WV HFMA Conference Tuesday October 21, 2014 Flatwoods, WV

Meeting Agenda Introductions Brief History Available Products Department Specialties Questions and Answers

Health Plan Introductions

Introductions Brad Minton VP Network Services Karen Lavery Provider Relations-Education Coordinator

The Health Plan History

A 501c-4 not-for-profit corporation, chartered in West Virginia and domiciled in Ohio (St. Clairsville) in 1979 One of the largest locally managed MCOs in Ohio and West Virginia, serving over 350,000 covered lives Established and financially secure with over $200 million in reserves Commercial service area encompasses 76 counties in Ohio and West Virginia

The Health Plan History Regional Expansion 2014 / 2015  17 Counties in SE Ohio, Virginia and Northern Kentucky National Expansion 2015  Acquiring Licenses in all 50 States  Focus on TPA Services and Government Programs  Regional Partnerships  Mergers and Acquisitions

Available Products

Health Plan Lines of Business Fully Insured Plans (HMO, EPO, POS, PPO), ACA Metal Plans Self Funded Plans (HMO, EPO, POS, PPO, THP RE) Managed Workers’ Compensation Program (Ohio MCO), TPA, Managed Disability, FMLA Administration PBM Management Capabilities Vision and Dental Programs Medicare Products (MAPD, DSNP, Medicare Supplement) WV Medicaid – Mountain Health Trust WV PEIA

Membership Breakdown

UPSHUR LEWIS RANDOLPH BARBOUR PLEASANTS WYOMING RALEIGH WOOD RITCHIE WIRT WAYNE BRAXTON HARRISON SUMMERS MONROE MERCER ROANE KANAWHA CLAY PUTNAM CABELL PRESTON WEBSTER POCAHONTAS NICHOLAS DODDRIDGE TYLER MONONGALIA WETZEL MARSHALL MINGO LOGAN MCDOWELL MASON JACKSON LINCOLN BOONE GILMER FAYETTE GREENBRIER CALHOUN BERKELEY MORGAN JEFFERSON HANCOCK OHIO BROOKE PENDLETON TUCKER HARDY GRANT MINERAL HAMPSHIRE TAYLOR MARION Current Service Area Approved By CMS Enrollment Application August 2014 OHIO PENNSYLVANIA MARYLAND VIRGINIA KENTUCKY HEALTH PLAN Medicaid Service Area August 2014

UPSHUR LEWIS RANDOLPH BARBOUR PLEASANTS WYOMING RALEIGH WOOD RITCHIE WIRT WAYNE BRAXTON HARRISON SUMMERS MONROE MERCER ROANE KANAWHA CLAY PUTNAM CABELL PRESTON WEBSTER POCAHONTAS NICHOLAS DODDRIDGE TYLER MONONGALIA WETZEL MARSHALL MINGO LOGAN MCDOWELL MASON JACKSON LINCOLN BOONE GILMER FAYETTE GREENBRIER CALHOUN BERKELEY MORGAN JEFFERSON HANCOCK OHIO BROOKE PENDLETON TUCKER HARDY GRANT MINERAL HAMPSHIRE TAYLOR MARION Service Area Prior to Expansion Expansion 2012 Expansion 2014 Expansion 2015 OHIO PENNSYLVANIA MARYLAND VIRGINIA KENTUCKY HEALTH PLAN MEDICARE SERVICE AREA August 2014

Third Party Administration Services

Customer service, CSF forms Claims processing and claims payment Medical management and utilization review Disease management Bank reconciliation services HIPAA certification administration Proprietary systems SPD development COB, subrogation, and fraud investigation Third Party Administration (TPA) Services

Enrollment meetings and ID cards Staff medical directors Staff pharmacists Staff social worker Month end report package Additional services include: stop-loss insurance and COBRA administration Third Party Administration (TPA) Services

Claims

Claims processed for physicians, facilities, and dental Strategic partnership with pharmacy and vision vendors allowing claims information to be loaded in our system in a timely manner 6 certified coders, 13 registered nurses, and 32 clinical technicians review claims Electronic and paper claims accepted with the ability to view all fields instantly at claim review  135,000 claims reviewed a month  85% of claims received are processed by 15 days 100% paperless within 24 hours Claims

Claims can be assigned daily based on priority, payment guidelines, or reviewer training/expertise We review 90% of claims upfront through various custom edits, not “pay and chase” We have access to secondary networks on a national basis for out-of-network discount negotiations In-house staff dedicated to COB research, subrogation, and funds recovery

Customer Service

All member and provider calls regarding benefits, claims issues, and eligibility are answered by a ‘live’ person employed and supervised by The Health Plan Call queues are structured by product line or group Abandonment rate considered ‘outstanding’ based on industry standards  Abandonment Rate for 2014 is 1.65% (Industry Standard 5%)  Speed of Answer for 2014 is 11 seconds (Industry Standard 30 seconds or higher) All forms of member contact documented on a “Contact Service Form” in the computer system as they are received and closed when issue is resolved

Customer Service Length of time to resolve issues calculated by system based on open and close dates Integrated systems allow customer service staff to view information below to resolve issues quickly:  Benefits  Claims History  Correspondence  Eligibility Information  s Dedicated in-house department handles all complaints, appeals, and grievances 1.4% complaints per thousand members per year

Medical Management

Utilization Management  14 full time registered nurses with certifications in managed care and care management Care/Case Management  7 full time registered nurses with certifications in case management Disease Management  6 full time registered nurses with certifications in diabetes education, obstetrics, and advance cardiac life support Social Work Services  3 full time licensed masters level social workers

