REGULAR MEETING OF THE GOVERNING BOARD OF THE INLAND EMPIRE HEALTH PLAN and IEHP HEALTH ACCESS. January 8, :00 AM.

Transcription

1 1 of 73 REGULAR MEETING OF THE GOVERNING BOARD OF THE INLAND EMPIRE HEALTH PLAN and IEHP HEALTH ACCESS January 8, :00 AM Board Report #274 Riverside County Administrative Center 4080 Lemon Street Board Chambers - First Floor Riverside CA If disability-related accommodations are needed to participate in this meeting, please contact Annette Taylor, Secretary to the IEHP Governing Board at (909) during regular business hours of IEHP (M-F 8:00 a.m. 5:00 p.m.) PUBLIC COMMENT AT INLAND EMPIRE HEALTH PLAN GOVERNING BOARD MEETINGS: The meeting of the Inland Empire Health Plan Governing Board is open to the public. A member of the public may address the Board on any item on the agenda and on any matter that is within the Board s jurisdiction. Requests to address the Board must be submitted in person to the Secretary of the Governing Board prior to the start of the meeting and indicate any contributions in excess of $ made by them or their organization in the past twelve (12) months to any IEHP Governing Board member as well as the name of the Governing Board member who received contribution. The Board may limit the public input on any item, based on the number of people requesting to speak and the business of the Board. All public record documents for matters on the open session of this agenda can be viewed at the meeting location listed above, IEHP main offices at th Street, Suite 120, Rancho Cucamonga, CA and online at I. Call to Order AGENDA II. III. IV. Agenda Changes: Board Secretary Comments from the Public on Matters on the Agenda Conflict of Interest Disclosure: V. Adopt and Approve of the Meeting Minutes from the December 11, 2017 Regular Meeting of the Governing Board of the Inland Empire Health Plan and IEHP Health Access VI. VII. Election of the Chairman of the Governing Board (San Bernardino County) Election of the Vice Chairman of the Governing Board (Riverside County)

2 2 of 73 Submittals to Inland Empire Health Plan and IEHP Health Access Governing Board AGENDA January 8, 2018 VIII. IEHP CONSENT AGENDA MEDICAL SERVICES DEPARTMENT (Jennifer N. Sayles, M.D., MPH) 1. Ratify and Approve the Memorandum of Understandings with Riverside County and San Bernardino County OPERATIONS DEPARTMENT (Bradley P. Gilbert, M.D.) 2. Approve the Ninth Amendment to the Lease Agreement with Southern California Edison Company 3. Approve the Professional Services Agreement with Jensen Construction Management, Inc. PROVIDER NETWORK DEPARTMENT (Kurt Hubler) 4. Approve the Annual Update to the January 2018 IEHP Provider Policies and Procedures Manuals and the Encounter Data Interchange Manual. 5. Ratify and Approve the First Amendment to the Ancillary Provider Agreement with Charter Hospice, Inc. 6. Ratify and Approve the First Amendment to the Ancillary Provider Agreement with Charter Hospice of the San Gabriel Valley, LLC 7. Ratify and Approve the New Capitated Primary Care Provider Agreement with the County of San Bernardino on Behalf of Arrowhead Regional Medical Center 8. Ratify and Approve the Fifth Amendment to the Hospital Per Diem Agreement with Desert Valley Hospital, Inc. 9. Ratify and Approve the Eighth Amendment to the Hospital Per Diem Agreement with Loma Linda University Medical Center 10. Ratify and Approve the Twelfth Amendment to the Hospital Per Diem Agreement with Physicians for Healthy Hospitals dba Hemet Valley Medical Center and Menifee Valley Medical Center 11. Ratify and Approve the Third Amendment to the Hospital Per Diem Agreement with Prime Healthcare Services III, LLC dba Montclair Hospital Medical Center 12. Ratify and Approve the Sixteenth Amendment to the Hospital Per Diem Agreement with Redlands Community Hospital 13. Ratify and Approve the Eighth Amendment to the Hospital Per Diem Agreement with St. Mary Medical Center 14. Ratify and Approve the Third Amendment to the Hospital Per Diem Agreement with San Gorgonio Memorial Hospital 15. Ratify and Approve the Fifth Amendment to the Hospital Per Diem Agreement with Veritas Health Services Inc., dba Chino Valley Medical Center

3 3 of 73 Submittals to Inland Empire Health Plan and IEHP Health Access Governing Board AGENDA January 8, Ratify and Approve the Third Amendment to the Hospital Per Diem Agreement with Victor Valley Hospital Acquisition, Inc., dba Victor Valley Global Medical Center 17. Ratify and Approve the Twenty-Third Amendment to the Provider Agreement with Riverside University Health System Medical Center 18. Approval of the Evergreen Contracts 1. Ancillary Provider Agreement with Center for Comprehensive Care and Diagnosis of Inherited Blood Disorder 2. Ancillary Provider Agreement with Desert View Endoscopy Center LLC 3. Ancillary Provider Agreement with Health Essentials Inc 4. Ancillary Provider Agreement with High Desert Hospice Inc. 5. Ancillary Provider Agreement with Jameco Home Health Agency Inc 6. Ancillary Provider Agreement with Joint Active Systems Inc 7. Ancillary Provider Agreement with Joint Neal Collins 8. Ancillary Provider Agreement with Optima Home Health Services Inc 9. Ancillary Provider Agreement with Orthopaedic Medical Supplies Inc 10. Ancillary Provider Agreement with Pearl Ventures 11. Ancillary Provider Agreement with Seasons Hospice & Palliative Care of California San Bernardino. 12. Ancillary Provider Agreement with Southland Endoscopy Center 13. Ancillary Provider Agreement with Seasons The Oaks Surgery Center 14. Ancillary Provider Agreement with Seasons Unicare Diagnostics Inc 15. Ancillary Provider Agreement with Seasons Willow Link LLC 16. Open Access Provider Agreement with Adam J Novak MD 17. Open Access Provider Agreement with Benny Guzman MD Corporation 18. Open Access Provider Agreement with Harry R Webb Jr MD 19. Open Access Provider Agreement with King-Yee Yu MD 20. Open Access Provider Agreement with Wu Kong-Tay MD Inc 21. Capitated Primary Care Provider Agreement with Radha Menon MD Inc 22. Capitated Primary Care Provider Agreement with Ram K Kamath Group Inc 23. Fee for Service Primary Care Provider Agreement with Mario A Diaz Gomez MD 24. Fee for Service Primary Care Provider Agreement with Elizabeth J DeMagno MD 25. Skilled Nursing Facility Provider Agreement with Spring Valley Post Acute LLC 26. Skilled Nursing Facility Provider Agreement with Vista Cove Care Center at Corona Inc 27. Participating Provider Agreement California Cataract Center 28. Participating Provider Agreement with Desert Pain Care Medicine Group Inc 29. Participating Provider Agreement with Elham Jafarimojarrad MD Inc 30. Participating Provider Agreement with Femcare Medical Associates of Inland Valley Inc 31. Participating Provider Agreement with Fred F Soeprono MD Inc. 32. Participating Provider Agreement with Helena Mba MD 33. Participating Provider Agreement with Paramount Medical 34. Participating Provider Agreement with The Gastro Group Inc. 35. Participating Provider Agreement with William M Kelly MD, Inc. 36. Participating Provider Agreement with Inland OB/GYN Associates Inc

