ADVANTAGE Health Solutions, Inc. SM

1. ADVANTAGE Health Solutions, Inc.SM ADVANTAGE Special Needs Plan Provider Model of Care Training

2. Advantage Mission Provide managed care solutions to improve outcomes, keep costs low and improve the health and wellness of the communities we serve

3. MOC Provider Training Requirement Upon initial enrollment, DE-SNP PCPs will undergo a comprehensive face-to-face or, web-based training. • All PCPs will receive general training that addresses all aspects of the health plan MOC, as well as the special needs of the SNP Population. • All PCPs will be required to complete the MOC training upon initial enrollment, on an annual basis and as otherwise required by ADVANTAGE . • DE-SNP participating PCPs must successfully complete the training before enrollment can be considered complete.

4. What are Medicare Special Needs Plans (SNPs) Medicare SNPs are specially designed Medicare Advantage Plans, which have the following features: • Enrollment is limited to Dual Eligible (DE) Medicare/Medicaid populations • Benefit plans are custom designed to meet the needs of this designated population • SNP members typically have additional election periods to change their Medicare coverage

5. Purposes of SNP The purposes of the Special Needs Plan are to: • Increase plan & beneficiary participation in managed care • Encourage access of “special needs” populations • Provide better coordination of care between primary, acute, and long term care providers • Reduce fragmentation • Improve quality outcomes

6. MEDICARE/MEDICAID COVERAGE If a member’s Medicaid status is Qualified Medicare Beneficiary (QMB) or Qualified Medicare Beneficiary Plus (QMB-Plus), he/she will pay $0 for Medicare covered services as set forth in the ADVANTAGE Health Solutions Summary of Benefits. If a members Medicaid status is not QMB or QMB-Plus, he/she may have to pay some coinsurance, co-payments, and deductibles depending on their Medicaid coverage, even if he/she otherwise qualify for full Medicaid benefits. A member’s Medicaid benefits will vary based on income level and other Medicaid Standards. Medicaid benefits may also change during each year. Regardless, while a member of the ADVANTAGE Health Solutions Special Needs Plan, members will have access to this plan’s benefits even if their Medicaid status changes.

7. SNP Approved Counties Hamilton, Hancock, Johnson, Marion, Morgan

8. Categories of Dual Eligibility The categories of Dual Eligibility under the state Medicaid program are: • Qualified Medicare Beneficiary (QMB): Individuals whose Medicare Part A and Part B premiums, cost sharing, and deductibles are paid by Medicaid. This excludes Part D cost sharing. • Qualified Medicare beneficiary with full Medicaid (QMB Plus): Individuals whose Medicare Part A and Part B premiums, cost sharing, and deductibles are paid by Medicaid and receive full Medicaid benefits. This excludes Part D cost sharing. • Specified Low Income Medicare Beneficiary (SLMB): Medicare Part B premiums are paid by Medicaid. • Specified Low Income Beneficiary with full Medicaid (SLMB Plus): Individuals whose Medicare Part B premiums are paid by Medicaid and receive full Medicaid benefits. • Qualified Disabled & Working Individual (QDWI): Individuals whose Medicare Part A premiums are paid by Medicaid. • Qualifying Individual (QI): Individual whose Medicare Part B premiums are paid by Medicaid. • Full Benefit Dual Eligible (FBDE): Individuals whose Medicare Part A premiums are paid by Medicaid, and in certain cases, Medicare Part B premiums. These individuals receive full Medicaid benefits.

9. Member Eligibility for SNPs To join ADVANTAGE’s Medicare SNP, individuals must: • Have Medicare Part A and Part B coverage • Live in the county where the plan they wish to join is offered. • Not have End Stage Renal Disease (ESRD) • Be eligible for some level of Medicaid Coverage

10. SNP Individualized Care Plan (ICP) SNP members have an Interdisciplinary Care Team that has clearly defined roles. The team provides the infrastructure necessary to coordinate the plan of care (POC) and to provide appropriate staff and program oversight. Interdisciplinary Care Team functions include: developing/implementing individualized care plans, coordinating care and sharing information with providers, caregivers and the member.

