SAN MATEO COMMUNITY HEALTH AUTHORITY

Transcription

1 THE SAN MATEO HEALTH COMMISSION and THE SAN MATEO COMMUNITY HEALTH AUTHORITY Regular Meeting December 13, :30 p.m. Health Plan of San Mateo 801 Gateway Blvd., 1st Floor, Boardroom South San Francisco, CA AGENDA 1. Call to Order/Roll Call 2. Public Comment/Communication 3. Approval of Agenda 4. Consent Agenda* 4.1 Report from Finance/Executive Committee 4.2 CHI Oversight Committee Minutes, July CMC Advisory Committee Minutes, September Quality Improvement Committee Minutes, September Physician Advisory Group Minutes, October Approval of Amendments to Agreements with San Mateo County Public Authority and the City of San Mateo for HealthWorx 4.7 Approval of Amendment to the Agreement with Delta Dental for the Healthy Kids Program 4.8 Waive Request for Proposal Process and Ratify Approval of Technology Procurements through CDW Government, LLC. 4.9 Approval of Commission Meeting Dates for Approval of San Mateo Health Commission Meeting Minutes from November 8, Specific Discussion/Action Items 5.1 Discussion/Action on 2018 HPSM Budget* 5.2 Presentation on HPSM Technology Priorities 6. Report from Chairman/Executive Committee 7. Report from Chief Executive Officer 8. Other Business Appreciation of Barbara Erbacher, Commissioner* 9. Adjournment *Items for which Commission action is requested. Government Code requires that public records related to items on the open session agenda for a regular commission meeting be made available for public inspection. Records distributed less than 72 hours prior to the meeting are available for public inspection at the same time they are distributed to all members, or a majority of the members of the Commission. The Commission has designated the Clerk of the San Mateo Health Commission located at 801 Gateway Boulevard, Suite 100, South San Francisco, CA 94080, for the purpose of making those public records available for inspection. Meetings are accessible to people with disabilities. Individuals who need special assistance or a disability-related modification or accommodation (including auxiliary aids or services) to participate in this meeting, or who have a disability and wish to request an alternative format for the agenda, meeting notice, agenda packet or other writings that may be distributed at the meeting, should contact the Clerk of the Commission at least two (2) working days before the meeting at (650) Notification in advance of the meeting will enable the Commission to make reasonable arrangements to ensure accessibility to this meeting and the materials related to it.

2 AGENDA ITEM: 4.1 DATE: December 13, 2017 M E M O R A N D U M Date: November 27, 2017 To: San Mateo Health Commission From: Michael Smigielski, Chief Financial Officer Subject: Financial Report for the Ten-Month Period Ending October 31, 2017 OVERVIEW OF FINANCIAL POSITION Preliminary 2017 Financial Results All Lines of Business The preliminary financial result for all lines of business for the month of October is a surplus of $10,969,620. Year-to-date the Plan has a surplus of $15,415,806. On page 13 is a Statistical and Financial Summary. Membership Below is a graph showing membership trends dating back to Total membership at the end of October 2017 stands at 147,140 an increase of 404 members from the previous month. There was an increase in MediCal of 251 members. 1

3 Revenue Below is a depiction of revenue by each line of business for Medi-Cal Lines of Business continue to provide the largest share of HPSM revenue which includes Medi-Cal, Medi-Cal Expansion, CCS and Medi-Cal Cal MediConnect. Medi-Cal is followed by the CareAdvantage lines of business. 2

4 HealthCare Expenses The graph below reflects how the healthcare dollar is being spent in Inpatient is the largest driver of costs YTD with Pharmacy close behind. Administrative Expenses Administrative expenses are expressed as a percentage of net revenue received. Administrative expenses are 5.1% of revenue as of October The following graph represents this percentage since

5 Investment and Interest On page 14 is the Schedule of Investments. Total interest earned for October was $462,032 and $2,946,840 year to date. Stabilization Reserve and Tangible Net Equity (TNE) The TNE calculation is included on page 15. The financial protocol requires us to have a minimum Stabilization Reserve of two months operating expenses. As of October 31, 2017 our required TNE was $35.0 million and our stabilization reserve was $154.9 million. Our current net equity is $301.9 million of which $86.1 million is uncommitted. 4

6 MEDI-CAL (MC) The Medi-Cal Statement of Revenue and expenses is included on page 19. Highlights are below: Month Actual Actual Year - to - Date Budget REVENUES $33,103,659 Capitation Revenue $335,908,271 $300,750,369 $1,849,570 MC Offset ($37,489,605) ($17,936,140) $34,953,229 Total Revenue $298,418,666 $282,814,229 EXPENSES $26,301,875 Total Health Care Costs $254,879,244 $249,645,189 $1,273,723 Administrative Expenses $12,770,253 $14,480,706 $ - SB78 Sales Tax $ - $ - $3,028,658 MCO Tax $33,564,103 $31,343,200 $30,604,256 TOTAL EXPENSES $301,213,600 $295,469,095 $ - Non-Operating Income $ - $ - $4,348,973 NET SURPLUS / (LOSS) ($2,794,934) ($12,654,866) 75.2% Medical Loss Ratio 85.4% 88.3% Utilization: ACTUAL YTD 10/17 BUDGET Annual 2017 Hospital Inpatient Expense Total PMPM Expense $50.34 $48.83 Physician, Outpatient & Other Medical Expense Total PMPM Expense $73.57 $78.42 Pharmacy Expense (Excludes Drug Rebates) Total PMPM Expense $44.55 $50.25 Medi-Cal has a surplus of $4.3M for the month of October and a year to date deficit of $(2.8M). Premium YTD is $15.6M favorable: $3.6M was due to the accounting of the MLR surplus and the remainder was due to prior year IHSS premium accruals. Expenses are ($5.2M) unfavorable to 5

7 budget. ($22.5M) is due to prior year costs in LTSS services (also shown in the premium line) offset by favorability in RX, +$5.8M and Ancillary Services $3.0M, SNF +$0.7M. Additional Medi-Cal Programs CCS The CCS Pilot began in April of The CCS Statement of Revenue and Expenses is included as page 24. CCS ended September with a surplus of $854,412 and a year to date surplus of $2,925,008 due to better than expected medical trends. Month Actual Actual Year - to - Date Budget REVENUES $ 2,439,661 Capitation Revenue $ 24,279,130 $ 24,442,935 $ 137,625 BHT Revenue $ 307,263 $ - $ 2,577,286 Total Revenue $ 24,586,393 $ 24,442,935 EXPENSES $ 1,546,474 Total Health Care Costs $ 19,629,579 $ 22,205,311 $ 103,160 Administrative Expenses $ 1,301,388 $ 1,724,721 $ 73,240 Premium Tax $ 730,418 $ 660,000 $ 1,722,874 TOTAL EXPENSES $ 21,661,385 $ 24,590,032 $ - Non-Operating Income $ - $ - $ 854,412 NET SURPLUS / (LOSS) $ 2,925,008 $ (147,097) 60.0% Medical Loss Ratio 79.8% 90.8% 6

8 Medi-Cal Expansion (MCE) On January 1, 2014, Medi-Cal eligibility was expanded to those adults under 138% of poverty as a result of the Affordable Care Act. Those members that were in the Low Income Health Program (LIHP) automatically transitioned and we are also receiving members signing up through Covered California. The MCE Statement of Revenue and Expenses is included as page 25. Highlights are below: Year - to - Date Month Actual Actual Budget REVENUES $ 15,849,150 Capitation Revenue $ 228,365,077 $ 163,507,077 $ 2,100,179 Medi-Cal Cap Offset $ (60,328,270) $ - $ 17,949,329 Total Revenue $ 168,036,807 $ 163,507,077 EXPENSES $ 10,779,107 Total Health Care Costs $ 117,643,198 $ 132,488,243 $ 810,737 Administrative Expenses $ 8,019,544 $ 11,269,488 $ 1,479,596 Premium Tax $ 16,262,238 $ 14,685,600 $ 13,069,440 TOTAL EXPENSES $ 141,924,980 $ 158,443,331 $ - Non-Operating Income $ - $ - $ 4,879,889 NET SURPLUS / (LOSS) $ 26,111,827 $ 5,063, % Medical Loss Ratio 70.0% 81.0% The MCE line of business ended October surplus of $4.9 million and a year to date surplus of $26.1 million. Revenue is $4.5M favorable to budget primarily driven by prior year adjustments. Medical expenses are $14.8M favorable to budget: $15.2M is due to lower than expected membership slightly offset by medical expenses ($0.4M). HPSM also received preliminary rates for this population. Medi-Cal Expansion rates have continued to decline based on actual experience. Following is the history of our rates since the expansion began in January of /14-6/14 07/14-12/14 01/15-06/15 07/15-6/16 07/16-6/17 07/17-6/18 $ $ $ $ $ $