4 4 of 73 Submittals to Inland Empire Health Plan and IEHP Health Access Governing Board AGENDA January 8, 2018 POLICY AGENDA AND STATUS REPORT ON AGENCY OPERATIONS: ADMINISTRATION (Bradley P. Gilbert, M.D.) 19. Monthly Membership Report Third Quarter Review of the IEHP Compliance Program FINANCE DEPARTMENT (Keenan Freeman) 21. Review of Monthly Financials INFORMATION TECHNOLOGY DEPARTMENT (Michael Deering) 22. Delegation of Authority to Approve the Agreement with Inland Empire Health Information Organization. MEDICAL SERVICES DEPARTMENT (Jennifer N. Sayles, M.D., MPH) 23. Approve the Award of Request for Proposal # to Aunt Bertha, Inc. 24. Approve the Award for Request for Proposal # to MD Live and Increase to Project Budget 25. Overview of the 2018 Independent Practice Associations Global Quality Pay For Performance Program 26. Overview of the 2018 Primary Care Physician Global Quality Pay For Performance Program MAIN OBJECTIVES FOR THE NEXT 90 DAYS AND SUMMARY COMMENTS (Bradley P. Gilbert, M.D.) 27. Main Objectives for the Next 90 Days and Summary Comments IX. IEHP HEALTH ACCESS CONSENT AGENDA PROVIDER NETWORK DEPARTMENT (Kurt Hubler) 28. Ratify and Approve the First Amendment to the Ancillary Provider Agreement with Charter Hospice, Inc. 29. Ratify and Approve the First Amendment to the Ancillary Provider Agreement with Charter Hospice of the San Gabriel Valley, LLC 30. Ratify and Approve the New Capitated Primary Care Provider Agreement with the County of San Bernardino on Behalf of Arrowhead Regional Medical Center 31. Ratify and Approve the Fifth Amendment to the Hospital Per Diem Agreement with Desert Valley Hospital, Inc.

5 5 of 73 Submittals to Inland Empire Health Plan and IEHP Health Access Governing Board AGENDA January 8, Ratify and Approve the Eighth Amendment to the Hospital Per Diem Agreement with Loma Linda University Medical Center 33. Ratify and Approve the Twelfth Amendment to the Hospital Per Diem Agreement with Physicians for Healthy Hospitals dba Hemet Valley Medical Center and Menifee Valley Medical Center. 34. Ratify and Approve the Third Amendment to the Hospital Per Diem Agreement with Prime Healthcare Services III, LLC dba Montclair Hospital Medical Center 35. Ratify and Approve the Sixteenth Amendment to the Hospital Per Diem Agreement with Redlands Community Hospital 36. Ratify and Approve the Eighth Amendment to the Hospital Per Diem Agreement with St. Mary Medical Center 37. Ratify and Approve the Third Amendment to the Hospital Per Diem Agreement with San Gorgonio Memorial Hospital 38. Ratify and Approve the Fifth Amendment to the Hospital Per Diem Agreement with Veritas Health Services Inc., dba Chino Valley Medical Center 39. Ratify and Approve the Third Amendment to the Hospital Per Diem Agreement with Victor Valley Hospital Acquisition, Inc., dba Victor Valley Global Medical Center 40. Ratify and Approve the Twenty-Third Amendment to the Provider Agreement with Riverside University Health System Medical Center 41. Approval of the Evergreen Contracts 1. Ancillary Provider Agreement with Center for Comprehensive Care and Diagnosis of Inherited Blood Disorder 2. Ancillary Provider Agreement with Desert View Endoscopy Center LLC 3. Ancillary Provider Agreement with Health Essentials Inc 4. Ancillary Provider Agreement with High Desert Hospice Inc. 5. Ancillary Provider Agreement with Jameco Home Health Agency Inc 6. Ancillary Provider Agreement with Joint Active Systems Inc 7. Ancillary Provider Agreement with Joint Neal Collins 8. Ancillary Provider Agreement with Optima Home Health Services Inc 9. Ancillary Provider Agreement with Orthopaedic Medical Supplies Inc 10. Ancillary Provider Agreement with Pearl Ventures 11. Ancillary Provider Agreement with Seasons Hospice & Palliative Care of California San Bernardino. 12. Ancillary Provider Agreement with Southland Endoscopy Center 13. Ancillary Provider Agreement with Seasons The Oaks Surgery Center 14. Ancillary Provider Agreement with Seasons Unicare Diagnostics Inc 15. Ancillary Provider Agreement with Seasons Willow Link LLC 16. Open Access Provider Agreement with Adam J Novak MD 17. Open Access Provider Agreement with Benny Guzman MD Corporation 18. Open Access Provider Agreement with Harry R Webb Jr MD 19. Open Access Provider Agreement with King-Yee Yu MD 20. Open Access Provider Agreement with Wu Kong-Tay MD Inc

