REGULAR MEETING OF THE GOVERNING BOARD OF THE INLAND EMPIRE HEALTH PLAN. August 08, Board Report #259

Transcription

1 1 of 47 REGULAR MEETING OF THE GOVERNING BOARD OF THE INLAND EMPIRE HEALTH PLAN August 08, 2016 Board Report #259 San Bernardino County Government Center 385 N. Arrowhead Ave, First Floor San Bernardino, 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. Board Secretary: Any changes to the agenda packet including the Information Relative To The Possible Conflict of Interest Form COMMENTS FROM THE PUBLIC ON MATTERS ON THE AGENDA Conflict of Interest Disclosure: V. Adopt and Approve the Meeting Minutes from the July 11, 2016 Regular Meeting of the Governing Board of the Inland Empire Health Plan VI. CONSENT AGENDA ADMINISTRATION (Bradley P. Gilbert, M.D.) 1. Update on Additional Authorized Staffing Positions Under Board Approved Guidelines

2 2 of 47 Staff Reports and Recommendations #259 August 08, 2016 FINANCE DEPARTMENT No Items INFORMATION TECHNOLOGY DEPARTMENT (Michael Deering) No Items MARKETING DEPARTMENT (Susan Arcidiacono) No Items MEDICAL SERVICES DEPARTMENT (Jennifer N. Sayles, M.D./Marcia Anderson) No Items OPERATIONS DEPARTMENT (Rohan Reid) 2. Approve the Fourth Amendment to the Multi-Tenant Office Lease with th Street, LLC Suite 208-E PROVIDER NETWORK DEPARTMENT (Kurt Hubler) 3. Ratify and Approve the Second Amendment to the Per Diem Hospital Agreement with Prime Healthcare Services III, LLC DBA Montclair Hospital Medical Center 4. Ratify and Approve the Third Amendment to the Hospitalists Agreement with HNI Medical Services of California, P.C. 5. Ratify and Approve the Second Amendment to the Health-Plan Provider Agreement with San Bernardino County Fire Protection District 6. Ratify and Approve the New Participating Privider Agreenment with IE Health and Wellness Management, Inc., A Texas Corporation 7. Approval of the Standard Templates to the Following Master Agreements and Attachments, and Authorization for the Chief Executive Officer of IEHP to Sign the Agreements and Attachments: 1) Autism Master Agreement 2) Behavioral Health Master Agreement (Excluding Medicare) 3) Behavioral Health Master Agreement (All Lines of Business) 4) Community Based Adult Services Provider Agreement (All Lines of Business) 5) Exhibit K-1 Autism Master Agreement 6) Master Admitter Hospitalist Agreement (No Medicare) 7) Master Admitter Hospitalist Agreement (All Lines of Business) 8) Master Agreement (Excluding Medicare) 9) Master Agreement (Medicare Only) 10) Master Agreement (All Lines of Business) 11) Master Capitated Hospital Agreement 12) Master Per Diem Hospital Agreement 13) Master Per Diem Hospital Agreement for Behavioral Health Services 14) Master Hospitalist Template 15) Master IPA Agreement (All Lines of Business)

3 3 of 47 Staff Reports and Recommendations #259 August 08, ) Master IPA Agreement (Excluding Medicare) 17) Master IPA Agreement (Medicare Only) 18) Master Letter of Agreement Appeal Reviewer Blanket Evergreen 19) Master Letter of Agreement Autism Blanket Evergreen 20) Master Letter of Agreement Blanket PCP SPD 21) Master Letter of Agreement Long Term Sub Acute SNF Evergreen 22) Master Letter of Agreement Member Specific 23) Master Letter of Agreement Member Specific - Out of Network Autism Providers 24) Master Letter of Agreement Mental Health Provider (LCSW MFT Psychologist Psychiatrist) 25) Master Letter of Agreement Mental Health Provider (LCSW MFT) 26) Master Letter of Agreement Mental Health Provider (Psychiatrist) 27) Master Letter of Agreement Mental Health Provider (Psychologist) 28) Master Participating Provider Agreement Vision 29) Master Participating Provider Agreement Vision (Exam Only) 30) Master Skilled Nursing Facility Provider Agreement (Excluding Medicare) 31) Master Skilled Nursing Facility Provider Agreement (All Lines of Business) 32) Master SNFist Agreement Template 33) Master Transportation Template 34) Home Health Attachment B 35) Home Health Hospice Attachment B 8. Approval of Evergreen Contracts: a) Ancillary Provider Agreement with Ajeet R. Singhvi, M.D. Effective September 1, 2016, additional five (5) year term. b) Ancillary Provider Agreement with Cindy Wiemann dba Omni Medical Effective October 1, 2016, additional five (5) year term. c) Ancillary Provider Agreement with Golden Valley Medical & Oxygen Service Effective September 1, 2016, additional five (5) year term. d) Ancillary Provider Agreement with Inland Valley Hospice Care, Inc. Effective September 1, 2016, additional five (5) year term. e) Ancillary Provider Agreement with Neogenomics Laboratories Inc. Effective October 1, 2016, additional five (5) year term. f) Ancillary Provider Agreement with Option Care Enterprises Inc dba Walgreens Infusion Services Effective September 1, 2016, additional five (5) year term. g) Ancillary Provider Agreement with Serenity Hospice LLC Effective September 1, 2016, additional five (5) year term. h) Capitated Agreement with Heritage Provider Network Effective September 1, 2016, additional one (1) year term. i) Open Access Provider Agreement (Excluding Medicare) with Corona Pediatrics, Inc. dba Corona Pediatrics Effective September 1, 2016, additional five (5) year term. j) Open Access Provider Agreement (Excluding Medicare) with Juan M Acosta dba Clinica Medica Del Valle Effective September 1, 2016, additional five (5) year term.

