AmeriHealth Caritas Plan Updates

1. New Provider Communications • First Quarter, 2019 AmeriHealth Caritas Plan Updates Robin Milanak, LPN Regional Manager of Provider Network Management for Western PA

2. About AmeriHealth Caritas AmeriHealth Caritas is part of the Independence Health Group in partnership with Blue Cross Blue Shield of Michigan. AmeriHealth Caritas is one of the nation’s leaders in health care solutions for those most in need. Operating in 17 states and the District of Columbia, AmeriHealth Caritas serves more than 5.7 million Medicaid, Medicare and Children’s Health Insurance Program (CHIP) Participants through its integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Headquartered in Philadelphia, with offices in Harrisburg and Pittsburgh, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience serving low-income and chronically ill populations. For more information, visit www.amerihealthcaritas.com.

3. We help people: Get care Stay well Build healthy communities Our Mission and Values

4. Our Values Advocacy • Care of the Poor • Compassion • Dignity • Diversity • Hospitality • Stewardship

5. Three AmeriHealth Caritas Products in Western PA: 21 years or older Eligible for Medicaid/Medical Assistance Eligible for long-term services and supports or Medicare or BOTH Southwest Pennsylvania www.amerihealthcaritaschc.com A Medicare D-SNP plan is a Medicare Advantage plan designed for people who get both Medicare and Medicaid benefits and have special needs. Southwest Pennsylvania www.amerihealthcaritasvipcare.com • A Managed Medicaid/Medical Assistance plan • Northwest Pennsylvania • www.amerihealthcaritaspa.com AmeriHealth Caritas

6. Medical Assistance/Medicaid Program Updates: AmeriHealthCaritas Pennsylvania • AmeriHealth Caritas Pennsylvania Service Area • Northwest Medical Account Executives • 2019 Primary Care Practitioner (PCP) Quality Enhancement Program (QEP) Updates • 2019 Maternity QEP Updates • DHS Service Location Enrollment Deadline

7. AmeriHealth Caritas Pennsylvania Service Area

8. AmeriHealth Caritas Pennsylvania NW Region Physician Account Executives Issue Resolution and Telephonic Support Account Executives (handle claims, credentialing, and other operational issues telephonically and through e-mail): Shannyn Burzese Crawford, Erie, McKean, Mercer, Venango, & Warren counties Phone: 412-930-9419 Shelly Puskar Clarion, Clearfield, Elk, Forest, Jefferson, & Lawrence counties Phone: 412-525-1574 Michelle Wilkus Cameron & Potter counties Phone: 717-708-8277 Michael Sheehan Contracting, expansion, and recruitment; UPMC, Adagio, out of area providers Phone: 814-823-4554 Educational Account Executives (meets in network providers’ offices with staff in assigned counties): Wendy Fiffick Clarion, Clearfield, Elk, Forest, & Jefferson counties Phone: 814-241-9641 Nicole McCray Crawford, Erie, McKean, Mercer, Venango, & Warren counties Phone: 814-502-1466 Michael Monoski Cameron & Potter Counties Phone: 570-904-0299

9. 2019 PCP QEP Updates

10. The following nine HEDIS-based measures will be included in the Quality Performance component: Adolescent Well-Care Visit Ambulatory Care – ED Visits Annual Dentist Visit (ages 2-10 years) Medication Management for People with Asthma Diabetes Care (HbA1c Poor Control >9%) • Eligible for CPT II incentive 6) Controlling High Blood Pressure <140/90mm Hg 7) Well-Child Visits in the First 15 Months of Life, six or more 8) Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life 9) Plan All-Cause Readmission (new this year) QualityPerformance Components

11. CPT II Code Electronic Submission A $10 reimbursement per occurrence for the electronic submission of a claim containing a valid combination of the following CPT II codes:

12. A Top Performance Incentive will accompany the final payment for those groups whose average peer comparison percentile ranking across all quality measures is 65 percent or higher. • An Improvement Incentive will also be awarded to PCP groups that did not meet network targets but did show an improvement of 10 percent or more for a given measure over the prior year. This incentive will be calculated at the final payment of the program year. Additional QEP Updates

13. Payment Cycles 2019 PCP QEP Payment Cycles • Providers will be evaluated on these HEDIS measures through the 2019 calendar year and will be paid quarterly according to the following schedule: Complete 2019 program details are available in the updated QEP manual posted at www.amerihealthcaritaspa.com Providers  Resources  Quality Enhancement Program  2019 PCP QEP Manual

14. 2019 Maternity QEP Updates

15. The Quality Performance components will remain the same for 2019 and consist of the following three HEDIS-based measures: • Frequency of Ongoing Prenatal Care: >81% of expected visits • Prenatal Care in the First Trimester • Postpartum Care QualityPerformance Components