9 CAREADVANTAGE The CareAdvantage Statement of Revenue and expenses is included on page 22. Highlights are below: Year - to - Date Month Actual Actual Budget REVENUES $ - Capitation Revenue $ 185,066 $ - $ - Total Revenue $ 185,066 $ - EXPENSES $ 22 Total Health Care Costs $ (91,895) $ - $ 4,541 Administrative Expenses $ 199,575 $ - $ 4,563 TOTAL EXPENSES $ 107,680 $ - $ - Non-Operating Income $ - $ - $ (4,563) NET SURPLUS / (LOSS) $ 77,386 $ - Medical Loss Ratio -49.7% CareAdvantage ended as a D-SNP in December However, we will continue to see revenue and expenses as a result of retroactive activity. Currently there is a $77,386 surplus for the year. 8

10 Enrollment/Disenrollment With the impending termination of CareAdvantage, the goal was to enroll as many eligible CareAdvantage members into Cal MediConnect as possible. Disenrollments inched higher than enrollments at the end of October 2017, however, the graph does not reflect the work of the CA Outreach Unit who have saved 1017 members from being disenrolled. The CA Unit helps restore Medi-Cal eligibility or helps member restore SSI benefits. 9

11 CAREADVANTAGE CMC Cal MediConnect began on April 1, There were 9,258 members as of October 31st. The statement of Revenue and Expenses is included on pages 26 and 27. Highlights are below: Month Actual Actual Year - to - Date Budget REVENUES $ 15,884,858 Capitation Revenue $ 147,872,280 $ 151,791,660 $ 15,884,858 Total Revenue $ 147,872,280 $ 151,791,660 EXPENSES $ 14,766,977 Total Health Care Costs $ 145,014,444 $ 155,832,842 $ 1,322,996 Administrative Expenses $ 12,393,577 $ 14,055,512 $ 16,089,973 TOTAL EXPENSES $ 157,408,021 $ 169,888,354 $ - Non-Operating Income $ - $ - $ (205,115) NET SURPLUS / (LOSS) $ (9,535,741) $ (18,096,694) 93.0% Medical Loss Ratio 98.1% 102.7% Utilization ACTUAL YTD 10/17 BUDGET Annual 2017 Hospital Inpatient Expense Total PMPM Expense $ $ Physician, Outpatient & Other Medical Expense Total PMPM Expense $ $ Pharmacy Expense (Excludes Drug Rebates) Total PMPM Expense $ $ The CareAdvantage portion of Cal MediConnect had a deficit of ($205K) at the end of October and ($9.5M) deficit year to date. Revenue is ($3.9M) unfavorable to budget, ($4.0M) is due to lower than expected membership and the remainder is due to changes in member mix. Expenses are $10.8M favorable to budget: $4.1M is due to lower than expected membership and the remaining $6.6M is primarily due to better than expected RX expenses of $9.3M offset by OP Hospital ($5.2M) and IP Hospital ($4.7M) costs. 10

12 Medi-Cal CMC Month Actual Actual Year - to - Date Budget REVENUES $ 39,094,365 Capitation Revenue $ 112,142,966 $ 90,530,482 $ (282,297) Medi-Cal Cap Offset $ (4,458,007) $ (5,397,193) $ 38,812,068 Total Revenue $ 107,684,959 $ 85,133,289 EXPENSES $ 38,272,082 Total Health Care Costs $ 110,952,154 $ 77,850,929 $ 213,372 Administrative Expenses $ 1,946,280 $ 1,348,955 $ - Premium Tax $ (67,707) $ 3,851,200 $ 38,485,454 TOTAL EXPENSES $ 112,830,727 $ 83,051,084 $ - Non-Operating Income $ - $ - $ 326,614 NET SURPLUS / (LOSS) $ (5,145,768) $ 2,082, % Medical Loss Ratio 103.0% 91.4% The Medi-Cal portion of Cal MediConnect had a surplus of $326,614 at the end of October with a $(5,145,768) deficit year to date. 11

13 HEALTHWORX, HEALTHY KIDS, ACE HealthWorx: Ended October with a $(982,273) deficit year to date. Statement of Revenue and Expenses on page 20. Healthy Kids: ACE: Ended October with a $497,683 surplus year to date. Statement of Revenue and Expenses on page 21. Ended October with a $156,166 surplus year to date. Statement of Revenue and Expenses on page 23. CLAIMS In the month of October, the Health Plan paid a total of 351,504 claims representing $47,946,831 worth of services to our members with 99.2% of those claims being paid within 30 days. 12

14 Health Plan of San Mateo Fiscal Year 2017 Statistical and Financial Summary October-17 Month Year-to-Date Actual Budget Variance Operating Margin Actual Budget Variance 111,719,747 71,211,306 $40,508,441 Total Revenue 757,412, ,864,249 $42,548,337 92,186,857 64,222,789 $27,964,068 Total Health Care Costs 652,384, ,192,970 $10,191,602 3,946,878 4,341,167 ($394,289) Total Operational Admin Expenses 38,669,857 43,774,654 ($5,104,797) 4,616,392 5,066,428 ($450,036) Total MCO & AB78 Tax 50,942,351 50,664,275 $278,076 10,969,620 ($2,419,078) $13,388,698 Total Current Year Surplus (Deficit) 15,415,806 ($21,767,650) $37,183, % Admin Costs as a % of Revenue 5.1% Month Year-to-Date Current Prior Variance Membership Current MM's Budget MM's Variance 112, , Medi-Cal 1,121,872 1,150,720 (28,848) 9,258 9,299 (41) CareAdvantage CMC 93,700 96,280 (2,580) 1,610 1,605 5 CCS 16,220 16,500 (280) 1,056 1,056 0 HealthWorx 10,526 10, ,275 1, Healthy Kids 11,384 6,060 5,324 21,622 21, ACE 215, ,570 1, ,140 * 146,777 * 404 Total* 1,375,731 * 1,398,360 * (22,629) * Total does not include Medi-cal CMC members, who in theory are the same as the CA CMC membership Trended FS.xlsx 11/22/2017

15 HEALTH PLAN OF SAN MATEO SCHEDULE OF INVESTMENTS AS OF 10/31/17 MATURITY or DIVIDEND DATE 1/1/17 DESCRIPTION SECURITY CURRENT % RATE YIELD VALUE AS OF 10/31/17 % VALUE OF TOTAL INTEREST EARNED YTD 10/31/17 INTEREST EARNED CURRENT MONTH 10/31/17 SHORT-TERM INVESTMENTS 12/31/2017 $58,951,795 LAIF California State Fund 1.525% $59,461, % $497,845 $77,028 12/31/2017 $98,961,495 County of San Mateo Pooled Fund 1.607% $100,002, % $936,409 $136,450 02/20/18 02/10/18 04/23/18 $300,000 Knox Keene Bank Deposits 0.150% $300, % $375 $38 Various $0 Gov't Discount Notes* 0.000% $0 0.00% $0 $0 TOTAL $158,213,290 Weighted Average, excluding gov't notes 1.574% $159,763, % $1,434,629 $213,516 MONEY MARKET & CASH 10/31/2017 $40,271,509 Wells Fargo Institutional Securities 0.882% $40,497, % $225,759 $30,338 All Other Cash Accounts N/A $1,286,452 $218,177 TOTAL 33.15% $462,032 C:\Users\FrancineL\Dropbox (HPSM)\FloQast\FQ - Health Plan of San Mateo\2017\10 - October\02 Investments\ INTEREST xlsx

16 TNE CALCULATION As of 10/31/2017 Month # 10 YTD As of 10/31/2017 A. Minimum TNE Requirement $ 1,000,000 B. Revenue Annualized Premium Revenue: Medicaid 603,409,053 Medicare 148,057,345 Total YTD 751,466,398 Annualized 2% for the first $150 million 3,000,000 Plus 1% of annualized premium revenue in excess of $150 million 7,517,597 Total $ 10,517,597 C. Healthcare Expenditures Annualized, except capitated or managed hospital basis: Total Medical & Hospital $ 652,384,572 Less Inpatient Services Per Diem (includes LTC) (123,752,432) Less Primary Prof Svcs - Capitated (31,824,733) Less Write-Ins Other Capitated Med & Hosp Exp (15,698,562) Total YTD 481,108,844 Annualized 8% of first $150 million 12,000,000 Plus 4% of annualized health care expenditures in excess of $150 million 17,093,225 Total $ 29,093,225 Plus annualized hospital expenditures, paid on managed hospital payment basis: Inpatient Services Per Diem $ 123,752,432 Annualized 4% $ 5,940,117 Total Healthcare Expenditures $ 35,033,341 Net Equity $ 602,711,290 Required TNE (greater of A, B, or C) $ 35,033,341 TNE Excess $ 567,677,949 Committed Net Equity Stabilization Requirement (Equivalent ) $ 154,922,468 Land and Building 47,477,869 Strategic Investment - approved 54,180,269 Strategic Investment - (incurred) (15,543,721) Uncommitted Net Equity $ 361,674,406