4 4 of 47 Staff Reports and Recommendations #259 August 08, 2016 k) Fee-For-Service Primary Care Provider Agreement (All Lines of Business) with Neelam Gupta MD dba Ramona Medical Clinic Effective September 1, 2016, additional five (5) year term. l) Fee-For-Service Primary Care Provider Agreement with Rene Salhab M.D. Effective September 1, 2016, additional five (5) year term. m) Fee-For-Service Primary Care Provider Agreement (Excluding Medicare) with Loma View Pediatric Medical Clinic Inc Effective September 1, 2016, additional five (5) year term. n) Participating Provider Agreement with Comprehensive Primary Medical Associates Effective September 1, 2016, additional five (5) year term. o) Participating Provider Agreement with Desert Heart Rhythm Consultants Effective September 1, 2016, additional five (5) year term. p) Participating Provider Agreement with Ifeanyi Ugochuku dba Inland Surgical Group, Inc. Effective September 1, 2016, additional five (5) year term. q) Participating Provider Agreement with Indermohan S Luthra MD Effective September 1, 2016, additional five (5) year term. r) Participating Provider Agreement with Micha Rettenmaier Brown Lacey Partnership dba Gynecologic Oncology Associates Effective September 1, 2016, additional five (5) year term. s) Participating Provider Agreement with Radiation Oncology Physicians Inc Effective September 1, 2016, additional five (5) year term. t) Participating Provider Agreement with Riverside Medical Clinic Inc. Effective September 1, 2016, additional two (2) year term. u) Participating Provider Agreement with Rodolfo R Batarse dba Rodolfo R Batarse MD Effective September 1, 2016, additional five (5) year term. v) Participating Provider Agreement with Serendipity Hearing Inc dba Sonus SF0010 Effective September 1, 2016, additional one (1) year term. w) Participating Provider Agreement with Shadi A Qasqas MD Inc Effective September 1, 2016, additional five (5) year term. x) Participating Provider Agreement with William D Suval MD Inc Effective September 1, 2016, additional five (5) year term. y) Participating Provider Agreement (Medicare Only) with San Bernardino Medical Group, Inc. Effective September 1, 2016, additional five (5) year term. VII. POLICY AGENDA AND STATUS REPORT ON AGENCY OPERATIONS: ADMINISTRATION (Bradley P. Gilbert, M.D.) 9. Review of the Monthly Membership Report 10. Approve the Fiscal Year 2016/2017 Risk Sharing Funds Measurement and Distribution for the Medi-Cal Expansion Population Second Quarter Review of the IEHP Compliance Program

5 5 of 47 FINANCE DEPARTMENT 12. Review of the Monthly Financials Staff Reports and Recommendations #259 August 08, Ratify and Approve the Fourth Amendment to the Professional Services Agreement with Varis, LLC. INFORMATION TECHNOLOGY DEPARTMENT (Michael Deering) No Items MARKETING DEPARTMENT (Susan Arcidiacono) No Items MEDICAL SERVICES DEPARTMENT (Jennifer N. Sayles, M.D./Marcia Anderson) 14. Overview of the Medi-Cal and Medicare Healthcare Effectiveness Data and Information Set Results for HEDIS OPERATIONS DEPARTMENT (Rohan Reid) No Items PROVIDER NETWORK DEPARTMENT (Kurt Hubler) 15. Review of the 2015 Provider Network Status Study MAIN OBJECTIVES FOR THE NEXT 90 DAYS AND SUMMARY COMMENTS (Bradley P. Gilbert, M.D.) 16. Main Objectives for the Next 90 Days and Summary Comments VIII. IX. COMMENTS FROM THE PUBLIC ON MATTERS NOT ON THE AGENDA Recess Into The IEHP Health Access Meeting X. Reconvene From The IEHP Health Access Meeting Back Into The IEHP Meeting XI. ADJOURNMENT The next meeting of the IEHP Governing Board will be held on September 12, 2016 at the Riverside County Government Center.

6 6 of 47 CONSENT CALENDAR August 8, 2016 ADMINISTRATION 1. UPDATE ON ADDITIONAL AUTHORIZED STAFFING POSITIONS UNDER BOARD APPROVED GUIDELINES Recommended Action: Update On Additional Authorized Staffing Positions Under Board Approved Guidelines Contact: Bradley P. Gilbert, M.D., Chief Executive Officer Background: At the June 13, 2016 Governing Board Meeting, under Resolution 16-88, the Governing Board approved the proposal authorizing the CEO to approve additional staffing under the following guidelines: 1) Maintaining IEHP s General and Administrative (G&A) Expenses percentage at 5% or less. 2) Authorization only includes approval of additional staffing in IEHP s current position classifications. Approval of newly created positions will require Board approval; this does not include position title changes that do not have any significant financial impact. 3) Monthly reports to the Board under the Consent Agenda outlining any additional authorized positions with brief description of justification and related budget information. 4) This authority authorized for one year, through June 30, This process will allow for flexibility to match staffing to operational needs and will maintain high levels of service to our members and providers while concurrently maintaining accountability on a monthly basis to the Governing Board. Discussion: The following positions have been approved: CEO APPROVAL DATE POSITION TITLE SUPERVISOR SALARY RANGE 1 06/17/16 State Program Analyst Rebecca Mayer $51, /30/16 Director of Behavioral Health Marcia Anderson $140, /07/16 Behavioral Health Specialist Diana Gonzalez $41, /11/16 Administrative Assistant EPMO Queenie Flores $33, /12/16 LTC Nurse Tamara Gutierrez $71, /15/16 UM QA Training Manager Kathryn Gray $98, /15/16 Manager of Data Science Michael Deering Systems $110, /15/16 Healthcare Informatics Michael Deering Supervisor $84,195

