HomeMy WebLinkAboutContracts & Agreements_136-2010_CCv0001.pdf EARLY RETIREE REINSURANCE PROGRAM
CALIFORNIA PARTICIPATION AGREEMENT
$ This Early Retiree Reinsurance Program California Participation Agreement("Agreement") is made on the
7th day of September, 2010, by and between Health Net of California, Inc., and if applicable,Health Net
Life Insurance Company (if and only if and solely to the extent Health Net Life Insurance Company
provides Plan Sponsor with insurance products underwritten by Health Net Life Insurance Company),
(collectiwly, "Health Net") and the City of Redlands on behalf of itself and its health benefit plan ("Plan
Sponsor").
WHEREAS, Plan Sponsor seeks to participate in the Early Retiree Reinsurance Program (the "Program")
authorized by the Patient Protection and Affordable Care Act (the "Act") and implementing regulations;
and
WHEREAS, for purposes of the Program, Health Net is a health insurance issuer for health care coverage
benefits for Plan Sponsor's employees, retirees and their dependents according to that certain agreement
("Group Agreement") between Health Net and Plan Sponsor for the 12-month period beginning on April
1st of each year for which the Group Agreement is in effect("Plan Year"); and
WHEREAS, the Program requires Plan Sponsor to have a written agreement with its health insurance
issuer in compliance with 45 CFR 149.35(b)(2) that contains certain terms and conditions required for
participation in the Program; and
WHEREAS, the parties desire to enter into this written agreement to, among other things, set forth terms
and conditions related to participation in the Program including without limitation the disclosure of
information, data, documents and records (collectively, "Program Data") required by the Program as set
forth in the statute, implementing regulations at 45 CFR part 149 ("Program Regulations") and such other
guidance ("Program Guidance") as may be issued by the Secretary of the United States Department of
Health and Human Services("Secretary") (collectively,"Program Requirements");
NOW THEREFORE, in exchange for good and valuable consideration the receipt and sufficiency of which
is hereby acknowledged, Health Net and Plan Sponsor each agree as follows:
1. Defined Terms, Capitalized terms not specifically defined in this Agreement shall have the
meaning ascribed to them in the applicable Program Regulations or Program Guidance.
2. Effective Date. Except as otherwise provided herein, this Agreement shall take effect on the date,
if any, that Plan Sponsor becomes certified by the Secretary as required by 45 CFR 149.35(a)(1)
for participation in the Program ("Certification"). The data elements Health Net intends to
provide as of the date this Agreement is signed are set forth on the attached Exhibit A. The
parties agree that if necessary, prior to commencing services under this Agreement, the parties
shall negotiate a mutually acceptable written amendment to this Agreement signed by both parties
which sets forth additional technical performance specifications regarding the Program Data
("Technical Amendment").
3. Participation and Certification Responsibilities. Plan Sponsor acknowledges that the Program
Data covered by this Agreement is being submitted by or on behalf of Plan Sponsor for purpose of
the Plan Sponsor obtaining federal funds under the Program. Plan Sponsor agrees that Plan
Sponsor retains sole responsibility for applying to participate in the Program, for obtaining and
maintaining Certification to participate in the Program, and for complying with all applicable
Program Requirements and all applicable state and federal laws and regulations related to Plan
Sponsor's obligations under this Agreement. Plan Sponsor shall notify Health Net in writing of
the date on which Plan Sponsor becomes Certified to participate in the Program.
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4. Identification of Early Retirees. Plan Sponsor is responsible for identifying to Health Net.
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through mechanisms mutually agreed to by the parties, all Early Retirees for whom Plan Sponsor
requests that Health Net provide Program Data under this Agreement. Plan Sponsor represents to
Health Net that all of the infoiniation about Early Retirees provided to Health Net during the term
of this Agreement is and shall be true, accurate and complete and that Health Net may rely upon
such information in providing Program Data to Plan Sponsor. Health Net shall not be liable for
any action taken which is based on inaccurate or incomplete information supplied by Plan
Sponsor. Plan Sponsor shall notify Health Net in writing at least thirty (30) days in advance of
any change in such information, if possible. However,in no event shall Plan Sponsor provide this
information later than thirty(30) days after the effective date if advance notice is not possible. In
the event prior notification is not feasible, Health Net may rely on information previously
supplied by Plan Sponsor until receipt ofnotification of any change of such information from Plan
Sponsor. Plan Sponsor shall be responsible for any liability arising from the failure to provide
Health Net with such notice. Plan Sponsor shall be the sole and final decision-maker regarding
identification of Early Retirees,
5. Program Data Disclosure, Health Net agrees that it will supply data to Plan Sponsor as necessary
for Program Data submission and that, to Health Net's knowledge, such data shall be accurate.
The parties acknowledge and agree that Health Net relies on Plan Sponsor's identification of
Early Retirees, the data may include claims data submitted by the applicable network providers or
other third parties, and Health Net will use reasonable business efforts to verify the integrity Of the
information from the time of Health Net's receipt of the information. Generally, in providing
these services Health Net agrees to use reasonable business efforts, but Health Net shall assume
no obligation to modify its systems used otherwise to collect,store and transmit data that becomes
used or requested as Program Data. At the request of either party, any Program Requirements
published in the Program Regulations or Program Guidance shall be reduced to a mutually agreed
upon written instrument signed by the parties hereto and attached as an amendment to this
Agreement. Identification of Claims, Incurred Dates, Negotiated Price Concessions (as each of
those terms are defined in the Program), and other required elements of Program Data, other than
identification of Early Retirees, shall be made based only on information acquired by Health Net
in the normal course of conducting business according to the Group Agreement. Health Net
makes no representation or warranty regarding the timing or amount of Program reinsurance that
may be payable by the government to Plan Sponsor under the Program.
6, Projection Data. Health Net and Plan Sponsor acknowledge that,prior to the effective date of this
Agreement, Health Net shall provide Plan Sponsor with Projection Data as necessary for Plan
Sponsor's application for the Program as described in 45 CFR 149.40(f)(6). The parties
acknowledge and agree that such Projection Data shall be based only on the data in Health Net's
possession and control related to the Plan Sponsor,
7. Privacy Laws. The parties acknowledge and agree that the Program Data covered by this
Agreement includes protected health information ("PHI") covered by the Privacy Rule, that the
Secretary has asserted its authority to authorize disclosure of PHI for Program purposes in
accordance with the Privacy Rule in the Program Regulations (see 75 Fed. Reg. 24450 (May 5,
2010)at p.24454).
a. Privacy Representations and Warranties. Plan Sponsor represents and warrants that it has taken all
necessary steps to ensure Plan Sponsor's receipt of Program Data is in full compliance with all
applicable privacy requirements under state and federal laws and regulations, including but not
limited to the Privacy and Security Rules and, if applicable, that Plan Sponsor's health benefit plan
qualifies as and meets the obligations of a Covered Entity under the Privacy and Security Rules
(45 CFR 160-164), including without limitation the full implementation of the requirements
described in 45 CFR 164.530 and is not operating under the limited compliance requirements of
45 CFR 164,530(k) for fully inured group health plans.
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FlAti b. Program Data Delivered to Plan Sponsor. Plan Sponsor is hereby specifically directing Health Net
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WOO to furnish the Program Data to Plan Sponsor, Plan Sponsor hereby certifies that the plan
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NA documents for the Group's group health benefit plans (the "Benefit Plans") sponsored by Plan
Sponsor have been amended to incorporate the provisions required by Section 504(f) of the
Privacy Rule and that Plan Sponsor has issued the certification included herein as Exhibit C, in
compliance with Section 504(f)of the Privacy Rule.
c. Program Data Delivered to HHS or to Third Party. Plan Sponsor may direct Health Net to furnish
the Program Data directly to HHS or to a third party. Such direction shall not limit the obligations
of Plan Sponsor and Plan Sponsor's health benefit plan as described in this Section 7. Plan
Sponsor is hereby specifically directing Health Net to furnish the Program Data to HHS.
