FEE FOR SERVICE MEASURES

FEE FOR SERVICE MEASURES Fee for Service (FFS) Measures provide a single payment incentive to PCP sites in exchange for performing a service or activity. All 2018 measures require providers to submit a form to the Alliance attesting the completion of the health care service in order to receive CBI incentive payment. FFS incentives are paid on a quarterly basis, at the end of the quarter in which the attestation form was received, as long as the date of service was within the calendar year. There is no rate calculation for FFS measures; PCP Sites are paid each time a qualifying service is performed. Unlike Programmatic measures, there are no minimum eligible member requirements for FFS measures. PCP Site s will receive incentive payments for each member with a qualifying service, regardless of how many members were eligible for the measure. All CBI FFS forms must be submitted to the Alliance via fax within 21 days from the date of service. P a g e 64 of 72 Version 2018.5

PREVENTIVE CARE HEALTHY WEIGHT FOR LIFE (HWL) The Healthy Weight for Life (HWL) measure encourages PCPs to refer children and teens with a Body Mass Index (BMI) above the 85 th percentile to the Alliance Healthy Weight for Life program to receive counseling on nutrition and physical activity. It is important to for the PCP to conduct follow-up visits once the member is enrolled into the HWL program to provide further education for nutrition, physical activity and review the member s progress. Alliance staff help members with BMI at 85% or higher with comorbidities, to identify measurable goals that support the adoption of healthier lifestyles and reduce health care costs. MEASURE DESCRIPTION: Members ages 2-18, that have a BMI at or above the 85th percentile and have an HWL referral form completed and approved at the first, and subsequent six month follow up visit(s). MEMBER REQUIREMENT: N/A Membership: Linked members enrolled in the Medi-Cal program in Santa Cruz, Monterey or Merced counties, excluding Dual Coverage members. Ages: 2 18 years. Eligible Member Event/Diagnosis: BMI at or above the 85 th percentile. Exclusions: Visits that occur less than 6 months apart from same PCP Administrative Members Members with other health coverage California Children s Services (CCS) Members on date of service SERVICING PCP SITE REQUIREMENT: Forms must be completed by the linked PCP site to receive credit. FEE-FOR-SERVICE AMOUNT: The Alliance will pay $25 per approved initial HWL forms for members whom the Alliance did not receive a completed HWL form in the prior calendar year (2017). The Alliance will pay $50 per 6 month follow up HWL form for members whom the Alliance received an initial approved HWL form in 2017, or during the current CBI term (with a minimum 6 month gap between the forms). HWL forms submitted within 6 months of the preceding HWL form are not eligible for reimbursement. PAYMENT FREQUENCY: Quarterly, maximum of two payments per year per PCP. Payments are made on a quarterly basis. If a form from an earlier quarter was not paid in the quarter which the service was performed the payment will be made in the following quarter, up to quarter 4. All payments made are for service dates within the CBI year. P a g e 65 of 72 Version 2018.5

DATA SOURCE: HWL forms submitted by Providers to the Alliance. Forms must be submitted within 21 business days from date of service. RESOURCES: Healthy Weight for Life Program Overview HWL Form FFS Forms Required Data Fields FFS Forms Tips for Approval CODE SET LINKS: N/A, form based measure P a g e 66 of 72 Version 2018.5

MATERNITY CARE: TIMELY PRENATAL CARE Timely prenatal care is an important compentent in reducing complications and ensuring the physical and emotional well being of pregnant women and their babies. Women on Medi-Cal continue to have lower rates of timely prenantal care than privately insured women. The CBI program seeks to support provides in closing this gap and ensuring Medi-Cal women and babies receive quality timely prenatal care. The CBI Program incentivizes providers to ensure timely prenatal care for every pregnant woman within the first trimester to avoid adverse outcomes and reduce costs. MEASURE DESCRIPTION: Prenatal visit and completed Prenatal Care Form in the first trimester (by the end of the 13th week), or within 42 days of enrollment with the Alliance. Membership: Linked members enrolled in the Medi-Cal program in Santa Cruz, Monterey or Merced counties, excluding Dual Coverage members. Age: N/A Eligible Member Event/Diagnosis: Diagnosis of a pregnancy Exclusions: Members with other health coverage on date of service Administrative members on date of service Medi-Medi members on date of service California Children s Services (CCS) Members on date of service SERVICING PCP SITE REQUIREMENT: Forms must be completed by the linked PCP site to receive credit. FEE-FOR-SERVICE AMOUNT: $25 per Member/ Per Pregnancy PAYMENT FREQUENCY: Quarterly per pregnancy. Payments are made on a quarterly basis. If a form from an earlier quarter was not paid in the quarter which the service was performed the payment will be made in the following quarter, up to quarter 4. All payments made are for service dates within the CBI year. DATA SOURCE: Measure requires that provider submit completed Timely Prenatal Care form to the Alliance. Forms must be submitted within 21 business days from the date of service. RESOURCES: Prenatal Care Form P a g e 67 of 72 Version 2018.5