17 Printed: 15/Nov/2017 7:00:01 AM Report: 1100 Unit: HPALL Health Plan of San Mateo Consolidated Balance Sheet October 31, 2017 and September 30, 2017 Current Month Prior Month ASSETS Current Assets Cash and Equivalents $ 424,025,442 $ 457,034,016 Investments 159,463, ,998,843 Capitation Receivable from the State (91,688,549) (78,949,045) Other Receivables 27,223,302 36,493,094 Prepaids and Other Assets 7,511,927 7,241,953 Total Current Assets 526,535, ,818,862 Capital Assets, Net 73,416,426 73,723,735 Net Pension Asset 1,376,620 1,376,620 Assets Restricted As To Use 300, ,000 Total Assets 601,628, ,219,217 Deferred Outflows of Resources 1,082,648 1,082,648 Total Assets & Deferred Outflows $ 602,711,290 $ 657,301,865 LIABILITIES Current Liabilities Medical Claims Payable 88,232,596 87,556,557 Provider Incentives 1,343,655 1,126,839 Amounts Due to the State 134,873, ,280,671 Accounts Payable and Accrued Liabilities 64,169, ,215,342 Total Current Liabilities 288,619, ,179,409 Deferred Inflows of Resources 1,253,802 1,253,802 Total Liabilities & Deferred Inflows $ 289,873,017 $ 355,433,211 NET POSITION Invested in Capital Assets 73,416,426 73,723,735 Restricted By Legislative Authority 300, ,000 Unrestricted Stabilization Reserve 142,500, ,500,000 Unrestricted Retained Earnings 96,621,848 85,344,919 Net Position 312,838, ,868,654 Total Liabilities & Net Position $ 602,711,290 $ 657,301,865 Change in Net Position $ 15,415,806 $ 4,446,186

18 Printed: 21/Nov/2017 9:45:05 AM Report: 320 Unit: HPALL Health Plan of San Mateo Consolidated Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Month Year to Date Annual Budget OPERATING REVENUES Capitation and Premiums Medi-cal (includes MCE & Offsets) $ 52,757,886 $ 462,304, ,558,697 Unexpended Budget % of Budget $ $ 66,253, % CareAdvantage - 185,066 - (185,066) - Healthy Kids 259,119 2,130,659 1,374,414 (756,245) 155.0% HealthWorx 254,540 2,551,570 3,058, , % CCS Pilot 2,439,661 24,279,130 29,331,522 5,052, % CA Cal MediConnect 15,884, ,872, ,149,992 34,277, % MC Cal MediConnect 39,094, ,142, ,636,578 (3,506,388) 103.2% Total Operating Revenue 110,690, ,466, ,109, ,643, % OPERATING EXPENSES Health Care Expense PCP Capitation 3,502,430 31,824,733 41,907,312 10,082, % Hospital Inpatient 19,473, ,889, ,262,968 51,373, % Pharmacy 8,554, ,781, ,704,084 47,923, % Medical 16,782, ,861, ,789,406 39,928, % Long Term Support Services 42,145, ,796,071 74,533,299 (39,262,773) 152.7% Provider Incentives 106,240 1,412,728 5,146,401 3,733, % Other Medical 407,431 3,622,308 3,320,440 (301,867) 109.1% UMQA, Delegated and Allocation 1,214,999 13,196,994 17,974,630 4,777, % Total Health Care Expenses 92,186, ,384, ,638, ,253, % Administrative Expense Salaries and Benefits 2,666,474 25,555,207 36,285,400 10,730, % Staff Training and Travel 10,699 96, , , % Contract Services 1,273,737 13,726,378 20,433,650 6,707, % Office Supplies and Equipment 380,202 4,313,092 5,675,870 1,362, % Occupancy and Depreciation 527,945 4,613,149 5,830,100 1,216, % Postage and Printing 147, ,152 1,583, , % Other Administrative Expense 72,197 1,519,385 1,800, , % UM/QA Allocation (1,132,288) (12,150,007) (17,974,630) (5,824,623) 67.6% Total Admin Expense 3,946,878 38,669,857 53,968,420 15,298, % Premium Taxes 4,616,392 50,942,351 60,797,130 9,854, % Total Operating Expense 100,750, ,996, ,404, ,407, % Net Income/Loss from Operations 9,940,302 9,469,618 (32,294,539) (41,764,158) -29.3% NON-OPERATING REVENUES Interest Income, Net 462,032 2,946,840 1,000,000 (1,946,840) 294.7% Rental Income, Net 82, , , , % Third Party Administrator Revenue 184,399 1,837,530 2,188, , % Miscellaneous Income 300, ,475 2,404 (304,071) % Net Non-operating Revenues 1,029,317 5,946,188 4,177,310 (1,768,878) 142.3% CHANGES IN NET ASSETS $ 10,969,620 $ 15,415,806 $ (28,117,229) $ (43,533,035) -54.8% Member Counts 133,200 1,342,112 1,647, , % Admin exp as % of Net Revenues 3.57% 5.15% 6.33% Medical Loss Ratio 83.28% 86.81% 90.33%

19 Printed: 21/Nov/ :30:55 AM Report: LOB Inc Stmt Unit: CORP Health Plan of San Mateo HPSM Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Mo Actual Current Mo Budget % of Budget Y-T-D Actual Y-T-D Budget Y-T-D Variance % of Budget OPERATING REVENUE Total Operating Revenue OPERATING EXPENSE Total Health Care Expense G & A Allocation Expense Total Operating Expense NON-OPERATING REVENUE Interest, Net 462,032 83, % 2,946, ,333 2,113, % Rental Income, Net 82,649 82, % 855, ,910 33, % Miscellaneous Income 300, , ,270 - Total Non-Operating 844, , % 4,106,453 1,655,243 2,451, % Net Income/(Loss) $ 844,681 $ 165, % $ 4,106,453 $ 1,655,243 $ 2,451, % Medical Loss Ratio

20 Printed: 21/Nov/ :30:56 AM Report: LOB Inc Stmt Unit: MCSM Health Plan of San Mateo Medi-Cal Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Mo Actual Current Mo Budget % of Budget Y-T-D Actual Y-T-D Budget Y-T-D Variance % of Budget OPERATING REVENUE State Capitation $ 32,318,534 $ 29,174, % $ 329,941,810 $ 291,141,986 $ 38,799, % AIDS Capitation (818,920) - (818,920) - BHT Capitation 268, , % 2,396,498 2,144, , % HepC Capitation 516, , % 4,377,347 7,463,845 (3,086,498) 58.7% LTC Capitation ,536-11,536 - MC Cap Offset 1,849,570 (1,793,614) % (37,489,605) (17,936,140) (19,553,465) 209.0% Total Operating Revenue 34,953,229 28,343, % 298,418, ,814,229 15,604, % OPERATING EXPENSE PCP Capitation 1,507,126 1,505, % 14,659,218 15,054,766 (395,548) 97.4% Hospital Inpatient-Per Diem (1,653,696) 956, % 9,288,024 9,564,821 (276,797) 97.1% Hospital Inpatient-FFS 3,802,030 2,869, % 26,613,134 28,694,463 (2,081,329) 92.8% LTC/SNF 5,880,357 5,776, % 55,152,744 57,761,768 (2,609,024) 95.5% Pharmacy 2,393,927 3,848, % 31,442,767 38,487,154 (7,044,387) 81.7% Physician Fee for Service 1,977,530 2,247, % 21,660,310 22,477,653 (817,344) 96.4% Hospital Outpatient 1,894,500 1,715, % 19,284,166 17,151,939 2,132, % Other Medical Claims 2,002,161 2,204, % 18,255,497 22,044,977 (3,789,480) 82.8% Long Term Support Services 7,885,821 3,048, % 51,955,631 30,484,910 21,470, % Provider Incentives 19, , % 426,937 2,710,137 (2,283,199) 15.8% Health Care Supplmntl Benefits 17, , ,879 - Indirect Health Care Expenses 270, , % 1,998,922 1,005, , % UMQA (Allocation & Delegated) 304, , % 3,952,015 4,206,895 (254,880) 93.9% Total Health Care Expense 26,301,875 24,964, % 254,879, ,645,189 5,234, % G & A Allocation Expense 1,273,723 1,448, % 12,770,253 14,480,706 (1,710,453) 88.2% Premium Tax 3,028,658 3,134, % 33,564,103 31,343,200 2,220, % Total Operating Expense 30,604,256 29,547, % 301,213, ,469,095 5,744, % NON-OPERATING REVENUE Total Non-Operating Net Income/(Loss) $ 4,348,973 $ (1,203,441) % $ (2,794,934) $ (12,654,866) $ 9,859, % Member Counts 74,970 78, % 757, ,310 (26,131) 96.7% Medical Loss Ratio 75.25% 88.08% 85.41% 88.27%

