25 th <MPL <MPL 25 th % 25 th 25 th <MPL <MPL Eureka Fairfield Redding Santa Rosa 119 of 130

120 New Measures of Focus for 2018 Breast Cancer Screening (2017 MPL = 52.24%) Percentage of women years of age who had a mammogram to screen for breast cancer BCS Southeast Southwest Northeast Northwest Performance 25 th <MPL <MPL <MPL Rate 57.2% 52.06% 50.67% 46.04% Asthma Medication Ratio (2017 MPL = 54.55%) Percentage of members 5 64 years of age with asthma and had a ration of controller medication to total asthma medications of 0.50 or greater AMR Southeast Southwest Northeast Northwest Performance 75 th 25 th <MPL <MPL Rate 66.67% 59.74% 50.89% 50.39% Immunization for Adolescents with HPV (no benchmarks) Percentage of adolescents 13 years of age who had one dose meningococcal, one TDAP and Three two doses of HPV by 13 th B day. IMA Southeast Southwest Northeast Northwest Rate 30.17% 28.22% 11.19% 17.52% Eureka Fairfield Redding Santa Rosa 120 of 130

121 Changes to HEDIS 2018 Measurement set changes Specification change Immunization for Adolescents with HPV Replacement Remove: Screening for Clinical Depression and Follow up Plan (CDF) Replacement: Depression Screening and Follow Up for Adolescents & Adults (DSF) Potentially Retiring Management of Persistent Medication (MPM) ACE/ARB & Diuretics Children & Adolescents Access to Primary Care Practitioners (CAP) NCQA audit timeline Medical Record Project stops May 9 th instead of May 15 th Eureka Fairfield Redding Santa Rosa 121 of 130

122 Planned Improvement HEDIS Improvement Update Presented by: Nancy Steffen, Northern Region Associate Director of Quality, Analytics, and Project Management Eureka Fairfield Redding Santa Rosa 122 of 130

123 Strategic Planning Process Best Practices Interviews (8 plans, 1 MSO) Stakeholder Interviews o o o o o o PHC Board Members 3 NR, 4 SR PHC Executive Team members (Liz, Sonja, Kirt, Margaret, Patti) PHC Directors & Managers (Analytics, Care Coordination, Finance, IT, Member Services, Pharmacy, QI) 15 Primary Care Practices 3 Community Clinic Consortia Consumer Advisory Committee 123 of 130

124 HEDIS Strategic Plan Vision & Goals Vision: All PHC members consistently get the best quality care as evidenced by excellent HEDIS scores. Goals (set by Executive Team): Raise all HEDIS measures* to: 1) The minimum performance level (25th percentile) across all four regions by July ) Above the 50th percentile across all four regions by July ) Above the 75th percentile across all four regions by July * Includes only the measures for which DHCS holds PHC accountable to a minimum level of performance. 124 of 130

125 Strategic Plan Aim and Focus Areas Aim: Improve HEDIS Scores via population health management strategy Focus Areas: 1) Primary care population health management 2) PHC population health management and direct member engagement 3) Data and analytics infrastructure 125 of 130

126 Year 1 Activities Primary Care Population Health Management Partner with PCPs to implement DHCS mandated improvement projects QI led technical assistance and training to practices Restructure PCP QIP to optimize P4P with HEDIS improvement PHC Pop Hlth Mgmt & Direct to Member Engagement Train PHC management and staff on priority measures to expand leverage points for addressing gaps in care Test member outreach strategies and evaluate Data and Analytics Infrastructure Continue efforts to provide actionable data to practices and PHC staff and to develop data infrastructure, monitoring, and analytic capacity 126 of 130

127 Success through your Support Although the work is led by Quality and Performance Improvement, HEDIS is a highly collaborative process across the entire organization Eureka Fairfield Redding Santa Rosa 127 of 130