FFS Forms Required Data Fields FFS Forms Tips for Approval CODE SET LINKS: N/A, forms based measure P a g e 68 of 72 Version 2018.5

PRACTICE MANAGEMENT BUPRENORPHINE LICENSE (X-LICENSE WAIVER) Buprenorphine is a medication-assisted treatment drug for people diagnosed with opioid use disorder. In order to prescribe or dispense buprenorphine, physicians must qualify for a physician waiver, which includes completing the required training and applying for the physician waiver. MEASURE DESCRIPTION: This measure is intended to provide compensation for the amount of time spent in training and the cost of the X-License certification with the goal of expanding our provider network for medication-assisted treatment therapy. MEMBER REQUIREMENT: N/A Membership: N/A Ages: N/A Continuous Enrollment: N/A Eligible Member Event/Diagnosis: N/A EXCLUSIONS: N/A SERVICING PCP SITE REQUIREMENTS: N/A FEE-FOR-SERVICE AMOUNT: $1,000 per provider, which includes mid-level Providers, for the obtaining an X License through the DEA. Plan shall pay for each CBI group that the clinician practices under. Mid-level providers must be practicing under a supervising PCP physician with an X-Licensure to be eligible for incentive payment. PAYMENT FREQUENCY: Quarterly. Payments are made a single time after certification. Payments do not reoccur yearly or quarterly. DATA SOURCE: Receipt of X-License Waiver certification RESOURCES: Contact your Provider Services Representative for instructions on submitting X-License Waiver Certification CODE SET LINKS: N/A P a g e 69 of 72 Version 2018.5

PATIENT CENTERED MEDICAL HOME (PCMH) RECOGNITION This measure incentivizes PCP sites who adopt the Patient Centered Medical Home (PCMH) model of care to transform primary care practices into medical homes. The PCMH model can lead to higher quality of care and lower costs, while improving both care coordination and communication. MEASURE DESCRIPTION: PCP Sites who receive NCQA or The Joint Commission (TJC) documentation validating achievement of Patient Centered Medical Home (PCMH) recognition will receive incentive payment. PCMH recognition payment is made per NCQA/TJC application that ultimately results in PCMH recognition, regardless of the number of sites included on the application. After Provider has achieved PCMH recognition for a site(s), for each subsequent level of PCMH recognition earned for such site(s), the Alliance will pay the provider the difference between the payment associated with the level of PCMH recognition currently achieved and the largest PCMH recognition previously paid. MEMBER REQUIREMENT: N/A Membership: N/A Ages: N/A Continuous Enrollment: N/A Eligible Member Event/Diagnosis: N/A EXCLUSIONS: N/A SERVICING PCP SITE REQUIREMENTS: N/A FEE-FOR-SERVICE AMOUNT: $2,000 NCQA level 1 + $500 NCQA level 2 + $1,000 NCQA level 3 $2,500 (The Joint Commission) TJC PCMH recognition PAYMENT FREQUENCY: Quarterly. Payments are made a single time after certification. Payments do not reoccur yearly or quarterly. DATA SOURCE: Receipt of NCQA or TJC documentation of achievement RESOURCES: Contact your Provider Services Representative for instructions on submitting PCMH recognition documentation. CODE SET LINKS: N/A P a g e 70 of 72 Version 2018.5