8, Program Participation Fees. Plan Sponsor shall pay to the government any applicable fees or
expenses necessary to apply to or remain Certified in the Program. Plan Sponsor shall pay to
Health Net an annual fee to be mutually agreed upon by the parties in an amount based upon, and
not to exceed,Health Net's reasonable cost of providing the Program Data submission and related
services provided by Health Net under this Agreement. Health Net's liability, if any, to Plan
Sponsor arising from Health Net's breach of this Agreement and any amendments hereto shall be
limited to amounts paid by Plan Sponsor to Health Net under this Section 8 through the date of
such breach.
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9. Amendment.
a. Amendments Due to Law or Regulatory Changes. Health Net may amend this
Agreement at any time by giving written notice to Plan Sponsor if Health Net determines,
in its sole discretion, that such amendment is required to comply with any law or
regulatory requirement.
b. Amendments Effective on Anniversary Date. Upon 30 days prior written notice to Plan
Sponsor,Health Net may amend this Agreement effective on the first day of the next Plan
Year.
c. Acceptance of Amendments. Any amendment to this Agreement proposed by Health Net
pursuant to this Section 9 shall be deemed accepted by Plan Sponsor unless Plan Sponsor
gives Health Net written notice of non-acceptance within 15 days after the date of Health
Net's amendment notice,in which case this Agreement will terminate effective as of the
day before the date the amendment would have otherwise gone into effect.
10. Record Retention. Health Net shall maintain copies of the records submitted under the Program
on behalf of Plan Sponsor for 6 years after expiration of the Plan Year in which costs were
incurred or longer if required by law, and in accordance with the requirements of 45 CFR
149.350. Such records shall be furnished to the Secretary within a reasonably prompt time
following the date of the request. Plan Sponsor shall reimburse Health Net for reasonable costs of
retrieving and/or copying such data in response to government requests.
11. Government Audits. The parties shall cooperate and comply with government audits under the
Program. Plan Sponsor shall reimburse Health Net for its reasonable actual expenses incurred in
responding to such audits. Plan Sponsor shall notify Health Net promptly in writing in the event
of any audit or inquiry by any state or federal governmental enforcement agency regarding Plan
Sponsor's participation in the Program or Health Net's activities in connection therewith.
12. Cost Savings Programs. Plan Sponsor acknowledges that the Program Requirements include an
obligation to describe and maintain cost savings programs for benefit plan participaras with claims
for chronic and high cost conditions, in addition to policies and procedures to protect against
fraud, waste and abuse. The parties acknowledge that Health Net has provided Plan Sponsor with
a description of such programs operated by Health Net in the attached Exhibit B, and that subject
to Section 10 and Section 11 of this Agreement, Health Net agrees to provide the Secretary copies
of Health Net's policies and procedures to protect against fraud, waste and abuse within a
reasonably prompt time following the date of the request.
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13. Term and Termination. This Agreement shall remain in effect until terminated upon the first to
occur of any of the following events:
a. Plan Sponsor for any reasons fails to maintain Certification to participate in the Program
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b. The Secretary ceases satisfying Plan Sponsor's reimbursement requests under the
Program;
c. The Group Agreement is terminated
d. Plan Sponsor provides Health Net with written notice of non-acceptance of any
amendment within 15 days of the date of Health Net's amendment notice pursuant to
Section 9 hereof, in which case this Agreement will terminate the day before the effective
date of the amendment;
e. The parties mutually agree in writing to terminate this Agreement.
Once certified,Plan Sponsor shall notify Health Net immediately in writing if the events in(a)or
(b)of this Section 13 occur. In addition, either party may terminate this Agreement for any reason
upon sixty (60) days advance written notice or thirty (30) days advance written notice by Health
Net in the event Plan Sponsor breaches a material term of this Agreement.
14. Dispute Resolution.
14.1. Initiation: The parties agree to meet and confer within thirty(30) days of a written request
by either party in a good faith effort to informally settle any Dispute. The parties each agree and
understand that the meet and confer requirements set forth herein may be satisfied only by meeting
each of the following requirements: (a) an actual meeting must occur between executive level
employees of the parties who have authority to resolve the Dispute and are each prepared to
discuss in good faith the Dispute and proposed resolution(s) to the Dispute, and (b) such meeting
may take place either in person or on the telephone at a mutually agreeable time, and (c) unless
otherwise mutually agreed by the parties, neither party is allowed to have legal counsel present at
the meeting or to substitute legal counsel for the executive level employee, and (d) such meeting
and all related discussions between the parties shall be treated in the same manner as
confidential protected settlement discussions under the State Rules of Civil Procedure.
Confidentiality: All documents created for the purpose of, and exchanged during, the meet and
confer process and all meet and confer discussions, negotiations and proceedings shall be treated
as compromise and settlement negotiations subject to applicable state law. To the extent the
parties produce or exchange any documents, the parties agree that such production or exchange
shall not waive the protected nature of those documents and shall not otherwise affect their
inadmissibility as evidence in any subsequent proceedings.
14.2. Binding Arbitration. Any dispute arising under or in relation to this Agreement that has not
been resolved pursuant to Section 14.1 shall be resolved by binding arbitration described in this
Section 14 upon election by either party by notice to the other. .
14.3. Conduct of Arbitration. The arbitration shall be conducted in the county of Los Angeles
under the appropriate rules of the AAA or JAMS, as agreed by the parties.Any Arbitrator must be
either a judge, or an attorney licensed to practice law in the State of California, who is in good
standing with the State Bar, and has at least ten (10) years of experience with the arbitration of
health care financial disputes. The parties each understand and agree that the exhaustion of the
Meet and Confer Process set forth in Section 14.1 hereof is a condition precedent to binding
arbitration under this Section 14.3. The written arbitration demand shall contain a detailed
statement of the matter and facts and include copies of all material documents supporting the
demand. Arbitration must be initiated within one year after the date the Dispute arose by
submitting a written notice to the other party. The parties expressly agree that the deadline to file
arbitration set forth above shall not be subject to waiver, tolling, alteration or modification of any
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kind or for any reason except for fraud. The failure to initiate arbitration before such deadline shall
mean the complaining party shall be barred forever from initiating such proceedings.
All such arbitration proceedings shall be administered by the AAA or JAMS, as agreed by the
parties;however, the arbitrator shall be bound by applicable State and federal law, and shall issue
a written opinion setting forth findings of fact and conclusions of law. The parties agree that the
decision of the arbitrator shall be final and binding as to each of them. Judgment upon the award
rendered by the arbitrator may be entered in any court having jurisdiction. The arbitrator shall
have no authority to make material errors of law or to award punitive damages or to add to,
modify, or refuse to enforce any agreements between the parties. The arbitrator shall make
findings of fact and conclusions of law and shall have no authority to make any award, which
could not have been made by a court of law. The party against whom the award is rendered shall
pay any monetary award and/or comply with any other order of the arbitrator within sixty (60)
days of the entry of judgment on the award. The parties waive their right to a jury or court trial.