21 Printed: 21/Nov/ :30:56 AM Report: LOB Inc Stmt Unit: HWSM Health Plan of San Mateo HealthWorx Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Mo Actual Current Mo Budget % of Budget Y-T-D Actual Y-T-D Budget Y-T-D Variance % of Budget OPERATING REVENUE HealthWorx Premium 254, , % 2,551,570 2,548,623 2, % Total Operating Revenue 254, , % 2,551,570 2,548,623 2, % OPERATING EXPENSE Hospital Inpatient-Per Diem (5,539) 39, % 166, ,316 (226,135) 42.4% Hospital Inpatient-FFS 108,414 9, % 427,323 97, , % Pharmacy 74, , % 1,038,927 1,106,365 (67,438) 93.9% Physician Fee for Service 43,656 73, % 660, ,678 (75,280) 89.8% Hospital Outpatient 142,355 51, % 652, , , % Other Medical Claims (16,066) 15, % 145, ,944 (11,768) 92.5% Health Care Supplmntl Benefits ,893-1,893 - Indirect Health Care Expenses 3,816 1, % 28,606 14,396 14, % UMQA (Allocation & Delegated) 7,008 8, % 60,919 80,983 (20,064) 75.2% Total Health Care Expense 358, , % 3,181,617 3,101,958 79, % G & A Allocation Expense 29,257 27, % 260, ,753 (18,141) 93.5% Premium Tax 9,073 7, % 91,613 78,825 12, % Total Operating Expense 396, , % 3,533,842 3,459,535 74, % NON-OPERATING REVENUE Total Non-Operating Net Income/(Loss) $ (141,830) $ (91,091) 155.7% $ (982,273) $ (910,913) $ (71,360) 107.8% Member Counts 1,055 1, % 10,535 10, % Medical Loss Ratio % % % %

22 Printed: 21/Nov/ :30:56 AM Report: LOB Inc Stmt Unit: HKSM Health Plan of San Mateo Healthy Kids Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Mo Actual Current Mo Budget % of Budget Y-T-D Actual Y-T-D Budget Y-T-D Variance % of Budget OPERATING REVENUE Healthy Kids Premium 259, , % 2,130,659 1,145, , % Total Operating Revenue 259, , % 2,130,659 1,145, , % OPERATING EXPENSE Hospital Inpatient-Per Diem 1,005 48, % 19, ,720 (463,739) 4.1% Hospital Inpatient-FFS 9, , ,831 - Pharmacy 20,563 5, % 153,925 53, , % Physician Fee for Service 145,729 14, % 280, , , % Hospital Outpatient (79,915) 12, % 163, ,803 34, % Other Medical Claims (1,311) 8, % 60,760 84,973 (24,213) 71.5% Health Care Supplmntl Benefits 60,328 14, % 269, , , % Indirect Health Care Expenses 4, % 30,813 8,515 22, % UMQA (Allocation & Delegated) 1,921 2, % 17,560 24,010 (6,450) 73.1% Total Health Care Expense 162, , % 1,176,231 1,068, , % G & A Allocation Expense 8,578 8, % 97,264 82,647 14, % Premium Tax 25,824 4, % 361,687 45, , % Total Operating Expense 196, , % 1,635,181 1,196, , % NON-OPERATING REVENUE Miscellaneous Income % 2,205 2, % Total Non-Operating % 2,205 2, % Net Income/(Loss) $ 62,674 $ (4,925) % $ 497,683 $ (49,246) $ 546, % Member Counts 1, % 11,599 6,060 5, % Medical Loss Ratio 62.63% 93.29% 55.21% 93.29%

23 Printed: 21/Nov/ :30:56 AM Report: LOB Inc Stmt Unit: CASM Health Plan of San Mateo CareAdvantage Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Mo Actual Current Mo Budget % of Budget Y-T-D Actual Y-T-D Budget Y-T-D Variance % of Budget OPERATING REVENUE CareAdvantage Premium , ,066 - Total Operating Revenue , ,066 - OPERATING EXPENSE PCP Capitation Pharmacy (23) - - 7,840-7,840 - Provider Incentives Indirect Health Care Expenses (99,481) - (99,481) - UMQA (Allocation & Delegated) (1,414) - (1,414) - Total Health Care Expense (91,895) - (91,895) - G & A Allocation Expense 4, , ,575 - Total Operating Expense 4, , ,680 - NON-OPERATING REVENUE Total Non-Operating Net Income/(Loss) $ (4,563) - - $ 77,385 - $ 77,385 - Medical Loss Ratio % -

24 Printed: 21/Nov/ :30:56 AM Report: LOB Inc Stmt Unit: ACSM Health Plan of San Mateo ACE Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Mo Actual Current Mo Budget % of Budget Y-T-D Actual Y-T-D Budget Y-T-D Variance % of Budget OPERATING REVENUE Total Operating Revenue OPERATING EXPENSE Total Health Care Expense G & A Allocation Expense 180, , % 1,681,364 1,732,653 (51,289) 97.0% Total Operating Expense 180, , % 1,681,364 1,732,653 (51,289) 97.0% NON-OPERATING REVENUE Third Party Administror Revenue 184, , % 1,837,530 1,823,845 13, % Total Non-Operating 184, , % 1,837,530 1,823,845 13, % Net Income/(Loss) $ 3,885 $ 9, % $ 156,166 $ 91,192 $ 64, % Medical Loss Ratio

25 Printed: 21/Nov/ :30:57 AM Report: LOB Inc Stmt Unit: CCSM Health Plan of San Mateo CCS Pilot Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Mo Actual Current Mo Budget % of Budget Y-T-D Actual Y-T-D Budget Y-T-D Variance % of Budget OPERATING REVENUE CCS Capitation 2,439,661 2,444, % 24,279,130 24,442,935 (163,805) 99.3% BHT Capitation 137, , ,263 - Total Operating Revenue 2,577,286 2,444, % 24,586,393 24,442, , % OPERATING EXPENSE PCP Capitation 37,031 36, % 361, ,325 (4,929) 98.7% Hospital Inpatient-Per Diem (11,496) 335, % 573,232 3,353,927 (2,780,695) 17.1% Hospital Inpatient-FFS (60,356) 143, % 3,009,468 1,437,397 1,572, % LTC/SNF 55,448 66, % 534, ,000 (125,025) 81.1% Pharmacy 640, , % 5,674,940 6,193,002 (518,062) 91.6% Physician Fee for Service 110, , % 1,274,328 2,555,504 (1,281,176) 49.9% Hospital Outpatient 99, , % 2,810,626 2,054, , % Other Medical Claims 441, , % 3,442,105 2,576, , % Provider Incentives 722 6, % 9,632 65,361 (55,730) 14.7% Health Care Supplmntl Benefits ,875-2,875 - Indirect Health Care Expenses 3,942 2, % (292,898) 25,098 (317,996) % UMQA (Allocation & Delegated) 228, , % 2,228,901 2,917,728 (688,827) 76.4% Total Health Care Expense 1,546,474 2,220, % 19,629,579 22,205,311 (2,575,731) 88.4% G & A Allocation Expense 103, , % 1,301,388 1,724,721 (423,333) 75.5% Premium Tax 73,240 66, % 730, ,000 70, % Total Operating Expense 1,722,874 2,459, % 21,661,386 24,590,032 (2,928,646) 88.1% NON-OPERATING REVENUE Total Non-Operating Net Income/(Loss) $ 854,412 $ (14,710) % $ 2,925,007 $ (147,097) $ 3,072, % Member Counts 1,594 1, % 16,197 16,482 (285) 98.3% Medical Loss Ratio 60.00% 90.85% 79.84% 90.85%