16. CPT II Code Electronic Submission Claims submitted electronically containing a diagnosis related to pregnancy with any of the following eligible CPT II codes will be reimbursed according to the fees set forth below:

17. Payment Cycles 2019 Maternity QEP Payment Cycles • Providers will be evaluated on these HEDIS measures and the performance component beginning in January 2019 according to the schedule below: Complete 2019 program details are available in the updated QEP manual posted at www.amerihealthcaritaspa.com Providers  Resources  Quality Enhancement Program  2019 Maternity QEP Manual

18. QEP Tools AmeriHealth Caritas • Quality Enhancement Program tools are available on Navinet • to monitor and track progress. • Navinet • QEP Dashboard • Website, Provider Manual, QEP Manual • Speak to your Account Executive for more information

19. Medical Assistance Bulletin 99-18-11: Service Location Enrollment Deadline - July 1, 2019 Purpose: The purpose of the bulletin is to: Remind providers of the requirement to enroll each service location out of which they operate in the Medical Assistance (MA) Program; Provide instructions for the enrollment of service locations; Advise providers that claims will deny if the service location is not enrolled in PROMISe before the enrollment deadline Background Synopsis: As providers completed the revalidation process, the Department determined that there are providers who have not enrolled each service location at which they provide services. Providers must enroll all service locations where they offer services prior to July 1, 2019. The Department will deny claims for services provided at a service location that is not enrolled, beginning in July 2019.

20. 1) Institutional Locations: Individual providers who have clinical privileges at an institutional location do not need to enroll these places of service. Institutional locations are locations using place of service codes 21 (inpatient hospital), 22 (on campus-outpatient hospital), 23 (emergency room), 24 (ambulatory surgical center), 31 (skilled nursing facility) or 32 (nursing facility). However, if the individual provider is employed by the institution and the only place they provide services is the institutional location, the individual provider must enroll at the institutional location. 2) Radiologist and Anesthesiologist: Individual providers enrolled with the following provider types and specialties, who may have enrolled previously at only one service location, must enroll at every service location where they provide services, unless they are providing services at an institutional location as described above. Radiologist, provider type 31, specialty 341 Anesthesiologist, provider type 31, specialty 311 Certified Registered Nurse Anesthetist, provider type 32, specialty 320 Exceptions:IndividualProviders AmeriHealth Caritas

21. 3) Provider Groups: Groups of like individual providers, such as physicians, certified registered nurse practitioners and therapists, must enroll all of their service locations and receive a separate service location number for each service location. Additionally, each group member must enroll as an individual provider at each service location where the individual provider practices. Exceptions:Individual Providers (cont’d)

22. Agencies, entities and institutional providers need to enroll all service locations where they provide services to MA beneficiaries. • Example: Pharmacies must enroll each licensed pharmacy and receive a 13-digit number (pharmacy’s 9-digit MPI plus 4-digit service location code) for each separate pharmacy address. • Health systems and hospitals must enroll all facilities and locations at which they offer services and receive a 4-digit service location for each facility. • Providers that provide services under multiple provider types at the same location, must enroll each provider type as a different service location. • Example: If an entity is a licensed home health agency and a durable medical equipment provider operating out of one address, the entity must enroll separately as a home health provider and a durable medical equipment provider and will receive a unique 13-digit number for each provider type at the same address. Agencies, Entities, Institutions

23. Electronic Enrollment: Providers who need to enroll, revalidate or re-activate their enrollment, or enroll an additional service location, should visit the following website to enroll electronically: https://provider.enrollment.dpw.state.pa.us/ Initiate Additional Application Feature: Allows providers to copy information related to the same Federal Tax ID Number or Social Security Number from the original application to a new application for a different service location. Avoid re-typing information when submitting new application Providers who are unable to enroll electronically can call the Department and request a paper enrollment application: Phone number: 1-800-537-8862 (M-F 8AM-4:30PM) Enrollment

24. AmeriHealth Caritas Pennsylvania Community HealthChoices Program Updates: AmeriHealth Caritas Pennsylvania Community Health Choices Service Area and Implementation Dates Physician Account Executives CHC News/Updates

25. About AmeriHealth Caritas, cont’d. AmeriHealth Caritas Pennsylvania (PA) Community HealthChoices (CHC) maintains offices throughout the Commonwealth to support our network providers. AmeriHealth Caritas PA CHC 8040 Carlson Road Harrisburg, PA 17112 AmeriHealth Caritas PA CHC 11 Stanwix Street Pittsburgh, PA 15222 AmeriHealth Caritas PA CHC 200 Stevens Drive Philadelphia, PA 19113