7 7 of 47 CONSENT CALENDAR August 8, 2016 CEO APPROVAL DATE POSITION TITLE SUPERVISOR SALARY RANGE 9 07/15/16 Informatics Architect Michael Deering $85, /15/16 Project Coordinator x 2 Paulo Salazar $37, /20/16 Member Services Vanessa Representatives x 40 Hernandez $37, /20/16 Behavioral Health Coordinator Dr. Sarah Wilkinson $37,750 Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: Included in FY 16/17 Budget Approximately $3,204,302 annually (estimated salary and benefit impact). Attachments: None Reviewed by Counsel: N/A

8 8 of 47 CONSENT CALENDAR August 8, 2016 OPERATIONS DEPARTMENT 2. APPROVE THE FOURTH AMENDMENT TO THE MULTI-TENANT OFFICE LEASE WITH TH STREET, LLC SUITE 208-E Recommended Action: That the Governing Board of the Inland Empire Health Plan (IEHP) approve the Fourth Amendment to the Lease Agreement with th Street, LLC Suite 208-E, for the office space used to house the IEHP Health Navigators Program located in Victorville, California. The term of this agreement is for one (1) year, cost not to exceed $3,700. Contact: Rohan Reid, Chief Operations Officer Background: In August 2012 under Minute Order 09-98, the Governing Board approved the lease agreement with th Street for an office in Victorville, California to support IEHP s Health Navigator staff. The lease agreement was fully executed in September, 2012 In September 2013 under Minute Order 13-49, the Chief Executive Officer approved the First Amendment to the Multi-Tenant lease space with th Street, LLC that renewed lease for an additional one (1) year. In September 2014 under Minute Order 13-49, the Chief Executive Officer approved the Second Amendment to the Multi-Tenant lease space with th Street, LLC that renewed lease for an additional one (1) year. In September 2015 under Minute Order , the Governing Board approved the Third Amendment to the Multi-Tenant lease space with th Street, LLC that renewed lease for an additional one (1) year. Discussion: In November 2011, the IEHP Marketing department expanded their Health Navigator program efforts to the High Desert area. This required leasing office space to run a satellite office for staff to handle home visits in the High Desert area. The current leased space accommodates staff, supplies, and equipment needs. IEHP has opted to continue to occupy this space. Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: New Expenditure The total compensation payable under this Agreement shall not exceed $3,700 per contract year. Attachments: A copy of the Fourth Amendment is attached Reviewed by Counsel: Yes

9 9 of 47 Submittals to the Inland Empire Health Plan Governing Board CONSENT CALENDAR August 8, 2016 PROVIDER NETWORK DEPARTMENT 3. RATIFY AND APPROVE THE SECOND AMENDMENT TO THE PER DIEM HOSPITAL AGREEMENT WITH PRIME HEALTHCARE SERVICES III, LLC DBA MONTCLAIR HOSPITAL MEDICAL CENTER Recommended Action: That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Inland Empire Health Plan Per Diem Hospital Agreement with Prime Healthcare Services III, LLC dba Montclair Hospital Medical Center Contact: Kurt Hubler, Chief Network Officer Background: Prime Healthcare Services III, LLC dba Montclair Hospital Medical Center is currently a contracted Provider in the IEHP Provider Network. Discussion: This Amendment extends the Agreement term for three years, beginning July 1, 2016 through June 30, 2019 and the Attachment C1, Compensation Rates reflects Inpatient Hospital Services APR- DRG rates. All other items and conditions of the Agreement remain in full force and effect. Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: Included in FY 16/17 Budget Attachments: Copy of the Inland Empire Health Plan Per Diem Agreement is attached to the Minute Orders. Reviewed by Counsel: Yes

10 10 of 47 Submittals to the Inland Empire Health Plan Governing Board CONSENT CALENDAR August 8, 2016 PROVIDER NETWORK DEPARTMENT 4. RATIFY AND APPROVE THE THIRD AMENDMENT TO THE HOSPITALISTS AGREEMENT WITH HNI MEDICAL SERVICES OF CALIFORNIA, P.C. Recommended Action: That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Hospitalists Agreement with HNI Medical Services of California, P.C. as assignee and delegee of the Hospitalist Agreement by and between Inland Empire Health Plan and Srinivas Vuthoori MD A Professional Corporation dba Cambridge Hospitalists, effective June 15, Contact: Kurt Hubler, Chief Network Officer Background: HNI Medical Services of California, P.C. as assignee and delegee of the Hospitalist Agreement by and between Inland Empire Health Plan and Srinivas Vuthoori MD A Professional Corporation dba Cambridge Hospitalists is currently a contracted Provider in the IEHP Provider Network. Discussion: This Amendment includes a monthly stipend for the period of three (3) months from the date of this amendment, ending on September 15, All other items and conditions of the Agreement remain in full force and effect. Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: Included in FY 16/17 Budget Attachments: Copy of the Hospitalists Agreement is attached is attached to the Minute Orders. Reviewed by Counsel: Yes

11 11 of 47 Submittals to the Inland Empire Health Plan Governing Board CONSENT CALENDAR August 8, 2016 PROVIDER NETWORK DEPARTMENT 5. RATIFY AND APPROVE THE SECOND AMENDMENT TO THE HEALTH-PLAN PROVIDER AGREEMENT WITH SAN BERNARDINO COUNTY FIRE PROTECTION DISTRICT Recommended Action: That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Health Plan-Provider Agreement with San Bernardino County Fire Protection District effective July 1, Contact: Kurt Hubler, Chief Network Officer Background: Health Plan-Provider Agreement is currently a contracted Provider in the IEHP Provider Network. Discussion: This Second Amendment allows San Bernardino County Fire Protection District 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. The term of this Agreement is July 1, 2014, and shall terminate on September 30, Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: Included in FY 16/17 Budget Attachments: Copy of the Health Plan-Provider Agreement is attached to the Minute Order. Reviewed by Counsel: N/A