26 Printed: 21/Nov/ :30:57 AM Report: LOB Inc Stmt Unit: MESM Health Plan of San Mateo MCE Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Mo Actual Current Mo Budget % of Budget Y-T-D Actual Y-T-D Budget Y-T-D Variance % of Budget OPERATING REVENUE MCE Capitation 15,849,150 16,013, % 228,365, ,507,077 64,858, % MC Cap Offset 2,100, (60,328,270) - (60,328,270) - Total Operating Revenue 17,949,329 16,013, % 168,036, ,507,077 4,529, % OPERATING EXPENSE PCP Capitation 1,462,221 1,575, % 14,215,876 15,757,649 (1,541,772) 90.2% Hospital Inpatient-Per Diem 242, , % 6,713,993 7,433,216 (719,223) 90.3% Hospital Inpatient-FFS 1,005,142 2,229, % 12,510,844 22,299,648 (9,788,804) 56.1% LTC/SNF 529, , % 7,123,932 5,714,354 1,409, % Pharmacy 3,102,091 3,708, % 34,083,308 37,084,525 (3,001,217) 91.9% Physician Fee for Service 1,380,944 1,357, % 14,223,892 13,577, , % Hospital Outpatient 1,796,549 1,069, % 15,731,045 10,692,730 5,038, % Other Medical Claims 816,814 1,340, % 7,130,500 13,408,674 (6,278,174) 53.2% Long Term Support Services 61, , % 2,046,519 1,448, , % Provider Incentives 26, , % 334,824 1,296,276 (961,452) 25.8% Health Care Supplmntl Benefits 6, ,684-95,684 - Indirect Health Care Expenses 130,380 50, % 928, , , % UMQA (Allocation & Delegated) 218, , % 2,503,984 3,273,980 (769,997) 76.5% Total Health Care Expense 10,779,107 13,248, % 117,643, ,488,243 (14,845,045) 88.8% G & A Allocation Expense 810,737 1,126, % 8,019,544 11,269,488 (3,249,944) 71.2% Premium Tax 1,479,596 1,468, % 16,262,238 14,685,600 1,576, % Total Operating Expense 13,069,440 15,844, % 141,924, ,443,331 (16,518,351) 89.6% NON-OPERATING REVENUE Total Non-Operating Net Income/(Loss) $ 4,879,889 $ 169, % $ 26,111,827 $ 5,063,746 $ 21,048, % Member Counts 35,830 36, % 324, ,690 (42,197) 88.5% Medical Loss Ratio 60.05% 82.74% 70.01% 81.03%

27 Printed: 21/Nov/ :30:57 AM Report: LOB Inc Stmt Unit: CMSM Health Plan of San Mateo CA CMC Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Mo Actual Current Mo Budget % of Budget Y-T-D Actual Y-T-D Budget Y-T-D Variance % of Budget OPERATING REVENUE CA Cal MediConnect Premium 15,884,858 15,179, % 147,872, ,791,660 (3,919,380) 97.4% Total Operating Revenue 15,884,858 15,179, % 147,872, ,791,660 (3,919,380) 97.4% OPERATING EXPENSE PCP Capitation 495, , % 2,586,798 3,744,020 (1,157,222) 69.1% Hospital Inpatient-Per Diem 1,270, , % 10,035,750 8,590,475 1,445, % Hospital Inpatient-FFS 5,416,796 3,809, % 42,783,987 38,096,891 4,687, % Pharmacy 2,143,737 4,861, % 37,967,188 48,615,871 (10,648,683) 78.1% Physician Fee for Service 1,762,938 1,517, % 17,184,848 15,175,237 2,009, % Hospital Outpatient 2,182,323 1,090, % 16,110,560 10,903,710 5,206, % Other Medical Claims 1,159,392 2,534, % 14,268,322 25,341,092 (11,072,769) 56.3% Provider Incentives - 21, ,893 (216,893) - Health Care Supplmntl Benefits 96,660 91, % 916, ,669 1, % Indirect Health Care Expenses (187,909) 14, % (449,014) 149,615 (598,629) % UMQA (Allocation & Delegated) 426, , % 3,609,131 4,083,368 (474,238) 88.4% Total Health Care Expense 14,766,977 15,583, % 145,014, ,832,842 (10,818,398) 93.1% G & A Allocation Expense 1,322,996 1,405, % 12,393,577 14,055,512 (1,661,935) 88.2% Total Operating Expense 16,089,973 16,988, % 157,408, ,888,354 (12,480,333) 92.7% NON-OPERATING REVENUE Total Non-Operating Net Income/(Loss) $ (205,114) $ (1,809,669) 11.3% $ (9,535,741) $ (18,096,694) $ 8,560, % Member Counts 9,240 9, % 93,735 92,680 1, % Medical Loss Ratio 92.96% % 98.07% %

28 Printed: 21/Nov/ :30:57 AM Report: LOB Inc Stmt Unit: MMSM Health Plan of San Mateo Medi-Cal CMC Statement of Revenue & Expense for the Period Ending October 31, 2017 Current Mo Actual Current Mo Budget % of Budget Y-T-D Actual Y-T-D Budget Y-T-D Variance % of Budget OPERATING REVENUE MC Cal MediConnect Capitation 39,094,365 9,053, % 112,142,966 90,530,482 21,612, % MC Cap Offset (282,297) (539,719) 52.3% (4,458,007) (5,397,193) 939, % Total Operating Revenue 38,812,068 8,513, % 107,684,959 85,133,289 22,551, % OPERATING EXPENSE PCP Capitation Hospital Inpatient-Per Diem ,726 (3,726) - Hospital Inpatient-FFS 53, , % 2,612,498 2,066, , % LTC/SNF 2,830,560 3,273, % 34,143,620 32,735,200 1,408, % Pharmacy 179, , % 1,412,177 1,546,067 (133,890) 91.3% Physician Fee for Service 169, , % 2,702,185 3,092,701 (390,516) 87.4% Hospital Outpatient 208, , % 2,209,356 2,178,200 31, % Other Medical Claims 544, , % 6,610,877 5,662, , % Long Term Support Services 34,197,739 3,020, % 59,793,921 30,171,687 29,622, % Provider Incentives 59, , ,710 - Health Care Supplmntl Benefits Indirect Health Care Expenses ,600 (2,600) - UMQA (Allocation & Delegated) 27,938 39, % 825, , , % Total Health Care Expense 38,272,082 7,788, % 110,952,154 77,850,929 33,101, % G & A Allocation Expense 213, , % 1,946,280 1,348, , % Premium Tax - 385,120 - (67,707) 3,851,200 (3,918,907) -1.8% Total Operating Expense 38,485,454 8,308, % 112,830,727 83,051,084 29,779, % NON-OPERATING REVENUE Total Non-Operating Net Income/(Loss) $ 326,614 $ 204, % $ (5,145,767) $ 2,082,204 $ (7,227,971) % Member Counts 9,120 9, % 128,374 96,280 32, % Medical Loss Ratio 98.61% 91.48% % 91.45%

29 HEALTH PLAN OF SAN MATEO STATEMENT OF CASH FLOWS - DIRECT & INDIRECT METHOD FOR THE CURRENT PERIOD October 31, 2017 CURRENT MONTH CURRENT YEAR 10/31/2017 YEAR-TO-DATE 2017 CASH FLOW PROVIDED BY OPERATING ACTIVITIES Group/Individual Premiums/Capitation - - Title XVIII - Medicare Premiums 15,884, ,057,345 Title XIX - Medicaid Premiums 46,439, ,986,320 Investment and Other Revenues (388,269) (389,119) Medical and Hospital Expenses (93,476,189) (659,225,387) Administration Expenses (2,244,547) (102,973,667) NET CASH PROVIDED BY OPERATING ACTIVITIES (33,784,355) (24,544,508) CASH FLOW PROVIDED BY INVESTING ACTIVITIES Proceeds from Restricted Cash and Other Assets - - Proceeds from Investments - - Proceeds for Sales of Property, Plant and Equipment - - Payments for Restricted Cash and Other Assets - - Payments for Investments - - Payments for Property, Plant and Equipment - (326,088) Interest and Other Income Received 775,781 4,312,149 NET CASH PROVIDED BY INVESTING ACTIVITIES 775,781 3,986,061 CASH FLOW PROVIDED BY FINANCING ACTIVITIES: Principal payments under capital lease obligations - - NET CASH PROVIDED BY FINANCING ACTIVITIES - - NET INCREASE (DECREASE) IN CASH (33,008,574) (20,558,447) CASH AND CASH EQUIVALENTS AT THE BEGINNING OF THE MONTH/PRIOR YEAR 457,034, ,583,889 CASH AND CASH EQUIVALENTS AT THE END OF THE MONTH 424,025, ,025,442 RECONCILIATION OF NET OPERATING INCOME TO NET CASH FROM OPERATING ACTIVITIES: Operating Income 9,940,302 9,469, Depreciation and Amortization 307,309 2,960,219 Decrease (Increase) in Receivables 21,798, ,510,735 Decrease (Increase) in Prepaid Expenses (269,974) (225,999) Decrease (Increase) in Net Pension Assets - - Decrease (Increase) in Affiliate Receivables - - Increase (Decrease) in Amts due to State of CA (9,592,941) (195,961,799) Increase (Decrease) in Accounts Payable (56,860,109) (17,133,824) Increase (Decrease) in Medical Claims Payable (5,754,597) (17,787,292) Increase (Decrease) in Incurred But Not Reported 6,430,636 17,063,661 Increase (Decrease) in Provider Risk Sharing 216, ,174 Increase (Decrease) in Unearned Premium - - Aggregate Write-Ins for Adjustments to Net Income - - TOTAL ADJUSTMENTS (43,724,657) (34,014,126) NET CASH PROVIDED BY OPERATING ACTIVITIES (33,784,355) (24,544,508) DETAILS OF WRITE-INS AGGREGATED FOR ADJUSTMENTS TO NET INCOME Unrealized (Gain)/Loss on Equity Securities - - (Gain)/Loss on Sale of Assets - - Prior Period Rent Expense - - Realized (Gain)/Loss on Investment - - TOTALS - - I:\DMHC\DMHC Cashflow-MONTHLY\2017\DMHC CASHFLOW xlsx 11/16/2017