The parties recognize and agree that theirs is an ongoing business relationship, which may lead to
sensitive issues with respect to the exchange of information related to any Dispute. The parties
agree, therefore, to enter into such protective orders (including without limitation creating a
category of discovery documents"for attorney's eyes only" to the extent feasible given the nature
of the evidence and the Dispute). All discovery information shall be used solely and exclusively
for arbitration of the Dispute between the parties and may not be used for any other purpose.
After the arbitration award becomes final, each party shall return or destroy all documents
obtained from the other party during the course of the arbitration that are subject to a protective
order, and within thirty (30) days of such date shall provide to the other party an officer's
certificate signed under penalty of perjury indicating that all such information has been returned or
destroyed.
In all cases submitted to arbitration, the parties agree to share equally the administrative fee as
well as the arbitrator's fee, if any, unless otherwise assessed by the arbitrator. The administrative
fees shall be advanced by the initiating party subject to final apportionment by the arbitrator in this
award. The parties agree that the content and decision of any arbitration proceeding shall be
confidential unless disclosure is required by applicable State or federal statutes or regulations.
15. Miscellaneous
15.1. Headings. The headings used in this Agreement are for convenience only and shall not
affect the interpretation of this Agreement.
15.2. Assignment. Health Net may assign this Agreement. Plan Sponsor may not assign this
Agreement or any of the rights, interests, claims for money due, benefits, or obligations under this
Agreement without Health Net's prior written consent. This Agreement shall be binding on the
successors and permitted assignees of Health Net and Plan Sponsor.
15.3. Governing Law. Except as preempted by federal law, this Agreement will be governed in
accord with California law and any provision that is required to be in this Agreement by state or
federal law shall bind Plan Sponsor and Health Net whether or not set forth in this Agreement.
15.4. Waiver. Health Net's failure to enforce any provision of this Agreement will not constitute
a waiver of that or any other provision, or impair Health Net's right thereafter to require Plan
Sponsor's strict performance of any provision.
15.5. Notices. Notices must be sent to the addresses referenced in the Group Agreement.
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15.6. Counterparts. This Agreement may be executed in multiple counterparts. each of which
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shall be deemed an original, and counterpart signature pages may be assembled to form a single
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15.7. Integration. This Agreement sets forth the entire understanding of the parties relating to the
transactions it contemplates, and supersedes all prior understandings relating to them, whether
written or oral. There are no obligations, commitments, representations or warranties relating to
them except those expressly set forth in this Agreement.
15.8. Waiver/Modification/Amendment. No amendment of, supplement to or waiver of any
obligations under this Agreement will be enforceable or admissible unless set forth in a writing
signed by the party against which enforcement or admission is sought. No delay or failure to
require performance of any provision of this Agreement shall constitute a waiver of that provision
as to that or any other instance. Any waiver granted shall apply solely to the specific instance
expressly stated.
1 IN WITNESS WHEREOF, the parties have executed this Agreement as of the date first written above.
HEALTH NET OF CALIFORNIA, INC. CITY OF REDLANDS
By: By:L---
Authorized officer signature
Pat Gilbreath
Printed name Printed name
Mayor, City of Redlands
Title Title
Date: Date:
September 7, 2010
If and only if and solely to the extent Health ATTEST:
Net Life Insurance Company("HNL")provides
insurance products to Plan Sponsor underwritten
40111e.
by HNL:
Sam Irwin,City Cl.
HEALTH NET LIFE INSURANCE COMPANY
By:
Printed Name
Date:
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'**.! EXHIBIT A
DATA ELEMENTS
Two Data Sets will be Sent:
-Projection: May provide 2-year projections as described in Program Requirements
-Monthly Transmission: To be sent to meet MIS requirements
Data to be Transmitted Source
I Encrypted Member ID(Health Net ID) Direct from source system
First Name Direct from source system
Middle Initial Direct from source system
Last name Direct from source system
Date of Birth/Year of Birth Direct from source system
_Member Type(Employee, Spouse, Dependent) Direct from source system
Group Suffix Direct from source system
Medical Plan Code(benefit option) Direct from source system
Service/Incurred Date Direct from source system
Paid Date Direct from source system
Service Provider Direct from source system
Claim Type (e.g., Medical, MHN-provided Mental Direct from source system
Health, Rx, Capitation*)
Benefit Provided (e.g., Inpatient, Outpatient, Direct from source system
Physician. Rx, MIIN-provided Mental Health
services)
Paid Amount(Net of price concessions, rebates**) Direct from source system
Member required payment (deductible, copay, Direct from source system
coinsurance required by the benefit plan)
* Capitation will be based on the average capitation per member per month
** Information to be provided when it becomes available
Sample Report to be provided:
C:\Early Retiree
Subsidy Reportv3.xls
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EXHIBIT B
DESCRIPTION OF COST SAVINGS PROGRAMS AND
FRAUD, WASTE AND ABUSE PROGRAMS
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The following describes Health Net's Medical Management programs
and procedures that have generated or have the potential to generate
cost savings for plan participants with claims for chronic and high cost
conditions.
Utilization Management Coordinators process requests and electronically forward the record
to a prior authorization nurse if clinical review is required. The prior authorization nurse
evaluates the request utilizing Health Net National Medical Policies and InterQual*, Health
Net's primary source for clinical criteria for medical necessity and levels of care. If criteria
are met, authorization is approved. Approval notifications are sent to members and requesting
practitioners/providers.
If criteria are not met and additional clinical information is required, the practitioner/provider
will be contacted and the member notified of the need for additional information. When
additional information is received and criteria are still rot met, the request will be referred to a
Health Net Medical Director for review. Upon completion of the review by the Medical
Director, approved requests follow the above process and denied requests result in denial
letters to be distributed to members and practitioners/providers according to Health Net Policy
and Procedures.
LARGE-CASE MANAGEMENT SERVICES
Health Net and its delegates provide Case Management services to deliver individualized
assistance to members experiencing complex, acute or catastrophic illnesses or with
exceptional needs in all lines of business. The focus is on early identification of high-risk
members and application of a systematic approach to coordination of care to increase
satisfaction, to arrange medically appropriate care and to improve the health, functional status
and quality of life of Health Net members.
There is no cost threshold that triggers Health Net's case management intervention. Health
Nees predictive modeling identifies members who are at high risk for ongoing utilization,
hospital admission or readmission. Health Net provides case management based on the
member's identified needs and situation,regardless of cost.
Referrals for case management services are obtained from sources such as a predictive
modeling strategy (evaluating utilization, pharmacy, lab and encounter data), customer
service,contracted vendors, members, family members,providers,claims, concurrent review,
sales and other Health Net departments.
Examples of members appropriate for referral for case management include:
• Lack of established or ineffective treatment plan
• Potential or identified compromised patient safety
• New permanent or temporary alteration of functional status
• High cost injuries or illnesses
• History of non adherence to treatment. medications or multiple missed appointments
• Oker, under or inappropriate utilization of services
• Delayed discharge from the appropriate lexel of care
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• Lack of thmily or social support
• Lack of financial resources to meet health needs
• Actual or potential exhaustion of benefits
• Lack of education of disease course or process
• High Risk pregnancy
• Transplant evaluation and surgery
• Pain Management
• Continuity of care assistance
• Post discharge follow up
• NICU discharge
• Post Bariatric surgery with complications
• Hospice-pending or actual
• Avoidable inpatient admissions/readmissions
Goals of the case management programs are to:
• Consistently perform the activities of assessment,planning, facilitation and advocacy
for members throughout the continuum of care, in accordance with accreditation
standards and standards of practice.
• Collaborate and communicate with the member family, the physician and other
health care providers in the development and implementation of a care plan that is
driven by the member's goals for health improvement.