6 6 of 73 Submittals to Inland Empire Health Plan and IEHP Health Access Governing Board AGENDA January 8, Capitated Primary Care Provider Agreement with Radha Menon MD Inc 22. Capitated Primary Care Provider Agreement with Ram K Kamath Group Inc 23. Fee for Service Primary Care Provider Agreement with Mario A Diaz Gomez MD 24. Fee for Service Primary Care Provider Agreement with Elizabeth J DeMagno MD 25. Skilled Nursing Facility Provider Agreement with Spring Valley Post Acute LLC 26. Skilled Nursing Facility Provider Agreement with Vista Cove Care Center at Corona Inc 27. Participating Provider Agreement California Cataract Center 28. Participating Provider Agreement with Desert Pain Care Medicine Group Inc 29. Participating Provider Agreement with Elham Jafarimojarrad MD Inc 30. Participating Provider Agreement with Femcare Medical Associates of Inland Valley Inc 31. Participating Provider Agreement with Fred F Soeprono MD Inc. 32. Participating Provider Agreement with Helena Mba MD 33. Participating Provider Agreement with Paramount Medical 34. Participating Provider Agreement with The Gastro Group Inc. 35. Participating Provider Agreement with William M Kelly MD, Inc. 36. Participating Provider Agreement with Inland OB/GYN Associates Inc X. COMMENTS FROM THE PUBLIC ON MATTERS NOT ON THE AGENDA XI. ADJOURNMENT The next meeting of the IEHP Governing Board will be held on February 12, 2018 at the San Bernardino County Government Center.

7 7 of 73 CONSENT AGENDA January 8, 2018 MEDICAL SERVICES DEPARTMENT 1. RATIFY AND APPROVE THE MEMORANDUM OF UNDERSTANDINGS WITH RIVERSIDE COUNTY AND SAN BERNARDINO COUNTY That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the In- Home Support Services (IHSS) Memorandum of Understandings (MOU) with Riverside County Department of Public Social Services (DPSS), Riverside County IHSS Public Authority (PA), San Bernardino County Department of Aging and Adult Services (DAAS) and San Bernardino County IHSS PA Jennifer N. Sayles, M.D., MPH, Chief Medical Officer In June 2012, the state passed the Coordinated Care Initiative (CCI), whose goal is to integrate the delivery of medical, behavioral and long-term support services (LTSS) for eligible beneficiaries in California. The CCI required that IHSS be a Medi-Cal benefit available through the managed care health plan in specified counties. Riverside and San Bernardino counties are included in the initiative. The state removed IHSS as part of the Medi-Cal managed care benefit beginning in 2018, it remains a Medi-Cal FFS benefit. All stakeholders involved agree that the coordination and data sharing that took place under CCI improved the ability to provide services to Members/Clients. IEHP has separate IHSS related MOUs with the following entities: 1. Riverside County DPSS 2. Riverside County IHSS PA 3. San Bernardino County DAAS 4. San Bernardino County IHSS PA These MOUs allow IEHP and each individual party to share confidential recipient information to promote shared understanding of the consumer's needs and ensure appropriate access to IHSS. IEHP has been meeting collaboratively with all four (4) entities around the provision of IHSS since early These MOUs extend the agreements to December 31, 2022 and updates terms. There are no budget costs associated with these agreements.

8 8 of 73 CONSENT AGENDA January 8, 2018 None Yes

9 9 of 73 POLICY AGENDA January 8, 2018 OPERATIONS DEPARTMENT 2. APPROVE THE NINTH AMENDMENT TO THE LEASE AGREEMENT WITH SOUTHERN CALIFORNIA EDISON COMPANY That the Governing Board of the Inland Empire Health Plan (IEHP) approve the Ninth Amendment to the Lease Agreement with Southern California Edison Company (SCE), effective January 8th, Bradley P. Gilbert, M.D., Chief Executive Officer In June 2016 under Minute Order 16-85, the Governing Board approved the real property purchase of 9500 Cleveland Avenue, Rancho Cucamonga CA The acquisition of the Empire Lakes building provides IEHP with a corporate campus that allows centralized expansion, approximately 241,292 square feet, and with two current tenants; Southern California Edison Company (SCE) and State Farm. Currently, SCE occupies office space totaling 90,574 square feet in the 9500 Cleveland building. SCE has requested to extend their existing lease term to provide support for future operations. The Ninth Amendment includes the following terms: Commencement date of lease extension shall be May 1, 2020 Lease extension shall be thirty-eight (38) months Four (4) months of half rent to occur in month one though four (1-4) of lease extension Monthly base rent per square foot during lease extension term will be two dollars ($2), with a three percent (3%) annual increase Tenant is responsible for their own electrical charges IEHP will continue to collect rental income for SCE s leased space. Below is a revenue table: IEHP Revenue SCE Lease Term Total Revenue May January 2021 $ 819,000 February April 2021 $ 546,000 May April 2022 $ 2,249,520 May April 2023 $ 2,315,040 May June 2023 $ 398,580 Total Revenue $ 6,328,140

10 10 of 73 POLICY AGENDA January 8, 2018 None Yes

11 11 of 73 POLICY AGENDA January 8, 2018 OPERATIONS DEPARTMENT 3. APPROVE THE PROFESSIONAL SERVICES AGREEMENT WITH JENSEN CONSTRUCTION MANAGEMENT, INC. That the Governing Board of the Inland Empire Health Plan (IEHP) approve the Professional Services Agreement (Agreement) with Jensen Construction Management, Inc. (Jensen) for Project Management and Construction Management Services for IEHP s Campus Expansion Project for an amount not to exceed $415,150 effective January 8, Bradley P. Gilbert, M.D. In June 22, 2017 under Minute Order , the Governing Board approved IEHP s Campus Visioning Project and budget of $ million. IEHP s vision is to design, enhance and expand its campus which includes elements incorporating a courtyard circulation, outdoor wellness initiatives, gym facilities, learning and innovation center, and future ancillary needs. On September 18, 2017 IEHP advertised an RFP for Project Management and Construction Management Services on IEHP s third party Public Purchase website. All final proposals were due October 9, 2017 with the following two (2) vendors providing proposals: Jensen Construction Management, Inc. (Jensen) Honnold Construction Management of California Inc. The initial responses were reviewed and scored. RFP scoring was based on scale of weighted points on the following categories: Acknowledgment of RFP; Company profile and experience; Understanding of scope of service; Overall cost; and Local preference Four (4) IEHP evaluators conducted scoring on the categories listed above. All awarded points were combined for each vendor for a grand total with the following results: Vendor Score Jensen 79 Honnold Construction Management of California Inc 78