12 12 of 47 Submittals to the Inland Empire Health Plan Governing Board CONSENT CALENDAR August 8, 2016 PROVIDER NETWORK DEPARTMENT 6. RATIFY AND APPROVE THE NEW PARTICIPATING PROVIDER AGREEMENT WITH IE HEALTH AND WELLNESS MANAGEMENT, INC., A TEXAS CORPORATION Recommended Action: That the Governing Board of the Inland Empire Health Plan (IEHP) ratify and approve the Participating Provider Agreement with IE Health and Wellness Management, Inc., A Texas Corporation ( IEHWM ), effective July 12, Contact: Kurt Hubler, Chief Network Officer Background: IE Health and Wellness Management, Inc., A Texas Corporation ( IEHWM ) has agreed to participate in the IEHP network. Discussion: This Agreement was tailored to reflect the Annual Health Assessments services offered by IE Health and Wellness Management, Inc., A Texas Corporation ( IEHWM ). Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: Included in FY 16/17 Budget Attachments: Copy of the Participating Provider Agreement is attached to the Minute Order. Reviewed by Counsel: Yes

13 13 of 47 Submittals to the Inland Empire Health Plan Governing Board CONSENT CALENDAR August 8, 2016 PROVIDER NETWORK DEPARTMENT 7. APPROVE THE STANDARD TEMPLATES TO THE FOLLOWING MASTER AGREEMENTS AND ATTACHMENTS, AND AUTHORIZATION FOR THE CHIEF EXECUTIVE OFFICER OF IEHP TO SIGN THE AGREEMENTS AND ATTACHMENTS Recommended Action: That the Governing Board of the Inland Empire Health (IEHP) approve the IEHP Standard Template Agreements, referenced below in section (d), and authorize the Chief Executive Officer or his designee to execute the template, wherein the body of the document remains unchanged except for the identifying information of the individual provider and non-material changes per individual provider requirements. Contact: Kurt Hubler, Chief Network Officer Background: IEHP contracts with physicians and other providers using Governing Board approved Standard Template Agreements. On a periodic basis IEHP reviews the IEHP & IEHP Direct Standard Templates and updates are made to the templates, as necessary. The Governing Board has authorized the Chief Executive Officer to sign the Agreement in lieu of having the Chair of the Governing Board execute the documents. Discussion: The following standard templates are being presented to the Governing Board for the approval: 1. Autism Master Agreement 2. Behavioral Health Master Agreement (Excluding Medicare) 3. Behavioral Health Master Agreement (All Lines of Business) 4. Community Based Adult Services Provider Agreement (All Lines of Business) 5. Exhibit K-1 Autism Master Agreement 6. Master Admitter Hospitalist Agreement (No Medicare) 7. Master Admitter Hospitalist Agreement (All Lines of Business) 8. Master Agreement (Excluding Medicare) 9. Master Agreement (Medicare Only) 10. Master Agreement (All Lines of Business) 11. Master Capitated Hospital Agreement 12. Master Per Diem Hospital Agreement 13. Master Per Diem Hospital Agreement for Behavioral Health Services 14. Master Hospitalist Template 15. Master IPA Agreement (All Lines of Business) 16. Master IPA Agreement (Excluding Medicare) 17. Master IPA Agreement (Medicare Only) 18. Master Letter of Agreement Appeal Reviewer Blanket Evergreen 19. Master Letter of Agreement Autism Blanket Evergreen 20. Master Letter of Agreement Blanket PCP SPD 21. Master Letter of Agreement Long Term Sub Acute SNF Evergreen

14 14 of 47 Submittals to the Inland Empire Health Plan Governing Board CONSENT CALENDAR August 8, Master Letter of Agreement Member Specific 23. Master Letter of Agreement Member Specific - Out of Network Autism Providers 24. Master Letter of Agreement Mental Health Provider (LCSW MFT Psychologist Psychiatrist) 25. Master Letter of Agreement Mental Health Provider (LCSW MFT) 26. Master Letter of Agreement Mental Health Provider (Psychiatrist) 27. Master Letter of Agreement Mental Health Provider (Psychologist) 28. Master Participating Provider Agreement Vision 29. Master Participating Provider Agreement Vision (Exam Only) 30. Master Skilled Nursing Facility Provider Agreement (Excluding Medicare) 31. Master Skilled Nursing Facility Provider Agreement (All Lines of Business) 32. Master SNFist Agreement Template 33. Master Transportation Template 34. Home Health Attachment B 35. Home Health Hospice Attachment B Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: Included in FY 16/17 Budget Attachments: Copies of the above referenced Standard Templates are attached to the Minute Order. Reviewed by Counsel: Yes