26. Service Counties Phase One: January 1, 2018 – Southwest zone Phase Two: January 1, 2019 – Southeast zone Phase Three: January 1, 2020 – Northwest, Lehigh/Capital and Northeast zones AmeriHealth Caritas Pennsylvania Community HealthChoices

27. Upcoming Educational Provider Sessions AmeriHealth Caritas Pennsylvania Community HealthChoices • The Department of Human Services will host CHC Educational Provider Sessions in three locations across the state. Attendees must RSVP using the following links. • May 13-15: Lehigh/Capital Region Provider Summits • May 20-22: Northwest Region Provider Summits • June 4-6: Northeast Region Provider Summits • Additionally, a one-day transportation summit will be held in each region. The summits will occur from 8:30 to 3:30 pm on May 16, May 23 and June 7. RSVP for these summits here.  Leading up to the summits, emails will be sent to attendees regarding schedule, parking, and event location on each summit

28. AmeriHealth Caritas Pennsylvania SW Region Physician Account Executives • Educational Account Executives (meets in network providers’ offices with staff in assigned counties): • Wendy Fiffick • Armstrong, Blair, Cambria, Indiana counties • Phone: 814-241-9641 • Wendy Kunz • Allegheny, Beaver, Butler, Lawrence, and Westmoreland counties • Phone: 412-514-0828 • Kristi Wolfe • Bedford, Fayette, Greene, Somerset, Washington counties and West Virginia • Phone: 724-691-4245 • Issue Resolution and Telephonic Support Account Executives (handle claims, credentialing, and other operational issues telephonically and through e-mail): • Shannyn Burzese • Bedford, Fayette, Greene, Somerset, Washington counties and West Virginia • counties • Phone: 412-930-9419 • Shelly Puskar • Allegheny, Armstrong, Beaver, Blair, Butler, Cambria, Indiana, Lawrence, and Westmoreland counties • Phone: 412-525-1574 • Michael Sheehan • Contracting, expansion, and recruitment; UPMC, Adagio, out of area providers • Phone: 814-823-4554 AmeriHealth Caritas Pennsylvania Community HealthChoices

29. CHC News/Reminders • Dual Eligible members with traditional Medicare or Medicare Advantage as primary, do not require prior authorization for covered services participating or non-participating. For non-covered Medicare services, a prior authorization would be required. • Clarification Claims Address on CHC Provider Reference Guide: • Address for AmeriHealth Caritas PA CHC/AmeriHealth Caritas VIP Care is to be used for AmeriHealth aligned members only. • If traditional Medicare or other Medicare Advantage Plan is primary, claims are sent to AmeriHealth Caritas PA CHC claim mailing address.

30. CHC News/Reminders Continued Additional Resources to receive additional updates from the Office of Long-Term Living and also to learn more about the Community Health Choices Program in Pennsylvania visit the Department of Human Services webpage: http://www.healthchoices.pa.gov/info/about/community/

31. CHC News/Reminders Continued • Sign up to the OLTL list serve to receive additional updates on the CHC program in PA • OLTL-COMMUNITY-HEALTHCHOICES@LISTSERV.DPW.STATE.PA.US • Sign up to receive updates and information from AmeriHealth Caritas Pennsylvania Community Health Choices: • Visit our webpage : www.amerihealthcaritaschc.com →Provider→ Sign up for email alerts • *Complete the registration form online • With the Network News service you will receive the most important plan news, right in your e-mail in-box. You will also be able to: • Receive information faster than you would via standard mail or fax. • Keep, retrieve and share information electronically. • Reduce your paper files. • Link directly to other resources on our website. • Unsubscribe at any time.

32. CHC MCO Comparison Chart

33. Pennsylvania Department of Human Services Resources • Make sure you and your coworkers have the information you need about CHC. Take our 30-minute online training at http://www.healthchoices.pa.gov/providers/about/community/index.htm • If you have other questions about CHC, view our comprehensive question and answer document online at • http://www.healthchoices.pa.gov/cs/groups/webcontent/documents/document/c_274784.pdf • If you have any questions, please visit www.HealthChoices.pa.gov or email RA-PWCHC@pa.gov AmeriHealth Caritas Pennsylvania Community HealthChoices

34. Social Determinants of Health • What are social determinants of health? • Factors other than clinical care. These factors, known as the social determinants of health (SDOH) , include nutritious food, access to care, safe housing, reliable transportation, and community supports AmeriHealth Caritas Pennsylvania Community HealthChoices

35. What is the impact of SDOH ? • These underlying drivers of health impact every part of our physical, mental, and social well-being. When they work against someone or are left unaddressed, they create health inequalities – which lead to worse outcomes and more expensive care. • Addressing the impacts of SDOH is essential to the achievement of greater health equity.