12 12 of 73 POLICY AGENDA January 8, 2018 IEHP selected Jensen based on responsiveness, management structure, understanding of IEHP s specific scope of service, and relative experience. As IEHP begins the initiation phase of the Campus Expansion Project, Jensen will lead Project and Construction Management Services. Jensen will manage all major milestones, project schedule, and other key attributes throughout initiation and construction completion. The following deliverables are outlined within the Agreement for both Project Management and Construction Management Services: Project Management Administration: - Scheduling - Contract negotiations - Design development advisory - Architect and engineering advisory - Constructions drawing advisory - Construction commencement - Furniture equipment planning and installation - Communication Planning - Project closeout Construction Management Administration: - Project checklist - Preliminary project schedule - Preliminary construction schedule - Schedule of values - Periodic requisition for payments - Change orders - Project specifications - Manage test fit - Meetings - Project budget - Construction budget - Evaluations of alternatives - Supervision and inspections - Work letters - Documentations, records, and reporting - Project closeout Total compensation for these services shall not exceed $415,150, effective January 8, The Agreement also includes include three (3), one (1) year term extension options. Included in FY 17/18 Budget Yes

13 13 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 4. APPROVE THE ANNUAL UPDATE TO THE JANUARY 2018 IEHP PROVIDER POLICIES AND PROCEDURES MANUALS AND THE ENCOUNTER DATA INTERCHANGE MANUAL. That the Governing Board of the Inland Empire Health Plan (IEHP) approve the 2018 Annual update to the Provider Policies and Procedures Manual and the Encounter Data Interchange (EDI) Manual. Kurt Hubler, Chief Network Officer These Manuals are designed to help IEHP Providers, Hospitals and IPAs understand the rules and regulations IEHP must comply with, as governed by DHCS, DMHC, NCQA, and CMS. All contracted IPAs, Hospitals, Providers and Direct Ancillary Providers receive a copy of the Provider Manual CD to ensure they are aware of IEHP s standards. The Provider Manual CDs were mailed to IPAs, Hospitals, Providers and Direct Ancillary Providers during the last week of September with an effective date of January 1, IEHP updates the Manuals at minimum once a year. This Annual Update consists of any new policies and/or revisions made in the Annual Update from the previous year to comply with NCQA standards, legislative changes, regulatory requirements, clarifications imposed by DMHC, DHCS, CMS, as well as operational changes reflected in contract renewals. Interim policy updates are made throughout the year as needed, due to requirement changes. IEHP continues to post State and CMS benefit links on IEHP s Provider Portal. Included in FY 17/18 budget Yes

14 14 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 5. RATIFY AND APPROVE THE FIRST AMENDMENT TO THE ANCILLARY PROVIDER AGREEMENT WITH CHARTER HOSPICE, INC. That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the First Amendment to the Ancillary Provider Agreement with Charter Hospice, Inc., effective January 1, Kurt Hubler, Chief Network Officer Charter Hospice, Inc. is currently a contracted Provider in the IEHP Network. The First Amendment is to replace the Attachment A, Scope of Services and Attachment B, Compensation to include the Transitional Care Management (TCM) Services and rates. In addition, the amendment includes the new Attachments B1 - Quality Program and B2 - Encounter Code List for details related to TCM. Included in FY 17/18 Budget Yes

15 15 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 6. RATIFY AND APPROVE THE FIRST AMENDMENT TO THE ANCILLARY PROVIDER AGREEMENT WITH CHARTER HOSPICE OF THE SAN GABRIEL VALLEY, LLC That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the First Amendment to the Ancillary Provider Agreement with Charter Hospice of the San Gabriel Valley, LLC, effective January 1, Kurt Hubler, Chief Network Officer Charter Hospice of the San Gabriel Valley, LLC is currently a contracted Provider in the IEHP Network. The First Amendment is to replace the Attachment A, Scope of Services and Attachment B, Compensation to include the Palliative Care services and rates. In addition, the amendment includes the new Attachments B1 Palliative Care Encounter List. Included in FY 17/18 Budget Yes

16 16 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 7. RATIFY AND APPROVE THE NEW CAPITATED PRIMARY CARE PROVIDER AGREEMENT WITH THE COUNTY OF SAN BERNARDINO ON BEHALF OF ARROWHEAD REGIONAL MEDICAL CENTER That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the new Capitated Primary Care Provider Agreement with the County of San Bernardino on behalf of Arrowhead Regional Medical Center, effective January 1, Kurt Hubler, Chief Network Officer County of San Bernardino on behalf of Arrowhead Regional Medical Center has agreed to participate in the IEHP Provider Network in all product lines of business. The Agreement term beginning January 1, 2018 through December 30, 2022, was tailored to reflect the Primary Care Services offered by San Bernardino on behalf of Arrowhead Regional Medical Center. Included in FY 17/18 Budget Yes

17 17 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 8. RATIFY AND APPROVE THE FIFTH AMENDMENT TO THE HOSPITAL PER DIEM AGREEMENT WITH DESERT VALLEY HOSPITAL, INC That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Fifth Amendment to the Hospital Per Diem Agreement with Desert Valley Hospital, Inc., effective January 1, Kurt Hubler, Chief Network Officer Physicians for Desert Valley Hospital, Inc. is currently a contracted Provider in the IEHP Network. The Fifth Amendment includes the new Attachment regarding the Managed Care Medi-Cal Noncapitated or Carve Out Drugs. Included in FY 17/18 Budget Yes