• Accomplish the goals in the individual member's care plan.
• Provide members and their families with the information and education that
promotes self-care management.
• Assist in optimizing use of available benefits.
• Improve member and provider satisfaction.
• Promote effective utilization and monitoring of health care resources while ensuring
that services are coordinated and appropriate for the member.
• Provide members with tools to empower members to achieve optimal health,
independence and functioning in the most proactive and effective way.
Research shows that goals mutually developed with members positively influence case
management outcomes.
COMPLEX CASE MANAGEMENT
Health Net and its delegates make available Complex Case Management services to all
members. The goal of the complex case management program is that members with complex
conditions receive support and assistance with coordination of care and access to any needed
services. There is no cost threshold that triggers Health Net's complex case management
intervention.
Members are initially identified for participation in the program using data stratification that
includes:
• Claims and encounter data
• Hospital discharge data
• Pharmacy and lab data
• Health information lines
• Any of the Health Net Disease Management programs
• -fhe concurrent review and discharge planning process
• A member request for case management
• A practitioner request for case management
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Members are screened telephonically by a registered nurse and invited to participate in
complex case management if they meet established screening criteria. Members are also
afforded the opportunity to decline participation in the program.
The Health Net complex case management program includes an initial assessment of the use
of evidence based care plans and algorithms, documentation of member resources, barriers,
goals,progress and ongoing evaluation of member needs with adjustments of interventions as
needed.
Health Net's shared-risk medical groups generally are directed by Health Net to use Health
Net's vendor for complex-care management. Dual-risk medical groups are encouraged to use
this vendor, but may manage complex care directly or through a vendor of their choosing.
Each year the program is evaluated for it effectiveness using both established metrics and
documented measures of member satisfaction.
CHRONIC POPULATION DISEASE MANAGEMENT
Members face a wide variety of health care issues and concerns. Health Net knows that
members need support that extends beyond any single chronic condition to other conditions,
decisions, and lifestyle risks. The key to Health Net's Decision Powersm program is to engage
members in better managing their overall health, not just any one of their conditions. Decision
Power Health Coaches support members across a broad spectrum of conditions and needs*
Essentially. Health Coaches coach people, not their diseases. This "whole person" approach
allows our Health Coaches to support a greater number of members across a wider range of
conditions and issues.
Decision Power Health Coaches apply stage-of-change methods and motivational
interviewing to assess opportunities for behavior change to improve lifestyle management and
modify risk behaviors. Health Coaches are equipped to offer the right level of support and
provide non-judgmental coaching intended to move members along stages of change toward
the adoption of a healthier lifestyle. They help members recognize and minimize barriers to
behavior change and resolve feelings of ambivalence while increasing motivation.
Using a variety of proprietary tools and systems, Health Coaches help individuals address
knowledge gaps and set goals and action plans not only for their own lifestyle risks or
concerns, but also for those of their families. Health Coaches share evidence-based
information and help the member learn to recognize and honor his or her own values and
preferences in taking care of his or her own health.
CHRONIC POPULATION IDENTIFICATION/STRATIFICATION AND SUPPORT
Health Net members who may benefit from Health Coaching are identified and stratified,
through four core components: Data Analytics (medical inpatient/outpatient and pharmacy
claims), Member Outreach, Health Coaching, and Provider Engagement(encounter data).
Claims data are loaded monthly into a database;predictive modeling methodology is applied
to identify and stratify members according to risk. All newly identified chronic members are
sent a welcome packet that contains detailed information about their condition and are invited
to call a Health Coach for additional information.
Members are re-stratified monthly and can move up and down the risk scale based on the data
loaded into the system each month. The highest risk members are stratified for outbound
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Health Coaching calls. Members who fall below the highest risk level may be loaded for an
,NutoDialogrm call if they meet the predictive modeling criteria for this intervention. The
AutoDialog1 (IVR) call will provide education about their condition and the opportunity to
transfer to a Health Coach. To ensure member privacy, those who are targeted for
AutoDialogTm calls are identified as a targeted member before the message is delivered.
Health Net's Care Management programs, Disease Management, Preference-Sensitive
Condition support and Wellness programs are included for all members. There is no cost
sharing with the member for any of these services.
Chronic Condition support targets members who have one or more major chronic medical
conditions, such as:
• Coronary heart disease,
• Diabetes,
• Heart failure,
• Asthma, and
• Chronic obstructive pulmonary disease.
Using our whole-person approach, Health Net also supports the co morbid conditions
frequently associated with these conditions, including but not limited to
• Chronic pain,
• Obesity,
• Depression, and
• Hypertension.
Preference-Sensitive Condition support extends to conditions for which either medical
evidence supports multiple acceptable treatment options or there is inadequate medical
evidence about the treatment choices. Examples of preference-sensitive care include
choosing between treatments like mastectomy or lumpectomy in early-stage breast cancer;
surgery or conservative treatment for patients with back pain due to disc disease;and invasive
cardiac surgery- or medical management for chest pain due to C'HO. These are treatment
choices that should depend on an informed individual making a decision with her physician
that is based on the best clinical evidence and her own values.
Decision Power is specifically and uniquely designed to support members with comorbidities.
In fact, Health Coaches expect that members will have a variety of health concerns; one of
their primary goals is to help each member identify and manage the controllable aspects of his
or her conditions. Our primary Health Coach model meets the coordination needs of
members with multiple comorbidities and offers favorable cost and savings economics. For
members with multiple comorbid conditions, Health Coaches use our proprietary Chronic
Condition Guide to identify high priority issues; Health Coaches can also call on clinical
specialism when complex issues surface.
The SMARTP4 Re)ist -- Chronic Management Provider Coordination
Health Net and Decision Power's approach is to support the physician-patient relationship.
Most Disease Management Programs focus either on the physician or the member. Health
Net and Decision Power do both. Decision Power coordinates closely' with physicians,
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especially as part of the chronic illness management portion of our program. The program
also features the SMART-nm Registry.
The SMARTTm Registry is a proprietary tool that provides physicians with actionable clinical
information at the point of care to help them deliver high-quality, evidence-based care for
their patients. Each physician is provided a list of members identified in the various chronic
disease populations.
This list includes the key clinical parameters tracked for each member and identifies for each
member the significant gaps in care. The SMARTTM Registry also includes reports at an
individual patient level that can be included in the chart. These enable a much more focused
visit,eliminating the need for a search through voluminous paper records for key data and can
serve to guide treatment plans focused on closing gaps in care.
MEMBER EDUCATION
Frequency and Types of Support and Outreach:
Symptom management support extends to issues and needs for members who have minor
symptoms, questions, or concerns, like earaches, bee stings, and diaper rash. Even though
these may be "simple" issues, Health Coaches use motivational interviewing on every call,
and take every opportunity to educate callers,reinforce self-reliance,and remind them of their
access to existing resources.
• All commercial members receive an invitation to call Decision Power,
• Ongoing outreach mailings and telephone campaigns are targeted to identified
members,
• Ongoing Physician-referral campaigns,
• Internal referral training for customer service, case management etc, is refreshed
quarterly,
• Active employer participation and promotion of the program.
Health Net sends quarterly newsletters that advise members of available services and
reminders, along with recent and noteworthy health information. All members, regardless of
group definitions, also may receive personal emails and other health reminders or information
of their choosing at kvw‘v healthnet vom.