15 15 of 47 Submittals to the Inland Empire Health Plan Governing Board CONSENT CALENDAR August 8, 2016 PROVIDER NETWORK DEPARTMENT 8. APPROVAL OF EVERGREEN CONTRACTS Recommended Action: That the Governing Board of the Inland Empire Health Plan (IEHP) approve the listed Evergreen Contract for an additional one (1) to five (5) year term. Contact: Kurt Hubler, Chief Network Officer Background: Evergreen Contract A Contract that automatically renews on the same terms and subject to the same conditions as the original agreement, upon the approval of Governing Boards of Inland Empire Health Plan and IEHP Health Access, unless sooner terminated in accordance with the terms and conditions. Discussion: Renewal Under The Evergreen Clause Of The Following Agreements: a) Ancillary Provider Agreement with Ajeet R. Singhvi, M.D. Effective September 1, 2016, additional five (5) year term. b) Ancillary Provider Agreement with Cindy Wiemann dba Omni Medical Effective October 1, 2016, additional five (5) year term. c) Ancillary Provider Agreement with Golden Valley Medical & Oxygen Service Effective September 1, 2016, additional five (5) year term. d) Ancillary Provider Agreement with Inland Valley Hospice Care, Inc. Effective September 1, 2016, additional five (5) year term. e) Ancillary Provider Agreement with Neogenomics Laboratories Inc. Effective October 1, 2016, additional five (5) year term. f) Ancillary Provider Agreement with Option Care Enterprises Inc dba Walgreens Infusion Services Effective September 1, 2016, additional five (5) year term. g) Ancillary Provider Agreement with Serenity Hospice LLC Effective September 1, 2016, additional five (5) year term. h) Capitated Agreement with Heritage Provider Network Effective September 1, 2016, additional one (1) year term. i) Open Access Provider Agreement (Excluding Medicare) with Corona Pediatrics, Inc. dba Corona Pediatrics Effective September 1, 2016, additional five (5) year term. j) Open Access Provider Agreement (Excluding Medicare) with Juan M Acosta dba Clinica Medica Del Valle Effective September 1, 2016, additional five (5) year term. k) Fee-For-Service Primary Care Provider Agreement (All Lines of Business) with Neelam Gupta MD dba Ramona Medical Clinic Effective September 1, 2016, additional five (5) year term. l) Fee-For-Service Primary Care Provider Agreement with Rene Salhab M.D. Effective September 1, 2016, additional five (5) year term. m) Fee-For-Service Primary Care Provider Agreement (Excluding Medicare) with Loma View Pediatric Medical Clinic Inc Effective September 1, 2016, additional five (5) year term.

16 16 of 47 Submittals to the Inland Empire Health Plan Governing Board CONSENT CALENDAR August 8, 2016 n) Participating Provider Agreement with Comprehensive Primary Medical Associates Effective September 1, 2016, additional five (5) year term. o) Participating Provider Agreement with Desert Heart Rhythm Consultants Effective September 1, 2016, additional five (5) year term. p) Participating Provider Agreement with Ifeanyi Ugochuku dba Inalnd Surgical Group, Inc. Effective September 1, 2016, additional five (5) year term. q) Participating Provider Agreement with Indermohan S Luthra MD Effective September 1, 2016, additional five (5) year term. r) Participating Provider Agreement with Micha Rettenmaier Brown Lacey Partnership dba Gynecologic Oncology Associates Effective September 1, 2016, additional five (5) year term. s) Participating Provider Agreement with Radiation Oncology Physicians Inc Effective September 1, 2016, additional five (5) year term. t) Participating Provider Agreement with Riverside Medical Clinic Inc. Effective September 1, 2016, additional two (2) year term. u) Participating Provider Agreement with Rodolfo R Batarse dba Rodolfo R Batarse MD Effective September 1, 2016, additional five (5) year term. v) Participating Provider Agreement with Serendipity Hearing Inc dba Sonus SF0010 Effective September 1, 2016, additional one (1) year term. w) Participating Provider Agreement with Shadi A Qasqas MD Inc Effective September 1, 2016, additional five (5) year term. x) Participating Provider Agreement with William D Suval MD Inc Effective September 1, 2016, additional five (5) year term. y) Participating Provider Agreement (Medicare Only) with San Bernardino Medical Group, Inc. Effective September 1, 2016, additional five (5) year term. Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: Included in FY 16/17 Budget Attachments: A copy of the original Agreements are attached to the Minute Order and are maintained in IEHP s permanent file cabinets. Reviewed by Counsel: N/A

17 17 of 47 ADMINISTRATION 9. REVIEW OF THE MONTHLY MEMBERSHIP REPORT Recommended Action: Review and File Contact: Bradley P. Gilbert, M.D., Chief Executive Officer Background: This report reflects IEHP s actual membership versus the membership projections in the IEHP budget Discussion: Base Membership growth has been increasing; it remains predominately Medi-Cal Expansion Members, with some growth in regular Medi-Cal Membership as well. No other trends noted for June. Fiscal Year Month Forecast Membership Actual Membership + or Forecast + or Last Month FY 14/15 June, ,084,447 1,092,651 8,204 (93) FY 15/16 July, ,089,574 1,099,841 10,267 7,190 August, ,096,298 1,112,437 16,139 12,596 September, ,102,974 1,124,395 21,421 11,958 October, ,109,225 1,122,182 12,957 (2,213) November, ,115,436 1,124,726 9,290 2,544 December, ,122,604 1,127,581 4,977 2,855 January, ,129,730 1,134,643 4,913 7,062 February, ,136,814 1,143,302 6,488 8,659 March, ,143,858 1,148,179 4,321 4,877 April, ,150,863 1,153,720 2,857 5,541 May, ,154,830 1,162,082 7,252 8,362 June, ,158,760 1,172,959 14,199 10,877 Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable

18 18 of 47 Fiscal Impact: None Attachments: None Reviewed by Counsel: N/A

19 19 of 47 ADMINISTRATION 10. APPROVE THE FISCAL YEAR 2016/2017 RISK SHARING FUNDS MEASUREMENT AND DISTRIBUTION FOR THE MEDI-CAL EXPANSION POPULATION Recommended Action: That the Governing Board of the Inland Empire Health Plan (IEHP) approve the Fiscal Year 2016/2017 Risk Sharing Funds Measurement and Distribution for the Medi-Cal Expansion Population. Contact: Bradley P. Gilbert, M.D., Chief Executive Officer Background: In 2014, California implemented the Medicaid (Medi-Cal) Expansion (MCE) eligibility change based on federal guidelines from the Affordable Care Act (ACA). The ACA significantly increased the eligibility for Medi-Cal both in terms of the upper income limit (now 133% of the Federal Poverty Level) and by allowing childless adults who meet the income guidelines to be eligible. The MCE population is a major expansion of Medi-Cal eligibility for a population that has generally not had access to any health care coverage. As of July 2016, the MCE enrollment was 316,087. Discussion: As an update to the December 8, 2014 and July 13, 2015 Governing Board Items on the same subject, the distribution approved for calendar year 2014 and the first nine months of 2015 totaled $381.7 million that was awarded to Hospitals, IPAs, PCPs, and Specialists. As in prior fiscal years, the Risk Pool for Fiscal Year 2016/2017 will be based on a combination of quarterly utilization measures and quality metrics. The metrics for the measurements will be based upon MCE experience from October 1st through December 31st, 2015 and calendar year Due to the lag in receiving claims from providers, there is a nine month delay in processing payments for these periods. The Risk Pool funds for the fourth quarter of 2015 will be allocated into two primary pools; 60% to Hospitals and 40% to IPAs and physicians. The 2016 quarterly risk pool funds will be split 70% to Hospitals and 30% to IPAs and physicians. Hospital Metrics: Each Hospital s pool will be determined by the number of MCE bed days in their facility. The pool for the fourth quarter of 2015 will be awarded based upon the following metrics at 25% each: Readmission rates at or below 18% will be awarded a share of the pool based upon relative utilization. Physician/Specialist follow-up within seven calendar days of an inpatient hospital discharge will be distributed to hospitals that meet or exceed 22.1% based on relative utilization.

20 20 of 47 Progressing toward full participation in the IEHIE with pre-established milestones to complete. Connecting electronically and submitting electronic face sheets for patient submissions. The Hospital pool for calendar year 2016 will be awarded based on the following metrics at 25% each: Readmission rates, (excluding obstetrical days) at or below 16.9 % will be awarded a share of the pool based upon relative utilization. Physician/Specialist Follow-up within seven calendar days of an inpatient hospital discharge, (excluding obstetrical days) will be distributed based on two levels of achievement: Level 1= 21.2% threshold for 50% reimbursement. Level 2= 25% threshold for 100% reimbursement. Continue progressing towards full IEHIE participation. Electronic transmission of hospital lab results to IEHP. IPA Metrics: The IPA for the fourth quarter 2015 will be distributed based upon relative enrollment for the MCE population and awarded based upon the following metrics at 25% each; Readmission rates at or below 18.7% will be awarded a share of the pool based upon relative utilization. Physician//Specialist Follow-up within seven calendar days of an inpatient hospital discharge will be distributed to IPAs that meet or exceed 21.5% based on relative utilization. Member Satisfaction results from CAHPS and CAHPS like surveys; IPAs in the 75% percentile will receive 100%. IPA s with results in the 50% to 74% quartile will receive 75%. Eligibility file connectivity with the IEHIE by November 1, The IPA Pool for calendar year 2016 will be awarded based on the following metrics at 25% each: Readmission rates, (excluding obstetrical days) at or below 16.9 % will be awarded a share of the pool based upon relative utilization. Physician/Specialist Follow-up within seven calendar days of an inpatient hospital discharge, (excluding obstetrical days) will be distributed based on two levels of achievement: Level 1= 20.8% threshold for 50% reimbursement. Level 2= 25% threshold for 100% reimbursement. Continue progressing towards full IEHIE participation Member Satisfaction results from CAHPS or CAHPS like surveys. IPA s in the 75% quartile will receive 100%. IPA s with results in the 50% to 74% quartile will receive 75%. IEHP Direct Network Physician Metrics: IPA funds allocated to IEHP Direct will be distributed 70% to contracted Specialists based upon encounter data for the fourth quarter 2015 and calendar year 2016.

21 21 of 47 Thirty percent will be distributed to Primary Care Physicians for the fourth quarter 2015 based upon the following metrics at 50% each: Physician/Specialist Follow-up within seven calendar days of an inpatient hospital discharge will be distributed to hospitals that meet or exceed 21.5% based on relative utilization. Emergency Department Visit at or below 662 per thousand. For calendar year 2016, the IEHP Direct Primary Care Physicians metrics valued at 50% each shall be the following: Post inpatient acute discharge follow-up for MCE members within 7 days at 19.7%, excluding OB discharges. Emergency Department visits for all MCE members at or below 662/1000. Funds for this Risk Sharing Program were included in the Fiscal Year 2016/2017 budget as part of overall expenses for the MCE Members. Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: Included in the FY16/17 Budget Attachments: None Reviewed by Counsel: N/A

22 22 of 47 ADMINISTRATION SECOND QUARTER REVIEW OF THE IEHP COMPLIANCE PROGRAM Recommended Action: Review and File Contact: Bradley P. Gilbert, M.D., Chief Executive Officer Rohit Gupta, Director of Compliance / Compliance Officer Background: IEHP is required to implement an effective compliance program that meets the regulatory requirements set forth in 42 C.F.R (b)(4)(vi) and (b)(4)(vi). 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 Second Quarter Discussion: Centers for Medicare and Medicaid Services (CMS) Audits: Part D Transition Monitoring Program Analysis CY 2016 On May 24, 2016, IEHP submitted 30 selected rejected claims for the 2016 Transition Monitoring Program (TMPA) for Part D. As previously reported, the purpose of the TMPA is to evaluate point-of-sale (POS) rejected claims to ensure that Part D sponsors adequately administering Medicare Part D formulary transition requirements. For each reject claims, IEHP provided an explanation as to why the rejection was Appropriate or Inappropriate. All files were successfully submitted on time and accepted. CMS has not provided results and there is no indication that results will be provided to plans. The Compliance Department considers this audit as closed and will provide updates to the Governing Board should CMS communicate updates. State Program Audits: 2015 Compliance and Medical Survey (DMHC and DHCS) On July 16, 2015, IEHP received notification from the Department of Health Care Services (DHCS) of the medical audit and survey that will be conducted in coordination with the Department of Managed Health Care (DMHC). DHCS conducted a routine medical audit and DMHC conducted an 1115 Waiver Seniors and Persons with Disabilities (SPD) survey, a Cal MediConnect survey and a routine Knox-Keene Act Survey. The review period is October 1, 2014 through September 30, Per the Inter-Agency Agreements between DHCS and DMHC, medical surveys shall be conducted once every three years and will assess the Plan s overall