Preauthorization of Services  Provides oversight of health care services to members  Ensures services are medically appropriate and promotes access to care in a timely, effective, and efficient manner  Registered nurses help members get the care they need, when they need it, using nationally recognized criteria  Medical directors review any service that does not meet criteria Hospital Review  Registered nurses receive clinical information from hospitals about member’s care and progress  Monitors quality of care members receive  Assists with discharge planning Utilization Management

Care/Case Management Care Management – process to assist members in managing their medical conditions to improve their health status  Registered nurses assist members with ongoing health care needs through regular telephonic contact  Complete comprehensive assessments and establish a care plan with the member and their caregiver  Arrange follow-up to physicians and coordinate services through the sharing of care plans with members and their physicians Catastrophic Case Management – collaborative process to meet member’s comprehensive health care needs to promote quality, cost effective care  Certified registered nurses in case management that help members to achieve wellness by identifying appropriate providers and available resources  Supports members who have experienced life altering injury or illness such as traumatic brain or spinal cord injury or bone marrow or other solid organ transplant  Serves as the liaison by having direct communications with the member/caregivers, physicians, and providers of service to coordinate care across the continuum

Disease Management Uses nationally recognized evidence-based practice guidelines for:  Diabetes  Chronic obstructive pulmonary disease (COPD)  Congestive heart failure (CHF)  Prenatal care (high-risk pregnancy) Supports physician-patient relationship and plan of care through regular telephonic contact Helps with patient empowerment, self-management, and medication adherence in “Journey for Control” classes, one-on- one educational sessions, and educational material mailings Emphasizes prevention of exacerbations and complications by educating members with heart failure about weight gain and supplying them with a scale

Social Work Services 3 social workers with hospital, long-term care/rehab, and community experience Financial help for medications Accesses community resources Provides support and counseling

Other Medical Services Hospital Discharge Follow-up Calls  Registered nurses call members within 48 hours of acute discharge  Assess condition/answer questions  Discuss medications  Assist with follow-up In-house Nurse Information Line  Registered nurses available 24/7  Assist members to urgent or emergent level of care  Assist with out-of-area or emergent care needs  Assist with access to pharmacy or behavioral health benefits

Quality Improvement

External Quality Regulators Responsible for compliance with outside quality regulators:  National Committee for Quality Assurance (NCQA)  Centers for Medicare & Medicaid Services (CMS and BMS)  Employer groups Quality standards are applied to ALL Health Plan members regardless of employer group

Healthcare Effectiveness Data and Information Set (HEDIS ® ) Clinical practice guidelines  Primary care physician-driven guidelines from nationally recognized sources Accessibility and availability  Monitoring of a member’s ability to receive services in a timely manner and within reasonable travel distance Satisfaction of care  Survey driven Continuity and coordination of care Quality of care (variances, problems, complaints) All monitored for compliance to standards. Corrective action plans required when standards not met Outcomes

Health & Wellness Promotion Telephonic outreach Encourage members 18 years and older to participate in preventive care Provides personalized contact with members who are missing important services and/or testing like:  Well care visits and establishing with a PCP  Preventive health services  General and disease-specific discussions  Management of care after an event Can include any member group

Behavioral Health

Behavioral Health Unit All inclusive unit  Customer Service  Preauthorizations  Utilization Review  Case/Care/Disease Management  Claims Payment Services directed by evidence-based national guidelines  InterQual  Independent Reviewers also use InterQual Staffed by behavioral health professionals and certified nurses

Provider Network

HP Network  Contracted with 113 facilities in primary service area  Contracted with over 14,500 physicians  All contracting and service items (new providers, claims inquiries, questions, etc.) serviced by The Health Plan directly  NCQA Excellent Accreditation National Network capability through Global Care agreement Regional and national partnerships providing access to competitive discounts Provider Network

Tertiary Facilities Include:  Ohio State University  Cleveland Clinic  UPMC Children’s  Allegheny / West Penn  Nationwide Children’s  West Virginia University Hospital  Charleston Area Medical Center  Akron General Medical Center  Children’s Hospital Medical Center of Akron

Information Systems/Web

Information Systems All core systems developed and maintained in-house allowing for quick modifications/enhancements Custom core systems include:  Care/Case/Disease Management  Claims Adjudication  Enrollment  Medical Utilization  Provider Networking  Plan Design

Information Systems Integrated document imaging system ties to our core systems and secure web portals Work with numerous clearinghouses and direct providers to receive HIPAA EDI X12 compliant and noncompliant data formats All core systems are designed with data and hardware redundancy including a facility-wide generator for 24/7 run-time SSAE 16/SOC 1 audit performed yearly

Web Capabilities All web portals developed, maintained, and hosted in-house Website, healthplan.org, features:  Provider search  HRA and other health interactive tools  Information on advance care planning, preventive care, and pharmacy services Ability to create customized homepages for certain groups

Web Capabilities Secure Member Portal features:  Claims history, dollar and visit limitations  Copay information  Correspondence/EOB Secure Provider Portal features:  Member eligibility and copay amounts  Claim information  Referral information Secure Enrollment Portal for group administrators Secure Group and Broker Portal in development for 2014

Established as a community health organization, The Health Plan delivers a clinically driven, technology enhanced, customer-focused platform by developing and implementing products and services that manage and improve the health and well-being of our members. We achieve these results through a team of health care professionals and partners from across our community. Mission Statement

Thank You Questions?