Health Net employs wellness-related outreach efforts including IVR calls, direct mail and
outbound calls. Decision Power uses Health Coach referrals and case findings. Health
Coaches use every interaction as a means of identifying lifestyle issues. For example, on a hay
fever symptom call,a Health Coach may learn that the individual has an unhealthy body mass
index (BMI), and can refer the member to both general weight management support, as well
as the intensive weight management program, as appropriate
Onsite Health Fairs and Biometric Screenings - Health Net can enhance onsite health events
with biometric screenings. These services, available for an additional fee, can be arranged
through our preferred provider or another third-party vendor. Biometric screenings provide an
opportunity for identifying individuals with high blood pressure, BMI, cholesterol, etc. We
integrate data from screenings into our identification and outreach efforts, and can refer those
individuals to our telephonic lifestyle programs, as appropriate.
Additionally, providers, health plan case managers, customer service personnel, or other
partner resources can be a rich source of referrals to Health Net's Wellness Programs,
ERRP-C,I
12
All Health Net members also receive an annual NCQA Immunization reminder mailing. This
mailing includes reminders for men, women, teenagers and children.
Adult commercial HMO, POS and Medicare Advantage members identified with a new
antidepressant prescription receive a series of three educational mailings over a 12-week
period to inform them about depression. The content of the educational mailings includes the
following:
• Explanation of depression and skills for dealing with depression
• Appointment reminders for office visits with the member's provider and/or
behavioral health practitioners and providers(members are recommended to have at
least three follow-up visits in the first 12 weeks after beginning antidepressant
medication)
• Encouragement to continue the prescription antidepressant medication through
completion, usually at least six months(four to five months after complete remission
of symptoms)
• Information and resources about depression on the Health Net member portal at
www.healthnet.corn
• Information on how to opt out of the program
HEALTH NET WELLNESS–LIFESTYLE PROGRAMS
Lifestyle risk and wellness support provides support to members facing lifestyle issues such
as weight loss, smoking cessation, and stress management—by leveraging motivational
interviewing and the Decision Power behavior change Health Coaching model and online
tools,
Health Net's Decision Power program combines advanced analytics, sophisticated
engagement methods, and effective behavior change techniques. Decision Power includes
programs and educational materials on topics most affecting members including but not
limited to:
• Tobacco cessation
• Weight loss and weight management
• Cardio-metabolic risk management
• Stress management
• Diet and nutrition
• Exercise and fitness
• Preventive health screenings
• Flu vaccinations
• Sleep
Decision Power Wellness Program goals are to help our members with existing medical
conditions optimize their health and functional capacity. To attain significant value for both
members and employer groups, our programs focus on:
• Getting ahead of the medical cost curve by encouraging prevention behaviors
• Maximizing productivity and reducing absenteeism by teaching healthy
practices
• Improving total population health by coaching members at all health risk levels
and health states
• Creating a healthy work culture by offering personal programs that are
reinforced at the corporate level
I C
13
Health Net achieves these goals through a dynamic and engaging wellness offering that
supports individuals through our proven whole-person. total-population approach. Decision
v,4
Power:
• Uses lifestyle-based proprietary analytics to identify at-risk individuals
• Engages members through innovative outreach strategies
• Provides members with education and support through greater access to
specialty coaches,online resources,print materials, and onsite programs
For identification and stratification the Decision Power model uses Health Risk Questionnaire
(HRQ) data as well as proprietary lifestyle-based predictive models including the Wellness
Segmenter and CornrnunityGridmi. These models are able to identify individuals who are
likely to be smoking, obese,at cardio-metabolic risk, and/or have overall high lifestyle risk, in
the absence of HRQ data. Data sources for the models include medical claims, pharmacy
data, lab data and demographic data from eligibility files. We drive our outreach efforts
based on HRQ and/or these predictive models.
Health Net also offers, Health Net's Decision Powers" Healthy Discounts -- members save
with discounts on weight loss solutions with Jenny Craig® and Weight Watchers®, and on
other health and wellness products and services.
The following describes Health Net's policies and procedures in place
to protect against fraud, waste and abuse under the plan
Claims Fraud, Waste and Abuse
Except as otherwise noted below, Health Net's formal policies and procedures
documentation on this topic will be provided to MIS upon request. Health Net's claims
processing systems serve as the front line in combating inappropriately billed claims. Each
claim is subject to a variety of edits that:
• Verify data accuracy,
• Verify billed services are covered under the member's plan,
• Identify recovery opportunities,
• Process claims according to contractual arrangements with providers, and
• Discover any other suspect issues.
After a claim is processed, analytical data mining is used by Health Net's Special
Investigations Unit (SIU) to identify claims patterns, possible payment errors, utilization
trends and other indicators of potential Fraud. Waste and Abuse (FWA), as well as
investigating cases upon identification of potential FWA by quantifying the potential
exposure.
Data analysis assists in the detection and prevention of fraud, waste and abuse by
comparing claims information and other related data to help identify any potential errors in
billing and/or fraud indicators found in the data by procedure/prescription claim submitted.
Data mining can be used to identify norms, abnormalities, and individual variables that
describe statistically significant time-series trends. Examples of such statistically
significant time-series trends over a period and in comparison to relative time periods are:
• Standard deviations from the mean:
• Percent above the mean or median.
• Percent increase in charges,
1:1?Rl'-CA
14
• Number of visits services from one period to another.
Data analysis typically provides an overarching view of what is occurring and can help
identify trends and assist in the development of an efficient investigative process. The SIU
also utilizes a program named STARSTm to manually conduct analytical data mining, which
also includes the STARSentinelml program to provide automated analytical data mining
that is based on over 400 fraud rules that are commonly attributable to fraud, waste and
abuse.
Eligibility and Enrollment Fraud,Waste and Abuse
Health Net's Special Investigations Unit(SIU)uses the Evidence of Coverage(EOC)or the
contract(ASO, large group, government contract,etc.)as the primary tool for investigating
enrollment(or any type of member eligibility) fraud. These documents define the majority
of the SIU's capabilities for these areas. The SIU Department's Policies and Procedures
outlines the methods of how all investigations are to be handled. This document is
proprietary and confidential, and cannot be released without a signed Non-Disclosure
Agreement.
Important Note:
The information provided regarding State and federal laws and regulations, including, but not limited to
the Patient Protection and Affordable Care Act(PPACA), is based upon the latest information available to
Health Net as of the date this document was written. Health Net's re.sponses are non-exhaustive, subject to
further revision and clarification based iron the issuance of interpretive regulations and other guidance by
the government, and are provided for information purposes only. Please note that Health Net is unable to
provide legal, tax, or legislative implementation advice and recommends that our clients consult their
professional legal, tax and legislative implementation advisors in evaluating the requirements of these laws
and regulations and their impact on our clients'group health plans.
Health Net looks fonvard and remains committed to working with our clients, consultants, brokers and
vendors to provide health plan benefit structures that comply with all applicable state and federal laws and
regulations, includtAg but not limited to the Patient Protectim and Affordable Care Act,
ERRP-CA
15
EXHIBIT C
PLAN SPONSOR CERTIFICATION
1. In General. The undersigned certifies that the plan documents for the group health plans (the "Plans")
sponsored by been amended to incorporate the provisions required by
Section 504(f) of the regulations implementing the standards protecting the privacy of individually
identifiable health information, 45 CFR Part 164 (the "Privacy Rule"), which were promulgated under the
authority of the Health Insurance Portability and Accountability Act of 1996, Pub.L. 104-191 ("HIPAA").