30 FINANCE/EXECUTIVE COMMITTEE MEETING Meeting Summary Meeting Summary October 30, 2017 Health Plan of San Mateo 801 Gateway Blvd., 1 st Floor Boardroom South San Francisco, CA Members Present: John Ferrelli, Peggy Jensen, Don Horsley Staff Present: Maya Altman, Pat Curran, Mike Smigielski, Ian Johannsson, Khoa Nguyen, Lia Vedovini, Francine Lester 1.0 Call To Order The meeting was called to order at 12:59 pm by Commissioner Ferrelli. 2.0 Public Comment There was no public comment 3.0 Approval of Meeting Summary The minutes for July were approved as presented. 4.0 Preliminary Financial and Operational Report for the Nine-Month Period ending September 30, Mr. Smigielski, CFO reported that the month of September ended with a surplus of $3,455,162. Year-to-date the Plan has a surplus of $4,446,186. Membership Membership trends are dating back to Total membership at the end of September 2017 stands at 146,927, an increase of 251 members from the previous month. Revenue - Medi-Cal Lines of Business continue to provide the largest share of HPSM revenue, followed by CareAdvantage Lines of Business. Healthcare Expenses Inpatient is the largest driver of costs YTD with Pharmacy close behind.

31 Administrative Expenses - Administrative expenses are 5.4% of revenue as of September It is slightly lower than expected due to the unallocated HQAF revenue. Investment and Interest Total interest earned for September was $342,115 and $2,484,808 YTD. Stabilization Reserve and Tangible Net Equity (TNE) - As of September 30, 2017 our required TNE was $33.6 million and our stabilization reserve was $142.5 million. Our current net equity is $301.9 million of which $71.5 million is uncommitted. Medi-Cal - Medi-Cal has a deficit of $(1.8M) for the month of September and year to date deficit of $(7.1M). Premium is $8.9M favorable to budget primarily between the MC and MCE products. Expenses are $3.9M unfavorable to budget driven by unfavorable LTSS services ($16.3M) offset by favorability in RX, +$5.6M and SNF +$2.7M. Commissioner Horsley asked how concerned should we be with Medi-Cal losses and deficits. Mr. Smigielski stated that losses YTD are not significant and should be reconciled once HQAF is considered. CCS - CCS ended September with a surplus of $447,946 and a year to date surplus of $2,070,595 due to better than expected medical trends. Medi-Cal Expansion (MCE) The MCE Line of Business ended July with a surplus of $4.3M and a year to date surplus of $21.2M. The surplus is primarily due to the allocation of the Hospital Quality Assurance Fee (HQAF) between the MC and MCE product lines. Allocation instructions from DHCS were provided after the close. This will be resolved with the October close. Medical expenses are $12.4M favorable to budget: $1.8M

32 is due to lower than expected membership, however the remainder is due to $8.6M favorable IP costs and $2.4 M favorable RX expenses. CareAdvantage CareAdvantage ended as a D-SNP in December However, we will continue to see revenue and expenses as a result of retroactive activity. Currently there is a $81,949 surplus for the year. Enrollment/Disenrollment Disenrollments inched higher than enrollments at the end of September 2017, however, the graph in the report does not reflect the work of the CA Outreach Unit who saved 980 members from being disenrolled. The CA Unit helps restore Medi-Cal eligibility and SSI benefits. CareAdvantage Cal Mediconnect There are 9,261 members as of September 30 th. The CareAdvantage portion of Cal MediConnect had a surplus of $331K at the end of September and $(9.3M) deficit year to date. Revenue is $(4.6M) unfavorable to budget, ($3.5) is due to lower than expected membership and the remainder is due to changes in member mix. Expenses are $10M favorable to budget: $3.5M is due to lower than expected membership and the remaining $6.5M is primarily due to better than expected RX expenses of $6.8M. The Medi-Cal portion of Cal MediConnect had a deficit of ($273,924) at the end of September with a $(5,472,381) deficit year to date. Healthworx, Healthy Kids and ACE

33 Healthworx line of business ended September with a $(840,443) deficit year to date; Healthy Kids, $435,009 surplus YTD; ACE $152,281 surplus YTD. Claims The Health Plan paid a total of 344,145 claims in September, representing $49,889,445 worth of services to our members with 98.2% of those claims being paid within 30 days. 5.0 Approval of Fixed Assets and material Tangible Property Policy A change was proposed to the Policy and Procedure Manual for Fixed Assets and Material Tangible Property. A motion was made by Commissioner Jensen to approve the policy change increasing the amount of the items reported by the Finance Department from $3,000 to $9,000. It was seconded by Commissioner Horsley. The group agreed and the policy was approved as presented. 6.0 Report from the Compliance Department Mr. Johansson, Chief of Compliance reported: Privacy Breach There was 1 case in July where PHI was sent to the wrong translation vendor for Cal Medi-Connect and Medi-Cal, affecting 4 members. Breach letters were sent. In September there were 2 cases, the first affecting an ACE member who received the wrong PHI. A Breach letter was sent. The second case involved Medi-Cal, 3 members were affected when a subcontractor made a batch mailing error. Breach letters were sent. There was no Fraud, Waste or Abuse Cases to report.

34 State Agency Corrective Actions (1 Case) from DMHC related to errors in the 2015 Timely Access Survey. The plan was fined $12,500 for errors in the documentation, even after those errors were corrected. Mr. Johansson stated that there were many plans that were fined in this survey for this particular year, but also noted that they are taking measures to ensure that these errors are not repeated in the future. Commissioner Ferrelli asked about the range of fines and if there is an appeal process. Mr. Johansson replied that while fines may be imposed for a variety of reasons, he is not aware of the different fine amounts. He also noted that there is an appeal process, but in this case the Plan was aware of the errors. Mr. Johansson noted that for all of the issues discussed in this report Corrective Action Plans (CAPs) were implemented. CAPs will document actions taken to correct non-compliance. The Plan s focus is to address the root cause of non-compliance to mitigate risk and prevent recurrence. 7.0 San Mateo Health Commission Agenda Ms. Altman reviewed the draft agenda for the November Commission Meeting. 8.0 Other Business There was no other business discussed at this time. 9.0 Adjournment The meeting was adjourned at 1:24 pm.