18 18 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 9. RATIFY AND APPROVE THE EIGHTH AMENDMENT TO THE INLAND EMPIRE HEALTH PLAN HOSPITAL PER DIEM AGREEMENT WITH LOMA LINDA UNIVERSITY MEDICAL CENTER That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Eighth Amendment to the Inland Empire Health Plan Hospital Per Diem Agreement with Loma Linda University Medical Center, effective December 1, 2017 Kurt Hubler, Chief Network Officer Loma Linda University Medical Center is currently a contracted Hospital in the IEHP network. The Eighth Amendment is to replace the Attachment C3, Compensation Rates which includes the Diabetes Education and Medical Nutrition Therapy Services. Included in FY 17/18 Budget Yes

19 19 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 10. RATIFY AND APPROVE THE TWELFTH AMENDMENT TO THE HOSPITAL PER DIEM AGREEMENT WITH PHYSICIANS FOR HEALTHY HOSPITALS dba HEMET VALLEY MEDICAL CENTER AND MENIFEE VALLEY MEDICAL CENTER That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Twelfth Amendment to the Hospital Per Diem Agreement with Physicians for Healthy Hospitals dba Hemet Valley Medical Center and Menifee Valley Medical Center, effective January 1, Kurt Hubler, Chief Network Officer Physicians for Healthy Hospitals dba Hemet Valley Medical Center and Menifee Valley Medical Center are currently contracted Hospitals in the IEHP Network. The Twelfth Amendment includes the new Attachment regarding the Managed Care Medi-Cal Noncapitated or Carve Out Drugs. Included in FY 17/18 Budget Yes

20 20 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 11. RATIFY AND APPROVE THE THIRD AMENDMENT TO THE INLAND EMPIRE HEALTH PLAN PER DIEM HOSPITALAGREEMENT WITH PRIME HEALTHCARE SERVICES III, LLC, DBA MONTCLAIR HOSPITAL MEDICAL CENTER That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Third Amendment to the Inland Empire Health Plan Per Diem Hospital Agreement with Prime Healthcare Services III, LLC dba Montclair Hospital Medical Center, effective January 1, Kurt Hubler, Chief Network Officer Prime Healthcare Services III, LLC dba Montclair Hospital Medical Center is currently a contracted Hospital in the IEHP Network. The Third Amendment includes the new Attachment regarding the Managed Care Medi-Cal Noncapitated or Carve Out Drugs. Included in FY 17/18 Budget Yes

21 21 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 12. RATIFY AND APPROVE THE SIXTEENTH AMENDMENT TO THE HOSPITAL PER DIEM AGREEMENT WITHY REDLANDS COMMUNITY HOSPITAL That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Sixteenth Amendment to the Hospital Per Diem Agreement with Redlands Community Hospital, effective January 1, Kurt Hubler, Chief Network Officer Redlands Community Hospital is currently a contracted Hospital in the IEHP Network. The Sixteenth Amendment includes the new Attachment I regarding the Managed Care Medi-Cal Noncapitated or Carve Out Drugs. Included in FY 17/18 Budget Yes

22 22 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 13. RATIFY AND APPROVE THE EIGHTH AMENDMENT TO THE PER DIEM HOSPITAL AGREEMENT WITH ST. MARY MEDICAL CENTER That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Eighth Amendment to the Per Diem Hospital Agreement with St. Mary Medical Center, effective January 1, Kurt Hubler, Chief Network Officer St. Mary Medical Center is currently a contracted Hospital in the IEHP Network. The Eighth Amendment includes the new Attachment H regarding the Managed Care Medi-Cal Noncapitated or Carve Out Drugs. Included in FY 17/18 Budget Yes

23 23 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 14. RATIFY AND APPROVE THE THIRD AMENDMENT TO THE INLAND EMPIRE HEALTH PLAN HOSPITAL PER DIEM AGREEMENT WITH SAN GORGONIO MEMORIAL HOSPITAL That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Third Amendment to the Inland Empire Health Plan Hospital Per Diem Agreement with San Gorgonio Memorial Hospital, effective January 1, Kurt Hubler, Chief Network Officer San Gorgonio Memorial Hospital is currently a contracted Hospital in the IEHP Network. The Third Amendment includes the new Attachment regarding the Managed Care Medi-Cal Noncapitated or Carve Out Drugs. Included in FY 17/18 Budget Yes

24 24 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 15. RATIFY AND APPROVE THE FIFTH AMENDMENT TO THE HOSPITAL PER DIEM AGREEMENT WITH VERITAS HEALTH SERVICES INC., DBA CHINO VALLEY MEDICAL CENTER That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Fifth Amendment to the Hospital Per Diem Agreement with Veritas Health Services Inc., Chino Valley Medical Center, effective January 1, Kurt Hubler, Chief Network Officer Physicians for Victor Veritas Health Services Inc., Chino Valley Medical Center is currently a contracted Hospital in the IEHP Network. The Fifth Amendment includes the new Attachment regarding the Managed Care Medi-Cal Noncapitated or Carve Out Drugs. Included in FY 17/18 Budget Yes

25 25 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 16. RATIFY AND APPROVE THE THIRD AMENDMENT TO THE HOSPITAL PER DIEM AGREEMENT WITH VICTOR VALLEY HOSPITAL ACQUISITION, INC., DBA VICTOR VALLEY GLOBAL MEDICAL CENTER That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Third Amendment to the Hospital Per Diem Agreement with Victor Valley Hospital Acquisition, Inc., dba Victor Valley Global Medical Center, effective January 1, Kurt Hubler, Chief Network Officer Physicians for Victor Valley Hospital Acquisition, Inc., dba Victor Valley Global Medical Center is currently a contracted Hospital in the IEHP Network. The Third Amendment includes the new Attachment F1 regarding the Managed Care Medi-Cal Noncapitated or Carve Out Drugs. Included in FY 17/18 Budget Yes