11. SNP Individualized Care Plan (ICP) (cont.) Bio-Psycho-Social (BPS) Model Bio-psycho-social systems focus on member health and well-being using the critical components of behavior change, relationship building and member systems engagement that can result in the member realizing resiliency and self-efficacy. 11

12. SNP Individualized Care Plan (ICP) (cont.) Guiding Principles of the BPS model Moving from disease focus to member focus Identifying and employing the most effective intensity of evidence-based, plan-covered systems and services Behavior engagement for change Teaming with the member and care providers to enhance care outcomes Collaboration with plan sponsors to influence benefit design that supports our model 12

13. Provider Network

14. Life of a Member…

15. Health Risk Assessment (HRA) Assessments are initially mailed to the member within 10 days of CMS confirmation of eligibility. The D-SNP Program will complete health screenings within 90 calendar days of member’s effective date and AT LEAST annually thereafter (within one year of the last HRA). • Member or Care Giver is requested to complete the HRA and return to ADVANTAGE within 15 days (a self-addressed stamped envelope is provided). A health professional performs a telephonic outreach if HRA is not returned within 30 days of CMS confirmation. • At least three attempts are made to have a successful contact. A successful contact is defined as: • assisting the member to complete the HRA telephonically; • getting care giver or member’s verbal commitment to complete and submit the HRA within ten days; or establishing a more convenient date and time for member to take a follow-up call to complete the HRA; or scheduling an appointment with Member’s PCP.

16. Health Risk Assessment (HRA) – cont. Once an assessment is received the results are entered into our system. This data is collated with claims encounter data and the member is stratified into their risk level (1 – 4). • ADVANTAGE will produce monthly management reports on our completion rate and identify members who have not completed a health screen within 30, 60 and 90 calendar days.

17. Assignment and Stratification Within 10 days of completion of HRA, members will be assigned a dedicated Health Coach or Case Manager to assist the member in navigating the health care system in both the ambulatory and inpatient settings to ensure timely and appropriate access to needed services. • Each member will have an assigned case manager or health coach who is the primary liaison to the member, providers, and health plan. • A Health Coach for low level risk stratified members • A Certified RN Case Manager for medium to high level stratified members. • An Advanced Nurse Practitioner in the most complex cases

18. Assignment andStratification Each member’s health care professional acts as the liaison to the ICT and will assist the member and primary medical physician in the development of the member’s plan of care (POC) by providing all relevant information available: • Pharmacy and medical claims • History of admissions and use of ER • Review of primary medical record information if member at high risk • Member and/or care giver/taker interviews • HCC scores • Clinical impressions gleaned from interviews and face to face visits.

19. Interdisciplinary Care Plan (ICP) ADVANTAGE will develop and implement an individualized care plan (ICP) in consultation with the PCP and the beneficiary/caregiver for all beneficiaries. • ADVANTAGE communicates this ICP to the PCP (via e-mail, fax, or written correspondence with the beneficiary/caregiver). • ADVANTAGE conducts face-to-face or telephonic meetings with the provider, beneficiary/caregiver and/or disease manager/case manager or health coach. • The care plan is reviewed • at least every 6 months for members who are stratified at levels 1 and 2 • at least every 3 months for members stratified at levels 3 and 4.

20. ICP – cont. • Care Manager will monitor member profile of care (claims and lab data) at least quarterly to identify gaps in care and will perform outreach to encourage member compliance according to goals of member’s Plan of Care and HEDIS measures for preventive services. • The ICP will initiate the Transitional Care Program for all Members during the acute or sub-acute admission to ensure that appropriate resources are available and engaged across the continuum of care. • All ICPs are HIPPA compliant and submitted to the PCP via a secure web-based provider portal or via secured encrypted email.

21. Interdisciplinary Care Team (ICT)

22. Interdisciplinary Care Team (ICT) ICT Care Conferences • ICT Case Conferences are an integral part of the ADVANTAGE DE-SNP Model of Care • Focus on support of the Member through the review and modification of the Member's Individualized Care Plan (ICP) as health status requires or urgent/emergent events occur 22

23. Interdisciplinary Care Team (ICT) Care plan ICT conferences will be held within the first 90 days of Member enrollment and • at least annually for low and medium levels of risk • at least every six months for high level of risk. • Impromptu conferences can also be requested based on change in the patient’s condition or needs. 23

24. Interdisciplinary Care Team (ICT) ICT Care Conferences (PCP Participation) • DE-SNP PCPs are strongly encouraged to participate at minimum on a quarterly basis • PCPs are eligible to receive additional reimbursement for their time and participation • Reimbursement Criteria • Conference attended by the SNP members assigned PCP or PCP’s Nurse Practitioner or Physician Assistant • ADVANTAGE will initiate administrative payment and reimburse the PCP within 30 days of care conference completion 24

25. Providers • All current ADVANTAGE Medicare HMO network participating providers are able to provide services to DE-SNP members. • ADVANTAGE Medicare HMO network PCPs are eligible for special enrollment in the DE-SNP and receive enhanced reimbursement • PCPs in the field of General Practice, Family Practice, Pediatrics, Internal Medicine or OB/GYN • Any specialty who agrees to the responsibilities and requirements of a DE-SNP PCP