35 AGENDA ITEM: 4.2 DRAFT Present: CHI OVERSIGHT COMMITTEE MEETING DATE: December 13, 2017 Meeting Summary July 21, :00 a.m. Health Plan of San Mateo 801 Gateway Blvd., 2 nd Floor, Sunrise Room South San Francisco, CA Pamela Kurtzman, Francine Serafin-Dickson, Ashley McDevitt, Michelle Blakely, Maya Altman, Ron Robinson, Sherri Sager, Srija Srinivasan, Lee Michelson, Maria DeAnda, and Rayna Lehman. 1. Call to Order: Welcome, Introductions and Agenda Review Meeting was called to order at 9:00 am by Ron Robinson. 2. Public Comment No public comment. 3. Minutes from January 27, 2017 Minutes from January 27, 2017 were approved as presented. 4. Discussion of Themes for HK Reserves Priorities Ms. Srinivasan explained that she developed priorities and timelines based on the input she received from interviewing members of the CHI Committee (see Key Themes from Interviews of CHI Oversight Members, attached). A strong plurality recommended waiting at least two years before consideration of additional investments, i.e., until 2019 and after the 2018 midterm elections. She then reviewed the key themes document, describing input provided on local gaps other than health coverage that could be addressed by additional investments; the information members needed to consider additional investments; and proposed next steps. Ms. Srinivasan distributed the most recent financial statement and projections for the program. While FY was yet to close, it was projected to be close to breakeven with a $100,000 draw down from reserves. No additional funding was requested from funders since most HKs participants have transitioned to Medi-Cal. Ms. DeAnda asked if we are seeing any impacts stemming from the federal government s focus on immigrants and undocumented individuals. Medi-Cal numbers are going down, as is participation in other programs. There is concern that individuals may not seek benefits they are entitled to out of fear. Ms. Srinivasan said that there has been a 1% decrease in kids on Medi-Cal in the past 12 months. Ms. Sager reported that families at LPCH are opting for no care on the specialty side, and they have even seen some families removing their children from a transplant waiting list in fear that a parent may be deported and thus may not be present to care for the child. In some cases people are applying for charity care instead of Medi-Cal. She said she has not seen large numbers of people doing this, but it still is a real concern. LPCH staff is working on educating this population about the issues and referring more people to Legal Aid for assistance. Ms. Altman stated that for Medi-Cal the numbers have been flat but steadily declining. This could be due to an increase in the economic status of the county and rising housing costs; but this fear is another added layer. Page 1 of 3 CHI Oversight Committee Minutes July 21, 2017

36 Discussion ensued about membership projections and how reserves could be used to help people during this time of uncertainty about federal funding cuts. Other questions were asked about the handling of funds should there be a need to return money to the funders; who makes these decisions and when would these decisions be made? Ms. Srinivasan explained that the San Mateo Health Commission (Commission), as the governing body of the Health Plan of San Mateo, is responsible for ultimate approval but acts on the recommendations of this committee. The voting members and the committee develop recommendations to the Commission. To date, the Commission has honored the decisions of this committee. Funders that contributed at the highest amounts and have allowed the accumulation of funds could receive funds back as decided by this committee. The committee agreed there would be no decision to redirect reserve funding at this time. The consensus was to develop funding recommendations or make the decision to return funding by January However, if there are urgent unmet needs, members of the Committee did not want to leave funding idle. It was agreed to bring back any recommendations in January There was also concern about the legislative environment uncertainties and the potential impacts on needs. Ms. Sager spoke about the need to reauthorize CHIP funding and possible impacts if this does not occur. Other issues discussed were drops in HSA rolls; possible needs in populations aged 0-3 and opportunities to impact the health care of this population as well as school readiness; hunger and CalFresh and the impacts of incomes creating ineligibility for benefits but still having a need that impacts health. Ms. Srinivasan suggested that if committee members have recommendations to let her know so she can add the item to the January 2018 agenda. Ms. Sager asked if we have the ability to use funds to cover the subsidy for kids who are covered by Covered California if the repeal and replace action is defeated but we have an unstable insurance market as well as CHIP funding reductions. Ms. Srinivasan said this is possible for consideration. Because of the timing of the scheduled meetings and changes that can occur in between meetings, the group discussed the possibility of having a special meeting if needed. A question was raised about voting members (County Health System, First 5, Hospital Consortium, Human Services Agency, Silicon Valley Community Foundation, Central Labor Council, Health Plan of San Mateo, and recently added were the Sequoia HealthCare District and Peninsula Health Care District). Sherri Sager suggested having a discussion off line about how Packard could be more involved and elevated to a voting status. 5. Discussion of Revised CHI Oversight Roles Memorandum of Understanding Ms. Srinivasan asked the Committee to vote on the revised MOU, sent to Committee members prior to the meeting. The revisions made were to define roles and responsibilities, add the two new voting members (Sequoia HealthCare District and Peninsula Health Care District); and clarify financial stewardship. Ms. DeAnda suggested leaving in the wording on page 2 related to the Human Services Agency role since this describes processes that will continue. It was decided that this wording should remain in the document. Ms. Altman moved approval of the MOU with the change as noted above. Ms. Serafin-Dickson seconded the motion. All were in agreement and the motion passed. Page 2 of 3 CHI Oversight Committee Minutes July 21, 2017

37 6. Community-Based Organization (CBO) Contract Extension Recommendation Ms. Srinivasan presented the recommendation to extend the current five Community-Based Organization (CBO) contracts for one year. She reported that these organizations have continued to meet their enrollment targets. While legislative uncertainty remains, these contractors provide valuable services. She noted 95% of these costs are paid through the County s Health Coverage Unit budget, with only 5% of the cost covered through the CHI budget. There was a motion to approve the contract extensions, seconded by Ms. Altman. The motion was approved. 7. Acknowledging Ron Robinson Ms. Srinivasan acknowledged the contributions of Mr. Robinson and thanked him for the many ways he has guided the vision of universal health coverage for the children of San Mateo County. His leadership, vision, nurturing, and management acumen have enabled thousands of kids to grow up healthy with access to the health care they need. Their health and the ripple effects for our community are a testament to him and a lasting gift to San Mateo County s children. 8. Other Updates Mr. Michelson announced that this would be his last meeting since he will be retiring at the end of this year. He thanked the group and said he had enjoyed participating in the work of this committee. 9. Adjournment Meeting adjourned at 10:07 a.m. Next CHI Oversight Committee Meeting: Friday, January 26, 2018 at 9:00 a.m. Page 3 of 3 CHI Oversight Committee Minutes July 21, 2017

38 Key themes from interviews of CHI Oversight Members (3 or more mentions among 9 Oversight Cmtee members) 1. What do you see as the highest priority for the funding? Maintaining access to healthcare for all SM County kids in households with incomes <= 400% FPL (original CHI vision) o Affordable o Comprehensive o High-quality 2. Over what timeframe should we consider investments other than local health coverage/ outreach/ enrollment assistance? Sit tight and do not make any new commitments now. Update our knowledge of legislative landscape at the federal and state levels at least annually. Strong plurality of members recommends waiting to consider any new investments for at least two years e.g., 2019 (after 2018 midterm elections). 3. Are there local gaps you see that are strongly aligned with the purpose of the HK Trust Fund? Maximizing take-up of public benefits available to kids/ families: WIC, EITC Child hunger and access to healthy food for all kids o Note: Many partners engaged in local Ending Hunger Task Force Children s oral health needs, especially for children enrolled in Denti-Cal for their dental services o Note: SM County Oral Health Strategic Plan guides our key local priorities in this arena for Children/ Youth mental well-being and suicide prevention o Note: SM County Coalition for Safe Schools and Communities is key local collaborative working on these issues; F5 is initiating work in this arena 4. What information would you want (Who do you trust?) to consider additional investments? Need to work toward maximum leverage of any investment and not duplicate other funding See value in a collective process, adopting a collective impact approach Health System and key Healthcare entities have valuable expertise, including data such as Community Health Needs Assessment Want to understand some specifics about current reserve and % contributed by each funder (County - 46%; F5-16%; SHCD 24%; PHCD- 15%)

39 Proposed Next steps: July 2017: o Discuss these themes o Review specific information requested on total reserve % contributed by each funder and current operating budget, assumptions included in County FY budget o Discuss revised MOU January 2018 o Invite legislative expert (Political Solutions (County lobbyist), HPSM lobbyist or Children Now) to give us their perspective o Update key themes document, if needed July 2018 o Review updated financial projections and assumptions for County FY budget o Update key themes document, if needed

40 Health Plan of San Mateo Cal MediConnect Advisory Committee Meeting Minutes Friday, September 15, :30 a.m. Health Plan of San Mateo 801 Gateway Blvd., Boardroom South San Francisco, CA AGENDA ITEM: 4.3 DATE: December 13, 2017 Committee Members Present: Susy Castoria, Gay Kaplan, Ligia Andrade Zuniga, Sharolyn Kriger, Janet Hogan, Nancy Keegan, Pete Williams Committee Members Absent: Angie Pratt, Christina Kahn, Lisa Mancini, Teresa Guingona Ferrer, Danilyn Nguyen, and Diane Prosser. Staff Present: Maya Altman, Margaret Beed, M.D., Chris Baughman, Gabrielle Ault-Riche, and Melora Simon. Guests Present: Kim Martinez, Wider Circle; Darin Buxbaum, Wider Circle; Craig McCulloh; and, Sasha Martinez 1. Call to Order The meeting was called to order at 11:45 a.m. by Gay Kaplan. 2. Public Comment There was no public comment at this time. 3. Approval of Minutes The minutes for the July 21, 2017 meeting were approved as presented. M/S/P. 4. Ombuds Report Sasha Martinez from Legal Aid reported that they have not been seeing systemic issues. The main issue being experienced stems from earlier in the year related to people being dropped off the MSSP and IHO waivers. The cause is not clear at this point. This affects how spousal impoverishment is calculated. 5. Updates and Discussion a. Changes in DME DME Consulting Dr. Beed gave a report on some of the changes related to Durable Medical Equipment (DME). The health plan has begun a new process for members needing DME equipment using a company called DME Consulting Group. Jim Aguilar the co-founder of this is company has worked with the health plan for many years. The arrangement and new process with this vendor will help to streamline processes in determining the appropriate equipment for our members. Dr. Beed walked through the process and how it will benefit HPSM members with the right equipment, avoiding unnecessary delays with improved accuracy in the determination of medical necessity, improved workflow and oversight. This process is very effective especially for the more complex DME needs and is being utilized for Page 1 of 5 CMC Advisory Committee Minutes September 15, 2017