Furthermore, the Plan Sponsor agrees:
(a) not to use or further disclose individually identifiable health information created in
connection with the Plans except as required by law or for the Plans' administrative
purposes as described in the Plans' documents, as they are amended from time to time;
(b) to arrange for any of its agents or subcontractors that receive Protected Health
Information (within the meaning of the Privacy Rule) to use and disclose Protected
Health Information consistent with section 1(a)of this Certification;
(c) not to use or disclose the Protected Health Information for employment related actions or
in connection with benefits or benefit plans outside the scope of what Plan Sponsor has,
for Privacy Rule purposes, deemed its health care component;
(d) to report to the Plans any use or disclosure of Protected Health Information that is
inconsistent with the uses or disclosures for the Plans' administrative purposes as
described in the Plans' documents, as they are amended from time to time, that it
becomes aware of;
(e) to make available any Protected Health Information in any "designated record set" (as
such term is defined in the Privacy Rule)related to the Plans' participants or beneficiaries
that it has control of in accordance with Section 524 of the Privacy Rule;
(f) to make available for amendment or amend, to the extent required by Section 526 of the
Privacy Rule, the Protected Health Information in a designated record set which is related
to the Plans' participants or beneficiaries;
(g) to make information available the information required for an accounting of Protected
Health Information disclosures related to the Plans' participants or beneficiaries in
response to such person's exercise of their rights under such section:
(h) to make its internal practices, books and records relating to the use and disclosure of
Protected Health Information received available to the Secretary of the Depaitment of
Health and Human Services to assist the Secretary in determining the Plans or the Plans'
health insurance issuer's compliance with the Privacy Rule;
(i) where feasible to return or destroy any Protected Health Infoimation received when such
Protected Health Information is no longer needed by the Plan Sponsor for the purpose
which permitted the disclosure and, where such return or destruction of Protected Health
Information is not feasible,to limit its future use of the Protected Health Information to
the situations that make the return or destruction of the Protected Health Information not
feasible;and
(j) to limit access of its employees to the Plans' Protected Health Information(other than as
subjects of the Protected Health Information or subscribers to the coverage), except
where such employees are in job classifications which have been designated in the Plans'
documents as assisting in the Plans' administration and thus engaging in the use or
disclosure of Protected Health Information for treatment, payment and health care
operations purposes.
2, Interpretation The terms and conditions of this Certification shall be construed in light of any
applicable interpretation of and/or guidance on the HIPAA Privacy Rule issued by MIS or the Office of
Civil Rights from time to time.
FRI?P-C 1
16
3. Third Party Beneficiaries. Nothing in this Certification shall be construed to create any third party
beneficiary rights in any person, including any participant or beneficiary of the Plans.
4. Authority. The execution, delivery and performance of this Certification by the Plan Sponsor is within
its corporate powers, and not in contravention of its articles of incorporation, bylaws or any amendments
thereto and have been duly authorized by all appropriate corporate action, The person executing on behalf
of the Plan Sponsor has the requisite power and authority to make this Certification on the Plan Sponsor's
behalf.
IN WITNESS WHEREOF, the Plan Sponsor has caused this certification to be executed as of the date and
year set forth below.
By:
Title:
Date:
RAP (A
17
grP Health Net'
HEALTH NET
CASE MANAGEMENT OVERVIEW - CAUFORNIA
This document is intended to assist our clients who may choose to apply with the federal
government to participate in,the Early Retiree Reinsurance Programemtablished under the
Patient Protection and Affordable Care Act of 2010. The following describes Health Net's
Medical Management programs and procedures that have generated or have the
potential to generate cost savings for plan participants with claims for chronic and high
cost conditions.
Health Net's Case Management policies apply to all California Health Net commercial members.
This document discusses Health Net's Case Management Pre-Certification services, Large-Case Care
Management services, goals and outcomes, Complex Case Management, Health Net's Decision
Power chronic disease and preference-sensitive condition management, member education
outreach and Health Net's Wellness lifestyle and treatment programs.
It is important to note that Health Net's Case Management programs are highly integrated
between the health plan's internal Case Management, the medical group's Case Management,
Health Net Decision Power's disease management program, outside vendors and the members
themselves
LARGE CASE MANAGEMENT— HOSPITAL PRE-SERVICE/CERTIFICATION DECISIONS
Health Net's Utilization Management staff determines pre-service decisions for request
types that are not delegated to the medical groups. Pre-service decisions include both
the initial determination of requests for urgent and non-urgent service and requests for
continuation of services. Pre-service decisions are required for elective inpatient
admissions, referrals for selected ambulatory surgery, home health care, durable
medical equipment, home IV infusion and selected diagnostic and radiology procedures.
The purpose of obtaining a pre-service decision is to prospectively evaluate proposed
services to determine if they are medically necessary, covered by the member's benefit
plan, provided by a contracted practitioner or provider, where appropriate or possible,
and provided in the most appropriate setting.
The practitioner mails, telephones or faxes pre-service requests directly to Health Net.
Requests for pre-service decisions must include:
• Member demographics
• History and clinical findings
• Diagnosis with ICD-9 code
• Procedure with CPT code
• Reason for request
• Results of pertinent or applicable evaluation and tests already performed
• Any lab, X'ray, or other reports relevant to the request
• Pertinent medical information to facilitate the authorization decision
Page 1
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HEALTH NET
CASE MANAGEMENT OVERVIEW— CALIFORNIA
Utilization Management Coordinators process requests and electronically forward the
record to a prior authorization nurse if clinical review is required. The prior
authorization nurse evaluates the request utilizing Health Net National Medical Policies
and |nten]uar, Health Net's primary source for clinical criteria for medical necessity and
levels of care. If criteria are met, authorization is approved. Approval notifications are
sent to members and requesting practitioners/providers.
If criteria are not met and additional clinical information is required, the
practitioner/provider will be contacted and the member notified of the need for
additional information. When additional information is received and criteria are still not
met, the request will be referred to a Health Net Medical Director for review. Upon
completion of the review by the Medical Director, approved requests follow the above
process and denied requests result in denial letters to be distributed to members and
practitioners/providers according to Health Net Policy and Procedures.
LARGE-CASE MANAGEMENT SERVICES
Health Net and its delegates provide Case Management services to deliver individualized
assistance to members experiencing comp|px, acute or catastrophic illnesses or with
exceptional needs in all lines of business. The focus is on early identification of high-risk
members and application of a systematic approach to coordination of care to increase
satisfaction, to arrange medically appropriate care and to improve the health, functional
status and quality of life of Health Net members.
There is no cost threshold that triggers Health Net's case management intervention.
Health Net's predictive modeling identifies members who are at high risk for ongoing
utilization, hospital admission or readmission. Health Net provides case management
based on the member's identified needs and situation, regardless of cost.
Referrals for case management services are obtained from sources such as a predictive
modeling strategy (evaluating utilization, pharmacy, lab and encounter data), customer
semice, contracted vendors, members, family members, providers, claims, concurrent
review, sales and other Health Net departments.
Examples of members appropriate for referral for case management include:
• Lack of established or ineffective treatment plan
• Potential or identified compromised patient safety
• New permanent or temporary alteration of functional status
• High cost injuries or illnesses
• History of non adherence to treatment, medications or multiple missed
appointments
• Over, under or inappropriate utilization of services
• Delayed discharge from the appropriate level of care
• Lack of famMy or social support
Page 2
tx Health Net
HEALTH NET
CASE MANAGEMENT OVERVIEW — CALIFORNIA
• Lack of financial resources to meet health needs
• Actual or potential exhaustion of benefits
• Lack of education of disease course or process
• High Risk pregnancy
• Transplant evaluation and surgery
• Pain Management
• Continuity of care assistance
• Post discharge follow up
• NICU discharge
• Post Bariatric surgery with complications
• Hospice-pending or actual
• Avoidable inpatient admissions/readmissions
Goals of the case management programs are to:
• Consistently perform the activities of assessment, p|anning, facilitation and
advocacy for members throughout the continuum of care, in accordance with
accreditation standards and standards of practice.