26 26 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 17. RATIFY AND APPROVE THE TWENTY-THIRD AMENDMENT TO THE HEALTH PLAN-PROVIDER AGREEMENT WITH RIVERSIDE UNIVERSITY HEALTH SYSTEM MEDICAL CENTER That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Twenty-Third Amendment to the Health Plan-Provider Agreement with Riverside University Health System Medical Center, effective July 1, Kurt Hubler, Chief Network Officer Riverside University Health System Medical Center is currently contracted Hospital in the IEHP Network. This Twenty-Third Amendment allows Riverside University Health System Medical Center to participate in the intergovernmental transfer revenues allowed by the California Department of Health Care Services to maintain the availability of Medi-Cal health services to Medi-Cal beneficiaries. None Yes

27 27 of 73 CONSENT AGENDA January 8, 2018 PROVIDER NETWORK DEPARTMENT 18. APPROVAL OF THE EVERGREEN CONTRACTS That the Governing Board of the Inland Empire Health Plan (IEHP) approve the listed Evergreen Contracts for an additional one (1) year to five (5) year term. Kurt Hubler, Chief Network Officer An Evergreen Contract is a contract that automatically renews on the same terms and subject to the same conditions as the original agreement, unless sooner terminated in accordance with the terms and conditions. Renewal under the Evergreen Clause of the following Agreements effective, February 1, 2018: 1. Ancillary Provider Agreement with Center for Comprehensive Care and Diagnosis of Inherited Blood Disorder Additional five (5) year term. 2. Ancillary Provider Agreement with Desert View Endoscopy Center LLC Additional five (5) year term. 3. Ancillary Provider Agreement with Health Essentials Inc Additional five (5) year term. 4. Ancillary Provider Agreement with High Desert Hospice Inc Additional five (5) year term. 5. Ancillary Provider Agreement with Jameco Home Health Agency Inc Additional five (5) year term. 6. Ancillary Provider Agreement with Joint Active Systems Inc Additional one (1) year term. 7. Ancillary Provider Agreement with Joint Neal Collins Additional five (5) year term. 8. Ancillary Provider Agreement with Optima Home Health Services Inc Additional five (5) year term. 9. Ancillary Provider Agreement with Orthopaedic Medical Supplies Inc Additional five (5) year term. 10. Ancillary Provider Agreement with Pearl Ventures Additional five (5) year term. 11. Ancillary Provider Agreement with Seasons Hospice & Palliative Care of California San Bernardino Additional five (5) year term. 12. Ancillary Provider Agreement with Southland Endoscopy Center Additional five (5) year term. 13. Ancillary Provider Agreement with Seasons The Oaks Surgery Center Additional five (5) year term. 14. Ancillary Provider Agreement with Seasons Unicare Diagnostics Inc Additional five (5) year term. 15. Ancillary Provider Agreement with Seasons Willow Link LLC Additional five (5) year term. 16. Open Access Provider Agreement with Adam J Novak MD Additional five (5) year term. 17. Open Access Provider Agreement with Benny Guzman MD Corporation Additional five (5) year term. 18. Open Access Provider Agreement with Harry R Webb Jr MD Additional five (5) year term.

28 28 of 73 CONSENT AGENDA January 8, Open Access Provider Agreement with King-Yee Yu MD Additional five (5) year term. 20. Open Access Provider Agreement with Wu Kong-Tay MD Inc Additional five (5) year term. 21. Capitated Primary Care Provider Agreement with Radha Menon MD Inc Additional five (5) year term. 22. Capitated Primary Care Provider Agreement with Ram K Kamath Group Inc Additional five (5) year term. 23. Fee for Service Primary Care Provider Agreement with Mario A Diaz Gomez MD Additional five (5) year term. 24. Fee for Service Primary Care Provider Agreement with Elizabeth J DeMagno MD Additional five (5) year term. 25. Skilled Nursing Facility Provider Agreement with Spring Valley Post Acute LLC Additional two (2) year term. 26. Skilled Nursing Facility Provider Agreement with Vista Cove Care Center at Corona Inc Additional three (3) year term. 27. Participating Provider Agreement California Cataract Center Additional five (5) year term. 28. Participating Provider Agreement with Desert Pain Care Medicine Group Inc AMC Additional two (2) year term. 29. Participating Provider Agreement with Elham Jafarimojarrad MD Inc Additional five (5) year term. 30. Participating Provider Agreement with Femcare Medical Associates of Inland Valley Inc Additional five (5) year term. 31. Participating Provider Agreement with Fred F Soeprono MD Inc Additional five (5) year term. 32. Participating Provider Agreement with Helena Mba MD Additional five (5) year term. 33. Participating Provider Agreement with Paramount Medical Additional five (5) year term. 34. Participating Provider Agreement with The Gastro Group Inc Additional five (5) year term. 35. Participating Provider Agreement with William M Kelly MD Inc Additional five (5) year term. 36. Participating Provider Agreement with Inland OB/GYN Associates Inc Additional five (5) year term. Included in FY 17/18 Budget Yes

29 29 of 73 POLICY AGENDA January 8, 2018 ADMINISTRATION 19. MONTHLY MEMBERSHIP REPORT Review and File Bradley P. Gilbert, M.D., Chief Executive Officer This report reflects acutal membership projections in the IEHP budget. Membership remained flat in November. Fiscal Year Month Forecast Membership Actual Membership + or Forecast + or Last Month FY 17/18 July, ,262,618 1,258,068 (4,550) (845) August, ,264,702 1,256,441 (8,261) (1,627) September, ,266,787 1,255,361 (11,426) (1,080) October, ,268,872 1,250,763 (18,109) (4,598) November, ,270,956 1,250,975 (19,981) 212 None N/A

