AAHAM Meeting November,

Warning: Content may leave you feeling like this! 2

Nonprofit CO-OP Lewiston, Maine & Concord, New Hampshire Member-Led State-wide Broad Provider Network Wrap Around National Network 3

Your Provider Service Team Bill Schulz Director, Provider & Network Operations Debra McKinley Manager, Credentialing Matt Sanfacon Credentialing Coordinator Karen Getchell Manager, Provider Contracting Laura Pray Contracting Specialist Alyssa Rose, JD/MSW Manager, Provider Relations John Wilson PR Representative Jessica Moore PR Representative Jennifer Byatt NH PR Representative Lisa Dionne PR Representative Stephanie Gordon PR Representative 4

MCHO Partners Valence Health – TPA/Medical UM &Claims Health Dialogue – Nurse Line and Health Coaching Navitus – Pharmacy Manager Behavioral Health Care Plan (BHCP) – Behavioral Health

Your Wellness Counts at MCHO MCHO Outreach and Education 6 Make informed decisions with guidance from skilled coaches and get useful information from our online portal. 24/7 Access to Health Coaches Healthy Options Online Health and Wellness Portal Registered Nurses, Dieticians, Respiratory Therapists May call you to talk about your condition Provide information Help you make important medical decisions Over 6,000 health topics Use decision support tools and videos Complete your wellbeing assessment Join challenges to earn points and get rewards. Create personal goals and track progress

7 To get an estimation of: Advance Premium Tax Credit Premium Cost To find out if your doctor is In- Network

MCHO 2015 Plan Details 8 Source: Huffingtonpost.com

Metal Level Plan Design Categories are defined by the average share of total health spending on essential benefits paid for by the plan: Gold: 80% of costs paid by insurance company Moderate premiums with low out of pocket expenses Silver: 70% of costs paid by insurance company Moderate premiums with medium out of pocket expenses Bronze: 60% of costs paid by insurance company Low premiums with higher out of pocket expenses NOTE: There are still catastrophic plans available Silver Plans Bronze Plan Gold Plan

10 Plus plans include an Embedded Pediatric Dental Benefit *Please note that the above mentioned plans are pending approval by the Center for Medicare and Medicaid and may be subject to change.

Federal Poverty Guidelines for 2015 Plans 11

12 *Please note that the above mentioned plans are pending approval by the Center for Medicare and Medicaid and may be subject to change.

Chronic Illness Support Program Our Chronic Illness Support Program offers additional help for members with certain medical conditions that are ongoing and can be managed for better health. Benefits include reduced out-of-pocket costs (co-pays, deductible, and coinsurance) for:  disease management services;  office visits;  prescription medications;  Certain lab services, and medical supplies – when performed by an MCHO in-network provider. 13

Coronary Artery Disease 14

Tobacco Cessation Maine Community Health Options will cover: FDA-approved tobacco cessation medications (including both prescription and over-the-counter medications) with no out-of-pocket costs when prescribed by a health care provider Medications covered at no Out-Of-Pocket cost when prescribed by a Plan Provider Over-the-counter and prescription medications such as: Generic Nicotine Replacement Therapy (NRT): Gum, Patch, Lozenge Chantix (up to two 90-day treatment regimens) Tobacco cessation education and counseling NOTE: MCHO does not use the new “tobacco rating band” or charge higher premiums for smokers 15

Integrating Behavioral Health and Medical Health Maine Community Health Options: Provides enhanced access for behavioral health (BH) & substance abuse (SA) treatment at the same co-pay as primary care services Waives costs for the first 3 outpatient behavioral health visits *not available on Community Safe Harbor and Community Options HSA plans Allows BH/SA visits on the same day as medical visits, and facilitates immediate referrals without administrative roadblocks  Includes behavioral health and lifestyle modification support 16

Termination Procedures (after receipt of binding payment) Members receiving a tax credit Members who receive a tax credit and have paid the first month’s premium, but who fail to pay subsequent premiums will have a 90 day grace period to submit payment in full for outstanding premium due. MCHO will pay appropriate claims for the first 30 days of the grace period. MCHO may hold claims during the remainder of the grace period or until payment is received in full. If the outstanding balance is not paid in full by the end of the grace period, MCHO will terminate coverage and the member will be responsible for paying any services received during the final 60 days of the grace period. Members NOT receiving a tax credit If a member does not make a premium payment in full they will have a 30 day grace period to pay the outstanding premium owed. Coverage does not lapse. If the premium is not paid in full after the end of the grace period, MCHO may terminate their coverage. MCHO will not allow reinstatement after the grace period ends. 17

How to Access Resources Visit Professionals/Online-Resourceshttps:// Professionals/Online-Resources

Utilization & Care Management Prior Approval form on the MCHO website Providers can use the online Care Manager System or fax in PA form for routine requests UM phone line available 24/7 for urgent and after hours requests 2 Business Day turn-around time for Routine Initial Requests 48 hour turn-around time for Urgent Requests All Medical Necessity reviews go through our Lewiston-based Chief Medical Officer, Dr. John Yindra

Claims Cycle Critical importance of checking Member eligibility Grace Period Claims can be submitted by paper or electronically MCHO moving to weekly check runs EFT payment available

Noteworthy for 2015 Expansion into NH Utilization management coming in house New provider portal Transition to new behavioral health partner Always looking to improve so please send us your feedback! 22

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Thank you for your time and interest in Maine Community Health Options. Alyssa Rose Maine Community Health Options (Provider Relations) 24