26. Providers • Members will have the choice of access to at least two culturally appropriate primary medical homes located within 10 miles of his/her home. • All SNP members will be linked to their preferred primary care physician within thirty days of enrollment. • Utilizing the Monthly Provider Report Cards the Interdisciplinary care teams encourage referral to affiliated providers who demonstrate high rating of efficiency of care compared to their cohort group. 26

27. Providers PCP Responsibilities • Completion of MOC training • Adhere to universally accepted standards • Provide or arrange for the delivery of • Routine comprehensive preventative services • Medically necessary primary care treatment and urgent care services 27

28. Providers PCP Responsibilities (Cont.) • Coordinate or seek referrals for • Specialty physician services • Hospital inpatient and outpatient services • Ancillary services (lab, radiology, orthotics/prosthetics & DME) • Provide PCP visit within 14 days of DE-SNP member discharge from acute or SNF facility 28

29. Providers PCP Responsibilities (Cont.) • Participate/Direct the Interdisciplinary Care Team • Provide insight into the medical needs of the DE-SNP member • Review DE-SNP members ICPs • Assure ICP is supportive of the PCPs own plan of care for the member • Communicate with ADVANTAGE ICT staff 29

30. Providers PCP Incentives • DE-SNP PCPs will receive ($15) PMPM administration fee for each DE-SNP member assigned to his/her ADVANTAGE Medicare HMO panel roster • ICT Case Conferences reimbursed at ($40) for each DE-SNP member discussed • Access to the ADVANTAGE ‘provider portal’ for improved communication, member/provider report cards, panel rosters, and access to member ICP 30

31. Provider Education and Outreach • Interdisciplinary care teams encourage referral to affiliated providers who demonstrate high rating of efficiency of care compared to their cohort group. • Once a member has been assessed and stratified, they are contacted by the ICT. After the initial contact, the practitioner will receive a letter notifying them of: • The program in which the member is enrolled • The Clinical Practice Guidelines (CPG) on which the program is based • The Disease Management Educator coaching the member • Gaps in care (condition and prevention based) noted by claims or results needed from testing completed

32. Provider Education and Outreach • Once the initial letter is sent, based on stratification either every 3 months or every 6 month the practitioner will receive a letter with: • Gaps in care (condition and prevention based) noted by claims or results needed from testing completed

33. ADVANTAGE Provider Portal • All DE-SNP PCPs who register online through the ADVANTAGE ‘provider portal’ will have access to the ‘personal health record’ of each assigned member • PCPs will also find ‘provider report cards’ that details valuable information on PCP performance. • The provider portal will also allow the PCP to view their entire ADVANTAGE Medicare HMO roster of patients as well as contact information for the Care Manager assigned to the PCPs SNP members. • The “live” Provider Portal will be available soon. The following slides are for training purposes only. 33

34. http://www.advantageplan.com Link to registration/login will be in this area

35. Login for existing users, and first-time users can register here

36. Initial Login Screen This area will be customized for each provider. This will display your ENTIRE assigned member panel, across ALL ADVANTAGE product lines.

37. This is the patient’s homepage. All tabs above can be accessed for patient information.

38. Continuation of patient’s homepage. Again, the content of this page can be customized.

39. Each tab contains additional options to view/edit health information about each patient.

40. WEIGHT 11/04/2011 07/30/2011 01/04/2011 01/06/2010 01/15/2009 04/08/2011 06/16/2010 Providers will have the ability to choose a timeframe to view

41. Providers will have the ability to choose a timeframe to view This information will be auto-populated if the providers office has access to EMR. If not, the office can use this feature as an “EMR Lite”.

42. Pharmacy Name* Medication Name* SIG Days Supply* Quantity* Dose* Frequency* Refills* Patient Instructions*

43. Tool showing membership numbers by quarter Tool for ranking physicians within their specialty based on the Total Cost Index.

44. Tool showing medical conditions of all patients Tool showing admission rates

45. Tool showing Quality Performance Summary

46. Our Health Plan values the well-being of our members! • Our goal is to serve the Medicare dual-eligible populations of Indiana with value-added services that enhance quality of care.

47. Training Completion and Attestation Mail: 9045 River Road, Suite 200 Indianapolis, IN 46240 Fax: 317.663.1895 Email: lpoole@advantageplan.com Click here for the Attestation Form (http://www.advantageplan.com/MAplans/pdfs/SNP_Training_Attestation.pdf) Congratulations! You have completed the required SNP Provider training. Please click on the link below to download the attestation form. In order to validate your completion of this training, the attestation must be printed, signed, and returned to Lisa Poole, Provider Relations Specialist at ADVANTAGE Health Solutions, Inc., using one of the following methods: 47