30 30 of 73 POLICY AGENDA January 8, 2018 ADMINISTRATION THIRD QUARTER REVIEW OF THE IEHP COMPLIANCE PROGRAM Review and File Jennifer N. Sayles, M.D. MPH, Chief Medical Officer Pamela Jackson, Director of Compliance / Compliance Officer IEHP is required to implement an effective Compliance Program that meets the regulatory requirements set forth in 42 C.F.R (b)(4)(vi), (b)(4)(vi) and (a)(1)(iii). The principles outlined in the regulatory guidelines are applicable to all IEHP relevant decisions, situations, communications, and developments. The Governing Board is required to exercise reasonable oversight with respect to the implementation and effectiveness of the program. This report provides an update on the IEHP Compliance Program and activities during the Third Quarter of Compliance Program Administration: Compliance Committees: The Compliance department continues to work to implement the Fraud, Waste, and Abuse (FWA) Subcommittee. Beginning the First Quarter of 2018, the Special Investigation Unit (SIU) will conduct a FWA risk assessment. The results of the assessment will help identify areas of opportunities to further develop the FWA Program and address high risks for potential FWA. Additionally, the assessment will assist in solidifying the Committee Members. The first meeting will be planned for end of First Quarter Risk Assessment Update: In conjunction with consulting firm Compliance Strategies, the Compliance Department completed an Enterprise Wide Medicare Risk Assessment in April Based upon the results, remediation actions including action items and Corrective Action Plans (CAPs) were developed and completed. Actions were completed to address the issues and minimize the risks identified through the assessment. This project is now considered closed and the Compliance Department has begun planning the 2018 Enterprise Risk Assessment Annual Compliance Training: The Compliance Department launched the Annual Compliance Training on November 18, Compliance Training is a mandatory requirement that all active Teams Members, volunteers, and contractors must complete as a condition of their employment at IEHP to which 99% have completed. The Compliance Department is working with the Human Resources Department to

31 31 of 73 POLICY AGENDA January 8, 2018 develop an escalation process for the individuals who did not comply with the Annual Training requirements. The Compliance Department and Human Resources will ensure the remaining 1% of Team Members complete the Annual Training. SynerMed Investigation: On Friday October 20th, the IEHP Compliance hotline received a report which included allegations against SynerMed regarding their handling of referral denials and modifications. SynerMed is a Management Services Organization (MSO) for two of IEHP s contracted Independent Physician Associations (IPA): Inland Valleys IPA and Alpha Care Medical Group. The allegations included significant backlogs of denials and modifications that had not been fully processed with Member and Provider correspondence and fraudulent activities including falsification of letters with false dates placed in the computer files that were never sent to Members. IEHP immediately began an investigation into these allegations which included an unannounced onsite audit, in coordination with LA Care, at SynerMed headquarters to ascertain the veracity of the allegations. The onsite audit included multiple interviews with Notice of Action staff, the Senior Vice President of Medical Management, the Chief Medical Officer, and the Chief Compliance Officer/General Counsel. Based on the information obtained from the hotline reports, onsite audit, along with the information obtained during the interviews, IEHP has determined that there is sufficient evidence to substantiate the allegations reported. As such, IEHP took responsibility for all currently pending authorizations as of October 30, IEHP s contract with Employee Health Services DBA Inland Valleys IPA ends on December 31, 2017 and will not be renewed. IEHP requested Alpha Care Medical Group to terminate SynerMed as their MSO. Alpha Care Medical Group has terminated their relationship with SynerMed and confirmed that they will be acquiring a new MSO as of January 1, IEHP is in the process of developing transition plans for the PCPs affiliated with Inland Valleys, all will either affiliate with new IPAs, transfer Members to their other affiliations or have a direct contract with IEHP. SynerMed has committed to work with IEHP to safely transition Members with existing referrals, DME equipment, etc. Member transition plans have been submitted to DMHC and DHCS. The DHCS has issued a corrective action plan (CAP) to all health plans in California with an affiliation with SynerMed. IEHP submitted a CAP to DHCS on December 5, 2017, which has been accepted. IEHP is providing weekly updates to DHCS through this transition. 2. Auditing and Monitoring (A&M) Program: The A&M Manager position has been filled. Planning of the 2018 Risk Assessment is in progress and is expected to commence at the end of December The risk assessment will help the A&M Unit prioritize auditing and monitoring activities. The 2018 Audit Plan will address significant risks identified via the Risk Assessment. The Audit plan will list the audits that will be completed in 2018 and the timeframe in which they will be completed. Additionally, the A&M Manager is actively working with Human Resources to recruit qualified auditors. The A&M Manager is concurrently developing the A&M infrastructure via the implementation of applicable policies and procedures, audit templates, and dashboards.

32 32 of 73 POLICY AGENDA January 8, Special Investigations Unit: Special Investigation Unit Case Report Compliance experienced a 1% increase in reports related to privacy incidents from the 3rd quarter of 2016 (Q3-2016) to the 3rd quarter of 2017 (Q3-2017). This minimal increase reflects a steadiness in intake when comparing the two years. The number of cases reported to State/Federal agencies increased from 6 cases in Q to 8 cases in Q Only the privacy incidents which meet the breach criteria are reported to State/Federal agencies. For those incidents not considered breaches, trending issues were identified including unauthorized access/disclosure via mail and electronic format. Issues continue to be addressed through corrective action plans to ensure best practices are implemented to protect Member information. The number of fraud related cases reported to Compliance in Q compared to the number of cases for Q show a 24% decrease. Of those cases, 35 were reported to State/Federal agencies in Q compared to 11 cases reported in Q The types of fraud related cases reported to Compliance in Q include the following allegations: fraudulent billing (34%), drug seeking behavior (20%), and identity theft (20%). The SIU continues to investigate all allegations and report substantiated allegations to State/Federal agencies. SIU Cases Compared to Membership Growth: 3rd Quarter 2016 / 3rd Quarter 2017 Number of Cases July 2016 August 2016 Sept 2016 July 2017 August 2017 Sept 2017 FWA Cases Privacy Cases Membership (all LOBs) 1,194,432 1,220,280 1,228,796 1,251,901 1,247,102 1,249,262 1,260,000 1,250,000 1,240,000 1,230,000 1,220,000 1,210,000 1,200,000 1,190, Regulatory Audits: 2017 Department of Managed Health Care (DMHC) Financial Audit: DMHC conducted an on-site review and interviews with the Claims and Finance Departments between February 27, 2017 and April 5, On July 19, 2017, DMHC issued the Preliminary Report which contained two deficiencies: 1. Timely Acknowledgement of Provider Disputes and 2. Fidelity Bond. The Plan submitted CAP responses to these deficiencies on July 28, On August 28, 2017, the Department issued the Final Report which verified that DMHC deemed the two