23 23 of 47 performance in meeting the health care needs of its members. In addition, the Cal MediConnect medical survey assesses the Plan s provision of Medicaid based services. The joint audit was conducted on-site October 5, 2015 through October 16, The audit focused on the outcomes of our activities and processes, including our P&Ps, job aids, and process workflows. On February 9, 2016, IEHP held an on-site Exit Conference with DHCS to discuss the preliminary findings of the DHCS Medical Audit component of the DMHC-DHCS Joint Audit. The Plan was provided 15 working days to submit relevant information concerning the draft reports and findings. On April 5, 2016, IEHP received the findings and Corrective Action Plan (CAP) requests for the DMHC CMC Survey and the DMHC 1115 Waiver SPD Survey. The CAPs were due to DHCS by May 5, On April 8, 2016, IEHP received the findings and CAP requests for the DHCS Medical Audit. The CAPS were due to DHCS by May 6, On April 26, 2016, IEHP received the findings and CAP request for the DMHC KKA Survey. The CAPs were due to DMHC on June 9, The Compliance Department received CAP approval and closing letters from DHCS and DMHC on July 25, 2016 for the on-site Medical Audit and 1115 Waiver SPD Survey. The Compliance Department is pending CAP approval and a Closing Letter from DHCS for the CMC Survey. The Compliance Department will continue to update the Governing Board as updates become available. First Five San Bernardino Audit The Children and Families Commissions for Riverside and San Bernardino Counties promote, support, and enhance the health and early development of children prenatal through age five (5) through funding from the California Children and Families Act (Proposition 10). The First 5 San Bernardino County Program Audit took place on December 17, The review period is July 2015 to December The Compliance department is awaiting the results of the audit and the closing letter. The first half of the First 5 San Bernardino County Program Fiscal Audit took place on January 19, The review period is July 2015 to January The Compliance Department anticipates the results of the audit and the closing letter. The Compliance Department is awaiting confirmation of the audit date for the second half of the First 5 San Bernardino County Program Fiscal Audit. At this time, The Compliance Department considers the audit as closed as no additional information has been requested from the Agency. First Five Riverside Administrative Compliance Audit The Children and Families Commissions for Riverside and San Bernardino Counties promote, support, and enhance the health and early development of children prenatal through age five (5) through funding from the California Children and Families Act (Proposition 10).

24 24 of 47 The First 5 Riverside County Fiscal Audit on March 10, 2015 was conducted off-site as a desk review by the auditor. The Compliance Department is currently awaiting a status update on the audit from the auditors. The First 5 Administrative Compliance Audit took place on March 22, The review period is October 1, 2015 through December 31, The Compliance Department is awaiting the results of the audit and the closing letter. At this time, The Compliance department considers the audit as closed as no additional information has been requested from the Agency. Office of Inspector General Medical Loss Ratio On August 13, 2015, IEHP received notification from the Department of Health and Human Services, Office of Inspector General of the audit of California s implementation of medical loss ratio (MLR) standards for Medicaid managed-care plans. The objective of the audit is to determine potential Medicaid program savings if the California Department of Health Care Services required its Medicaid managed-care plans to meet the MLR standards established by the Patient Protection and Affordable Care Act (ACA). The DHS OIG MLR audit was conducted on-site September 14, 2015 and September 15, The audit is ongoing and we are awaiting the results of the audit. At this time, The Compliance Department considers the audit as closed as no additional information has been requested from the Agency. Medical Loss Ratio (MLR) Audit and Administrative Expense Evaluation On February 3, 2016, IEHP received notification from the Department of Managed Healthcare (DMHC) of the medical loss ratio (MLR) audit and administrative expense evaluation that will be conducted in coordination with the Department of Health Care Services (DHCS). The purpose of the evaluation is to assess the Plan s financial condition and the accuracy of previously reported financial information. The review period is July 1, 2014 through June 30, IEHP submitted documents to DMHC on April 4, 2016 and on April 29, Since the April 29, 2016 submission, DMHC has issued eight (8) Information Document Requests (IDR) requesting additional information and clarification of the data submitted. However, The Compliance Department has not received a Final Report, and the audit remains on-going. The Compliance Department will continue to provide updates to the Governing Board as updates become available. Special Investigation Unit (SIU) Case Report The Compliance Department experienced a 60% increase in investigations related to privacy incidents from the Second quarter of 2015 (Q2-2015) to the Second quarter of 2016 (Q2-2016). The number of cases reported to the State increased from 2 cases in Q to 8 cases reported in Q One of the privacy cases reported to the State involved a breach caused by Kaiser Permanente. The breach occurred as a result of the theft of a mail delivery service vehicle and affected 2,452 IEHP Members. Kaiser Permanente provided Member notification and media notice as required.