• Collaborate and communicate with the member/family, the physician and other
health care providers in the development and implementation of a care plan
that is driven by the member's goals for health improvement.
• Accomplish the goals in the individual member's care plan,
• Provide members and their families with the information and education that
promotes self-care management,
• Assist in optimizing use of available benefits,
• Improve member and provider satisfaction.
• Promote effective utilization and monitoring of health care resources while
ensuring that services are coordinated and appropriate for the member.
• Provide members with tools to empower members to achieve optimal health,
independence and functioning in the most proactive and effective way.
Research shows that goals mutually developed with members positively influence case
management outcomes.
COMPLEX CASE MANAGEMENT
Health Net and its delegates make available Complex Case Management services to all
members. The goal of the complex case management program is that members with
complex conditions receive support and assistance with coordination of care and access
to any needed services, There is no cost threshold that triggers Health Net's complex
case management intervention
Members are initially identified for participation in the program using data stratification
that includes:
Page
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HEALTH NET
CASE MANAGEMENT OVERVIEW — CALIFORNIA
• Claims and encounter data
• Hospital discharge data
• Pharmacy and lab data
• Health information lines
• Any of the Health Net Disease Management programs
• The concurrent review and discharge planning process
• A member request for case management
• A practitioner request for case management
Members are screened telephonically by a registered nurse and invited to participate in
complex case management if they meet established screening criteria. Members are also
afforded the opportunity to decline participation in the program.
The Health Net complex case management program includes an initial assessment of
the use of evidence based care plans and a|gori1hms, documentation of member
resources, barriers, goals, progress and ongoing evaluation of member needs with
adjustments of interventions as needed.
Health Net's shared-risk medical groups generally are directed by Health Net to use
Health Net's vendor for complex-care management. Dual-risk medical groups are
encouraged to use this vendor, but may manage complex care directly or through a
vendor of their choosing.
Each year the program is evaluated for it effectiveness using both established metrics
and documented measures of member satisfaction.
CHRONIC POPULATION DISEASE MANAGEMENT
Members face a wide variety of health care issues and concerns. Health Net knows that
members need support that extends beyond any single chronic condition to other
condbions, decisions' andhfesty|erisks. ThekeytoHea|thNet'sDecixionPoxver^*
program is to engage members in better managing their overall health, not just any one
of their conditions. Decision Power Health Coaches support members across a broad
spectrum of conditions and needs, Essentially, Health Coaches coach people, not their
diseases. This "whole person" approach allows our Health Coaches to support a greater
number of members across a wider range of conditions and issues.
Decision Power Health Coaches apply stage-of-change methods and motivational
interviewing to assess opportunities for behavior change to improve lifestyle
management and modify risk behaviors. Health Coaches are equipped to offer the
right level of support and provide non-judgmental coaching intended to move members
along stages of change toward the adoption of a healtfter lifestyle. They help members
recognize and minimize barriers to behavior change and resolve feelings of ambivalence
while increasing motivation.
Page 4
Health nno ,n /�V�t^
HEALTH NET
CASE MANAGEMENT OVERVIEW — CALIFORNIA
Using a variety of proprietary tools and systems, Health Coaches help individuals
address knowledge gaps and set goals and action plans not only for their own lifestyle
risks or concerns, but also for those of their families. Health Coaches share evidence-
based information and help the member learn to recognize and honor his or her own
values and preferences in taking care of his or her own health.
CHRONIC POPULATION IDENTIFICATION/STRATIFICATION AND SUPPORT
Health Net members who may benefit from Health Coaching are identified and
stratified, through four core components: Data Analytics (medical inpatient/outpatient
and pharmacy claims), Member Outreach, Health Coaching, and Provider Engagement
(encounter data).
Claims data are loaded monthly into a database; predictive modeling methodology is
applied to identify and stratify members according to risk. All newly identified chronic
members are sent a welcome packet that contains detailed information about their
condition and are invited to call a Health Coach for additional information.
Members are re-stratified monthly and can move up and down the risk scale based on
the data loaded into the system each month. The highest risk members are stratified
for outbound Health Coaching calls. Members who fall below the highest risk level may
be loaded for an AutoDia|ogT call if they meet the predictive modeling criteria for this
intervention. The AutoDialoglM (IVR) call will provide education about their condition
and the opportunity to transfer to a Health Coach. To ensure member privacy, those
who are targeted for AutoDialogTM calls are identified ase targeted member before the
message is delivered.
Health Net's Care Management programs, Disease Management, Preference-Sensitive
Condition support and Weilness programs are included for all members. There is no
cost sharing with the member for any of these services.
Chronic Condition support targets members who have one or more major chronic
medical conditions, such as:
• Coronary heart disease,
• Diabetes,
• Heart failure,
• Asthma, and
• Chronic obstructive pulmonary disease.
Using our whole-person approach, Health Net also supports the co morbid conditions
frequently associated with these conditions, including but not limited to
• Chronic pain,
Page 5
��0 Net'Health
HEALTH NET
CASE MANAGEMENT OVERVIEW — CALIFORNIA
• Obesity,
• Depression, and
• Hypertension.
Preference-Sensitive Condition support extends to conditions for which either medical
evidence supports multiple acceptable treatment options or there is inadequate medical
evidence about the treatment choices Examples of preference-sensitive care include
choosing between treatments like mastectomy or lumpectomy in early-stage breast
cancer; surgery or conservative treatment for patients with back pain due to disc
disease; and invasive cardiac surgery or medical management for chest pain due to
CHD. These are treatment choices that should depend on an informed individual
making a decision with her physician that is based on the best clinical evidence and her
own values.
Decision Power is specifically and uniquely designed to support members with
comorbidities. In fact, Health Coaches expect that members will have a variety of health
concerns; one of their primary goals is to help each member identify and manage the
controllable aspects of his or her conditions. Our primary Health Coach model meets
the coordination needs of members with multiple comorbidities and offers favorable
cost and savings economics. For members with multiple comorbid conditions, Health
Coaches use our proprietary Chronic Condition Guide to identify high priority issues;
Health Coaches can also call on clinical specialists when complex issues surface.
The SMARTT4 Registry — Chronic Management Provider Coordination
Health Net and Decision Power's approach is to support the physician-patient
relationship. Most Disease Management Programs focus either on the physician or the
member. Health Net and Decision Power do both. Decision Power coordinates closely
with physicians, especially as part of the chronic illness management portion of our
program. The program also features the SMARTT4 Registry.
The SK4ART`w Registry is a proprietary tool that provides physicians with actionable
clinical info/matonatthe point of care to help them deliver high-quality, evidence-
based care for their patients.
vidence'basedca,efOrtheirpatients. Each physician is provided a list of members identified in
the various chronic disease populations.
This list includes the key clinical parameters tracked for each member and identifies for
each member the significant gaps in care. The SMARTTM Registry also includes reports
at an individual patient level that can be included in the chart. These enable a much
more focused visit, eliminating the need for a search through voluminous paper records
for key data and can serve to guide treatment plans focused on closing gaps in care.
Page 6
�m� ��Health �
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HEALTH NET
CASE MANAGEMENT OVERVIEW — CALIFORNIA
MEMBER EDUCATION
Frequency and Types of Support and Outreach:
Symptom management support extends to issues and needs for members who have
minor symptoms, questions, or concerns, like earaches, bee stings, and diaper rash.