33 33 of 73 POLICY AGENDA January 8, 2018 deficiencies to have been corrected. As of September 18, 2017, the Plan received notification that the e-filing has been closed Department of Health Care Services (DHCS) Medical Audit: On August 10, 2017, IEHP received the 2017 Medical Audit entrance letter from DHCS. The audit period review is October 1, 2016 through September 30, On August 25, 2017, IEHP submitted all requested information as part of the pre-audit information request. Between September 15, 2017 and October 5, 2017, IEHP completed additional requests for supplemental information. Between October 16, 2017 and October 20, 2017, DHCS was on-site to perform interviews and an on-site review. As of December 4, 2017, IEHP has received one post on-site request and continues its post on-site review. The Plan expects to receive a preliminary report within the first quarter of Regulatory Data Validation and Monitoring Activities: CMS Call Center Monitoring 2017 Accuracy Study: CMS conducts monitoring of Medicare Part C and Part D organizations call centers to ensure they are able to provide interpreters for Limited English Proficient (LEP) callers, TTY services for the hearing and speech impaired, and accurate Part C and/or Part D benefit information. This monitoring was conducted from February 13, 2017, to June 2, IEHP was compliant with CMS Standards. Results of the study are as follows: Interpreter Availability TTY Functionality Information Accuracy Part C Part D IEHP All Plan Average IEHP All Plan Average 92.98% 89.56% 83.05% 88.96% N/A 91.44% % 91.52% % 95.74% 89.74% 93.26% IEHP will be included in a test of the new system in January None Yes

34 34 of 73 POLICY AGENDA January 8, 2018 FINANCE DEPARTMENT 21. REVIEW OF MONTHLY FINANCIALS Recommended Action Review and File Contact Keenan Freeman, Chief Financial Officer Background This report is presented monthly and is a Summary of the Financial Statements. Discussion Summary Income Statement for the Month Ended November 30, Highlights: Enrollment of approximately 1.3M members generated a net surplus of $8.1 M for the month ended November 30, The positive revenue variance of $3.8M is due to higher membership counts in LTC, BHT, OB, and SPD offset by counts in MCE Non-Duals and HEP C. We also had a favorable $3.0M variance related to the release of the MCE rate adjustment reserve for FY1516. The negative medical cost variance of $10.5 M is due to an increase in costs relating to facility (MLTSS Duals), the expansion of the transportation benefits, and hospice care. Summary Income Statement for the Month Ended November 30, 2017 on the following page. Fiscal Impact Included in FY 17/18 Budget Reviewed by Counsel N/A

35 POLICY AGENDA January 8, 2018 Inland Empire Health Plan Summary Income Statement for the Month Ended November 30, 2017 Operating Revenue Actual Budget Variance $ Medi-Cal 337,127, ,055,007 6,072,220 Medicare 29,768,401 31,992,135 (2,223,735) Net Revenue 366,895, ,047,143 3,848,486 Medical Costs Total Medi-Cal Costs 314,857, ,975,167 (10,882,391) Total Medicare Costs 30,570,796 30,996, ,692 Total Medical Costs 345,428, ,971,655 (10,456,698) Gross Margin 21,467,274 28,075,487 (6,608,213) Operating Expenses Total Operating Expenses 17,146,178 18,729,500 1,583,322 Operating Surplus (Deficit) 4,321,096 9,345,987 (5,024,891) Total AB85 3,606,530 1,942,896 1,663,634 Other Income (Expense) 327, ,528 (110,231) Property Management Income (Expense) (126,689) (86,241) (40,448) Total Non Operating Income (Expense) 3,807,137 2,294,183 1,512,955 Net Surplus (Deficit) 8,128,234 11,640,170 (3,511,936) Note: T otals may be subject to immaterial rounding differences. 35 of 73

36 36 of 73 POLICY AGENDA January 8, 2018 Discussion Summary Income Statement on a Year-To-Date basis for the period ended November 30, Highlights: Member Months of approximately 6M generated a net surplus of $23.3 M for the five months ended November 30, 2017: The $10.2M negative revenue variance is due to MCE Duals rate retractions offset by favorable gains in retroactive enrollment for Dual MLTSS and LTC Non-Dual membership. The negative medical cost variance is due to a 50% increase in the MLTSS institutional enrollment dating back to 1/2017 impacting facility costs, the expansion of transportation benefits, and higher pharmacy costs. Non-operating income includes $36M in AB85 25% rate range revenue. $25M was recorded in August 2017 related to FY1516 AB85 25%. Summary Income Statement for the Five Months Ended November 30, 2017 on the following page.

37 37 of 73 POLICY AGENDA January 8, 2018 Inland Empire Health Plan Year-To-Date Summary Income Statement for the period ended November 30, Operating Revenue Actual Budget Variance $ Medi-Cal 1,639,102,538 1,643,446,355 (4,343,818) Medicare 150,774, ,646,150 (5,871,615) Net Revenue 1,789,877,072 1,800,092,505 (10,215,433) Medical Costs Total Medi-Cal Costs 1,564,967,235 1,514,971,216 (49,996,019) Total Medicare Costs 157,312, ,311,919 (5,000,385) Total Medical Costs 1,722,279,539 1,667,283,136 (54,996,404) Gross Margin 67,597, ,809,369 (65,211,837) Operating Expenses Total Operating Expenses 81,021,732 94,233,260 13,211,529 Operating Surplus (Deficit) (13,424,199) 38,576,109 (52,000,308) Total AB85 36,013,567 9,813,836 26,199,730 Other Income (Expense) 1,698,178 2,189,323 (491,146) Property Management Income (Expense) (936,014) (628,346) (307,668) Total Non Operating Income (Expense) 36,775,730 11,374,814 25,400,917 Net Surplus (Deficit) 23,351,531 49,950,923 (26,599,391) Note: T otals may be subject to immaterial rounding differences.