36. Our Commitment To The SDOH • AmeriHealth Caritas Pennsylvania Community HealthChoices assesses, identifies, and addresses health care and social determinants of health needs in the populations we serve, helping to enable our members to live healthier lives and achieve maximum independence. AmeriHealth Caritas Pennsylvania Community HealthChoices

37. ICD-10 diagnosis codes to identify SDOH Submit claims with the appropriate supplemental ICD-10 Z code SDOH supplemental ICD-10 Z codes should not be used as the admitting or principal diagnosis An example of the SDOH descriptions and diagnosis codes are below: • Inadequate material resources • Z753 Unavailability and inaccessibility of health care facilities • Z754 Unavailability and inaccessibility of other helping agencies • Education • Z550 Illiteracy and low-level literacy • Z551 Schooling unavailable and unattainable • Z558 Other problems related to education and literacy • Z559 Problems related to education and literacy, unspecified AmeriHealth Caritas Pennsylvania Community HealthChoices

38. Questions about Social Determinants of Health AmeriHealth Caritas Pennsylvania Community HealthChoices • Contact your Account Executive to discuss and review all aspects of the Social Determinants of Health.

39. AmeriHealth Caritas VIP Care Eligibility A Quick Guide to Understanding the AmeriHealth Caritas VIP Care Member Eligibility

40. Member Eligibility – Requirements AmeriHealth Caritas VIP Care • Members are eligible to enroll in AmeriHealth Caritas VIP Care if they are: • Entitled to Medicare Part A, and enrolled in Medicare Part B. • Live in our service area which includes the following counties: Lehigh/Capital Counties: Berks, Dauphin, Lancaster, Lebanon Lehigh, Northampton, Perry, Wyoming, and York Counties Southwest counties of PA: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington, Westmoreland • Enrolled in the Pennsylvania Medical Assistance program. • However, individuals with end-stage renal disease (ESRD) generally are not eligible to enroll in AmeriHealth Caritas VIP Care unless the individual meets exceptions to ESRD eligibility rules outlined in Chapter 2, Section 20.2, of the CMS Medicare Managed Care Manual.

41. VIP Care Member ID Card Health Plan Information Prescription Drug Information Member & PCP Information Claims Contact Information AmeriHealth Caritas VIP Care

42. Member Eligibility — Helpful Tips AmeriHealth Caritas VIP Care • The following is a list of helpful tips to keep in mind when determining a member’s eligibility: • Dual eligibles are able to change plans monthly, therefore providers should verify the eligibility of their patients prior to each visit. • Obtain the Pennsylvania Medicaid card. • AmeriHealth Caritas VIP Care is not a Medicare supplement. • Make sure the correct primary care physician (PCP) is listed on the member’s identification card.

43. Model of Care (MOC) Annual Training Reminder

44. Model of Care Annual Training Requirement AmeriHealth Caritas VIP Care • As a Medicare Advantage Dual Special Needs Plan, AmeriHealth Caritas VIP Care, is required by the Centers for Medicare and Medicaid Services (CMS) to provide annual training of its Model of Care (MOC) and providers who care for our beneficiaries are required to complete and attest to receiving this training. • Providers may receive training in the following ways: • In person from a training seminar or a Network Management Account Executive • Access an online interactive Model of Care training module on our website at www.amerihealthcaritasvipcare.com, under the Provider Training and Education link. • Receive or request printed Model of Care training materials from Provider Services at 1-800-521-6007 or by calling your Network Management Account Executive.

45. AmeriHealth Caritas VIP Care Welcome Packet • Are you a new AmeriHealth Caritas VIP Care Provider? • Would you like additional information? • Contact your Account Executive for Education • Check out our website: • www.amerihealthcaritasvipcare.com/Provider • Click on the link to download a welcome packet AmeriHealth Caritas VIP Care

46. 2019 Provider Notices Updates • CARE for Older Adults – HEDIS Measures • Distributed to participating provider in April 2019 • Group of assessments used as preventive screenings for adults age 66 and older. • Encourage practices to document completion of screenings either by providing appropriate codes or completing a form • Physical Activity in Older Adults • CMS monitors the quality of care of beneficiaries enrolled in Medicare Advantage plans • One method used is the Health Outcomes Survey – one area of focus is the physical activity area • Survey asks if beneficiaries have had conversations with their doctors regarding physical activity AmeriHealth Caritas VIP Care

47. Questions???? AmeriHealth Caritas VIP Care