25 25 of 47 The number of fraud cases investigated in Q compared to the number of cases for Q shows a 31.9% increase. Of those cases, 39 were reported to State/Federal agencies in Q compared to 22 cases reported in Q (a 43.6% decrease of reported cases). The decrease in reported fraud cases is a result of additional guidance from the State as to the type of fraud cases which should be reported. The increase in overall cases reflects the steady growth of IEHP Membership in Q Trends continue to show that the increase in cases closely follows the increase in IEHP Membership. SIU Cases Compared to Membership Growth: 2nd Quarter 2015 / 2nd Quarter 2016 Number of Cases April 2015 May 2015 June 2015 April 2016 May 2016 June 2016 FWA Cases Privacy Cases Membership (all LOBs) 1,069,862 1,101,939 1,096,204 1,143,889 1,150,956 1,162,557 1,160,000 1,140,000 1,120,000 1,100,000 1,080,000 1,060,000 Director of Compliance / Compliance Officer Update: Effective August 8, 2016, Steve Sohn, Managing Counsel, will act as interim Compliance Officer for IEHP. Rohit Gupta will be leaving IEHP in early August to pursue other opportunities. Rohit has played a significant role in the expansion and development of the IEHP Compliance Department, navigating IEHP through the CMS Program Audit in 2014, and further developed the IEHP Compliance Program to ensure compliance with regulatory, contractual and legislative requirements. Dr. Bradley Gilbert and the Compliance Department will inform the Governing Board as updates are available. Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: None Attachments: None Reviewed by Counsel: Yes

26 26 of 47 FINANCE DEPARTMENT 12. REVIEW OF THE MONTHLY FINANCIALS Recommended Action: Review and File Contact: Bradley P. Gilbert, M.D., Chief Executive Officer Background: This report is presented monthly and is a Summary of the Financial Statements. Discussion: Summary Income Statement for the Month Ended June 30, Highlights: Enrollment of approximately 1.17 million generated a favorable actual result compared to budget of $6.6 million for the month ended June 30, 2016: Enrollment of approximately 1.17 million generated a favorable actual result compared to budget of $6.6 million for the month ended June 30, 2016: Increase of $36.9 million due to DHCS settlement of a Notice of Dispute for previous years SPD rates periods. Decrease of $36.2 million due to Reserve for CCI rate decrease due to significant delays in rate adjustments by the State. Increase of $17.6 million due to CMS Risk Factor reimbursement due to increased HCC scores with supplemental data submissions. Total operating expenses just under $1.0 million less than budget. Strategic Priorities: Quality of Care Access to Care Practice Transformation Human Development Technology Not Applicable Fiscal Impact: Included in FY 15/16 Budget Attachments: Summary Income Statement for the Month Ended June 30, 2016 (next page) Reviewed by Counsel: N/A

27 27 of 47 Inland Empire Health Plan Summary Income Statement for the Month Ended June 30, 2016 Actual Budget Variance $ Operating Revenue Medi-Cal 312,208, ,656,867 (22,448,665) Healthy Kids 130, ,663 9,846 Medicare 60,736,643 30,898,473 29,838,170 Net Revenue 373,075, ,676,003 7,399,352 Medical Costs Total Medi-Cal Costs 287,093, ,895,373 (16,801,498) Total Healthy Kids Costs 212, ,239 62,209 Total Medicare Costs 47,258,205 29,233,280 18,024,926 Total Medical Costs 334,564, ,278,891 1,285,637 Gross Margin 38,510,827 32,397,112 6,113,715 Operating Expenses Total Operating Expenses 12,340,868 13,330,263 (989,396) Operating Surplus (Deficit) 26,169,959 19,066,849 7,103,110 Other Income (Expense) 238,350 47, ,218 Property Management Income (Expense) (203,702) (264,610) 60,909 Third Party Agreement (TPA) - 20,000 (20,000) Behavioral Health Clinic 348, , ,273 ED Navigator Project - 12,500 (12,500) Hospital Community Fund 500, ,000 Net Surplus (Deficit) 25,364,582 18,731,870 6,632,711

28 28 of 47 FINANCE DEPARTMENT 12. REVIEW OF THE MONTHLY FINANCIAL REPORTS (continued..) Recommended Action Review and File Contact Bradley P. Gilbert, M.D., Chief Executive Officer Background This report is presented monthly and is a Summary of the Financial Statements. Discussion Summary Income Statement on a Year-To-Date basis for period ended June 30, Highlights: Enrollment of approximately million generated a favorable actual result compared to budget of $86.7 million for the year ended June 30, 2016: Increase of $36.9 million due to DHCS settlement of a Notice of Dispute. Decrease of $49.1 million due to Reserve for CCI rate decrease as noted for June. Increase of $30.6 million due to Medicare Part-D subsidies. Increase of $17.6 million due to CMS Risk Factor reimbursement as noted for June. Increase of $11.7 million due to P4P Pharmacy adjustment. Total operating expenses for the year just under $18 million less than budget primarily due to position vacancies. Fiscal Impact Included in FY 15/16 Budget Attachments Summary Income Statement for the Twelve Months Ended June 30, 2016 (next page) Reviewed by Counsel N/A

29 29 of 47 Inland Empire Health Plan Year-To-Date Summary Income Statement for the Twelve Months Ended June 30, Actual Budget Variance $ Operating Revenue Medi-Cal 3,677,981,074 3,863,636,920 (185,655,847) Healthy Kids 1,536,951 1,447,959 88,991 Medicare 376,113, ,618,567 13,494,621 Net Revenue 4,055,631,212 4,227,703,446 (172,072,234) Medical Costs Total Medi-Cal Costs 3,305,958,309 3,581,129,239 (275,170,929) Total Healthy Kids Costs 1,503,399 1,816,446 (313,048) Total Medicare Costs 375,525, ,430,030 33,095,324 Total Medical Costs 3,682,953,674 3,925,375,715 (242,422,040) Gross Margin 372,677, ,327,731 70,349,806 Operating Expenses Total Operating Expenses 138,917, ,809,964 (17,892,828) Operating Surplus (Deficit) 233,760, ,517,767 88,242,634 Other Income (Expense) 1,396, , ,983 Property Management Income (Expense) (3,830,187) (2,971,017) (859,170) Third Party Agreement (TPA) - 40,000 (40,000) Behavioral Health Clinic 2,053,483 1,500, ,483 ED Navigator Project 30, ,000 (120,000) Hospital Community Fund 750, ,000 Net Surplus (Deficit) 228,201, ,495,568 86,706,035