Even though these may be "simple" issues, Health Coaches use motivational
interviewing on every call, and take every opportunity to educate callers, reinforce self-
re|iance' and remind them of their access to existing resources.
• All commercial members receive an invitation to call Decision Power,
• Ongoing outreach mailings and telephone campaigns are targeted to identified
members,
• Ongoing Physician-referral campaigns,
• Internal referral training for customer semice, case management etc, is refreshed
quarterly,
• Active employer participation and promotion of the program.
Health Net sends quarterly newsletters that advise members of available services and
reminders, along with recent and noteworthy health information. All members,
regardless of group definitions, also may receive personal emails and other health
reminders or information of their choosing at www.healthnet.com.
Health Net employs wellness-related outreach efforts including IVR calls, direct mail and
outbound calls. Decision Power uses Health Coach referrals and case findings. Health
Coaches use every interaction as a means of identifying lifestyle issues. For example, on
a hay fever symptom call, a Health Coach may learn that the individual has an
unhealthy body mass index (BMI), and can refer the member to both general weight
management support, as well as the intensive weight management program, as
appropriate.
Onsite Health Fairs and Biometric Screenings - Health Net can enhance onsite health
events with biometric screenings. These services, available for an additional fee, can be
arranged through our preferred provider or another third-party vendor. Biometric
screenings provide an opportunity for identifying individuals with high blood pressure,
BM/, cholesterol, etc. We integrate data from screenings into our identification and
outreach efforts, and can refer those individuals to our telephonic lifestyle programs, as
appropriate.
Additionally, providers, health plan case managers, customer service personnel, or other
partner resources can be a rich source of referrals to Health Nets Weilness Programs.
All Heath Net members also receive an annual NCQA Immunization reminderma/|ing.
This mailing includes reminders for men, vvomen. teenagers and children.
Page 7
Health �
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HEALTH NET
CASE MANAGEMENT OVERVIEW— CALIFORNIA
Adult commercial HMO, POS and Medicare Advantage members identified with a new
antidepressant prescription receive a series of three educational mailings over a 12-
week period to inform them about depression. The content of the educational mailings
includes the following:
• Explanation of depression and skills for dealing with depression
• Appointment reminders for office visits with the members provider and/or
behavioral health practitioners and providers(members are recommended to
have at least three followup visits in the first 12 weeks after beginning
antidepressant medication)
• Encouragement to continue the prescription antidepressant medication through
completion, usually at least six months (four to five months after complete
remission of symptoms)
• Information and resources about depression on the Health Net member portal
at www.healthnet.com
• Information on how to opt out of the program
HEALTH NET WELLNESS– LIFESTYLE PROGRAMS
Lifestyle risk and wellness support provides support to members facing lifestyle issues—
such as weight loss, smoking cessation, and stress management—by leveraging
motivational interviewing and the Decision Power behavior change Health Coaching
model and online tools.
Health Net's Decision Power program combines advanced ana|ytics, sophisticated
engagement methods, and effective behavior change techniques. Decision Power
includes programs and educational materials on topics most affecting members
including but not limited to:
• Tobacco cessation
• Weight loss and weight management
• Cardio-metabolic risk management
• Stress management
• Diet and nutrition
• Exercise and fitness
• Preventive health screenings
• Flu vaccinations
• Sleep
Decision Power Wellness Program goals are to help our members with existing medical
condrtons optimize their health and functional capacity. To attain significant value for
both members and employer groups, our programs focus on:
Page 8
al; Health Net'
HEALTH NET
CASE MANAGEMENT OVERVIEW — CALIFORNIA
• Getting ahead of the medical cost curve by encouraging prevention
behaviors
• Maximizing productivity and reducing absenteeism by teaching healthy
practices
• Improving total population health by coaching members at all health risk
levels and health states
• Creating a healthy work culture by offering personal programs that are
reinforced at the corporate level
Health Net achieves these goals through a dynamic and engaging wellness offering that
supports individuals through our proven whole-person, total-population approach.
Decision Power:
• Uses lifestyle-based proprietary analytics to identify at-risk individuals
• Engages members through innovative outreach strategies
• Provides members with education and support through greater access to
specialty coaches, online resources, print materials, and onsite programs
For identification and stratification the Decision Power model uses Health Risk
Questionnaire (HRQ) data as well as proprietary lifestyle-based predictive models
including the Weilness Segmenter and CommunityGridT . These models are able to
identifyindividuo|s who are likely to be smoking, obese, at cardio-metabolic risk, and/o/
haveoverall high lifestyle risk, in the absence of HRQ data. Data sources for the models
include medical claims, pharmacy data, lab data and demographic data from eligibility
files. We drive our outreach efforts based on HRQ and/or these predictive models.
Health Net also offers, Health Net's Decision Powers" Healthy Discounts — members save
with discounts on weight loss solutions with Jenny Craig® and Weight Watchers®, and
on other health and wellness products and services.
Page 9
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HEALTH NET
FRAUD, WASTE AND ABUSE PROGRAM OVERVIEW
This document is intended to assist our clients who may choose to apply with the
federal government to participate in the Early Retiree Reinsurance Program
established under the Patient Protection and Affordable Care Act of 2010. The
following describes Health Net's policies and procedures in place to protect against
fraud, waste and abuse under the plan.
This document discusses Health Net's policies and procedures regarding Fraud, Waste and Abuse.
Health Net's formal policies and procedures documentation on this topic will be provided to HHS
upon request.
Claims Fraud, Waste and Abuse
Health Net's claims processing systems serve as the front line in combating
inappropriately billed claims. Each claim is subject to a variety of edits that:
• Verify data accuracy,
• Verify billed services are covered under the member's plan,
• Identify recovery opportunities,
• Process claims according to contractual arrangements with providers, and
• Discover any other suspect issues.
After a claim is processed, analytical data mining is used by Health Net's Special
Investigations Unit (SIU) to identify claims patterns, possible payment errors, utilization
trends and other indicators of potential Fraud, Waste and Abuse (FWA), as well as
investigating cases upon identification of potential FWA by quantifying the potential
exposure,
Data analysis assists in the detection and prevention of fraud, waste and abuse by
comparing claims information and other related data to help identify any potential
errors in billing and/n/ fraud indicators found in the data by procedure/prescription
claim submitted.
Data mining can be used to identify norms, abnormalities, and individual variables
that describe statistically significant time-series trends. Examples of such statistically
significant time-series trends over a period and in comparison to relative time periods
are:
• Standard deviations from the mean;
• Percent above the mean or median,
• Percent increase in charges,
• Number of visits/services from one period to another. •
Data analysis typically provides an overarching view of what is occurring and can help
identify trends and assist in the development of an efficient investigative process. The
SlU also utilizes a program named 5T4R3`mto manually conduct analytical data
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HEALTH NET
FRAUD, WASTE AND ABUSE PROGRAM OVERVIEW
mining, which also includes the STARSentiner program to provide automated
analytical data mining that is based on over 400 fraud rules that are commonly
attributable to fraud, waste and abuse.
Eligibility and Enrollment Fraud, Waste and Abuse
Health Net's Special Investigations Unit (SIU) uses the Evidence of Coverage (EOC) or
the contract (ASO, large group, government contract, etc.) as the primary tool for
investigating enrollment(or any type of member eligibility) fraud. These documents
define the majority of the SIU's capabilities for these areas. The SIU Department's
Policies and Procedures outlines the methods of how all investigations are to be
handled. This document is proprietary and confidential, and cannot be released
without a signed Non-Disclosure Agreement.
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