41 wheel chairs as well. Vendors are required to repair their own equipment. This process was launched in September Dr. Beed will present more information on this subject in the future. b. Rates Proposal to DHCS Ms. Altman reported on the ongoing discussions at the state level around the CCI and CMC programs. The focus in these discussions earlier this year had been around saving CCI because of the poison pill in the state s budget and the threats of shutting down the program. Thankfully, the CCI was extended for two years but the extension excluded IHSS from the program. This has shifted the attention to other options. HPSM has been working on the Community Care Settings Pilot (CCSP) which helps people transition from or prevents being placed into nursing homes, and find alternative housing settings. Ms. Altman talked about a meeting with the Justice in Aging that focused on rates and distributed a handout of the slides from that meeting. In review of these slides, Ms. Altman touched on: The Coordinated Care Initiative Goals to improve quality of care and emphasize community settings as opposed to institutions. Spectrum of Care Settings noting the programs that are in CMC and CCI - specifically IHSS, CBAS, MSSP and CPOs (care plan optional services which are not funded by Medi-Cal) Access to Assisted Living for Low-Income Individuals: SSI Recipients; and those under the Assisted Living Waiver (not for CMC members) Rate structure per member per month and the different risk categories, and how they blend and recast rates. Reviewed some of the possible transitions and rate impacts i.e., moving from a nursing facility to assisted living going from an institutional rate to the community well rate but then the member is not eligible for IHSS. She noted that in these instances the health plan has been paying for these services in the assisted living setting using Care Plan Options. She reviewed the issues for health plans: plan does not receive reimbursement commensurate with costs; paying as CPO services means expenses are not counted in next rate setting process. Conclusion: goal of the advocates is to expand choice and access to less restrictive setting and to make the program sustainable; less complex rate structure and continue to incentivize providing services in home/community settings. The question was asked about cost savings. Ms. Altman stated that shared savings has been a big topic in the state. Rates are based on experience and trends but if this is not quantifiable they do not count it as savings. She also noted that it takes a couple of years to recalibrate rates so we are always two years behind. This is a big topic as managed care becomes more prevalent. Page 2 of 5 CMC Advisory Committee Minutes September 15, 2017

42 c. Grievance & Appeals Report Q (not numbered on the agenda) Ms. Ault-Riche reported on the first quarter of 2017 (January March 2017): Part C Appeals was up from the previous quarter; this time last year was 10 standard level appeals compared to 56 this year. This is due to process changes in UM. Grievances have gone down since last quarter which is typical for the second quarter of the year (the first quarter always being the highest of the year), however is up from the 2 nd quarter of the previous year. Grievances by category showed Customer Services as the largest category which continues to be a good sign that it is not access or quality of care. The percentages by category have remained flat. Appeals by type show the distribution of appeals has remained the same from the previous quarter. DME is always the highest and the new process with DME should improve this category going forward. Rate of Overturned Appeals: the percentage of medical and prescription drugs has gone. Staff researched this issue and Dr. Beed reported that there has been an increase in authorization requests without clinical information. Staff is addressing these situations with the providers. Resolution within 24 Hours of Receipt was down from the previous quarter. Most are related to pharmacy. Rate of Complaints per 1,000 members has gone down from the previous quarter but is higher from the previous year this quarter. This is attributed to the increase in appeals. Timeliness of Complaint Resolution shows an improvement and meeting goal on all areas. Tracking of PCP changes indicates no trends or major issues. d. CMC Dashboard Ms. Simon reported on: Performance on DY 2 and 3 Quality Withhold Measures: she stated that for most measures performance is above target. Of note is the annual flu vaccine; medication adherence for diabetes; encounter data; and, contact by care coordinator which are well above the target. Performance Financial Performance: she reported this continues to be less than desired. Enrollment is down to 9,241 but added 91 new enrollment in August which is up. o Related to Risk Adjustment, the first final year estimate shows an increase of 1.36 that is above our budgeted amount but below our aspirational target. o Medical Costs related to inpatient is not complete but this is down from June but still above budget and target. Other medical costs are lower than expected; and pharmacy is lower than budget but above target. o Offsets of Pharmacy Rebate information is a lag indicator in that continues to come in. Page 3 of 5 CMC Advisory Committee Minutes September 15, 2017

43 Transition Care 84%: A question was asked at the last meeting about what the California average of percentage of members who have an ambulatory care follow up visit after hospitalization and Ms. Simon reported that our rates at about 84% and the California average is about 77%. A copy of the slides she presented is attached. e. WiderCircle Ms. Altman introduced Mr. Darin Buxbaum and Ms. Kim Martinez from WiderCircle which has been working with HPSM members in a pilot project with a sample group of seniors to boost connections with other people and movement in their lifestyle. He explained that research has shown that there is health benefits associated with keeping people connected and involved with activities and that this is a challenge in these assisted living settings. Ms. Altman had recently attended the first graduation of one of their groups. Mr. Darin Buxbaum and Ms. Kim Martinez of WiderCircle reviewed the attached presentation. In their presentation, they gave an overview of the pilot project and its goals for the 12 group meetings including safely connecting with others, boosting movement and activity. They talked about some of the exercises the members participated in and shared inspiring member stories including a video from the graduation. The participants expressed their gratitude for what the program has given then and how it changed their outlook and attitude in life. The pictures show the story of joyful times spent together, smiling faces and laughter. During these group sessions, the facilitators would share information and used this opportunity for educational purposes such as teaching how to use social media and presenting/discussing patient rights. During these sessions, the members became more familiar with one another and comfortable sharing their experiences. Some of the outcomes presented were improved mental and physical component scores. Mr. Buxbaum noted that the Net Promoter Score (NPS) the program received was very high (100 for this pilot) and members are actively trying to bring new people into the group. CMS looks favorably at these scores knowing that for every point improvement on NPS there has been a common decrease in overall healthcare expenditures and in inpatient admissions. This also affects CMS STAR ratings. Next steps they will be working with a Spanish speaking group in Colma that is in the Mid-Peninsula property; and the community dwelling group that will be in the south end of the county. Ms. Zuniga asked how this program might reach people with physical limitations. Mr. Buxbaum replied that new programs are being developed that meets the needs of populations that may be frailer or have other reasons why it may be difficult for them to get out and about. This new program will still be based on the same science but allows people to connect even if they have physical limitations. In other areas, some of the inclusion/exclusion criteria and as long as people are get to the groups they are able to participate and they help with providing transportation to help. Page 4 of 5 CMC Advisory Committee Minutes September 15, 2017

44 f. IHSS Update Ms. Hogan reported: IHSS referrals for August were 224 which is up from the month prior. Total caseload is up to almost 4,800 for recipients; providers is up to about 5,300 Because of Homebridge issues with ACPs being available, they are cutting down on the number of referrals going over August was down to five referrals. Homebridge is currently serving a total of 118 cases in August. That has gone down to 111 at this point. Staff is trying to balance out the number HCPs that are available versus the number of contract mode users. The others coming to the registry are hiring their own providers. Registry is increasing in referrals, up to about 120 a month. A question regarding the number of social workers and their average case load per worker was asked. Ms. Hogan stated she could bring this information to future meetings. g. Other State/CMS Updates Ms. Simon reported that CMS is sending a postcard to members to remind them to get their flu shot. Mr. Craig McCulloh from the Commission on Disability reported on a piece of federal legislation called HR620 which changes the way the ADA is enforced and puts the burden on the individual person to provide information on the specific section of the ADA are in violation before they can go to court with a lawsuit. He expects this to have a negative impact on people with disabilities. The Commission on Disability has recommended a opposed position to the Board of Supervisors. Ms. Zuniga added that it is not only the Commission on Disabilities that is opposition, there are a number of civil liberty rights groups and others are really concerned as well. 6. Adjournment The meeting adjourned at 1:12 p.m. Next meeting: November 17, 2017 at 11:30 a.m. Health Plan of San Mateo 801 Gateway Blvd., Suite 100, South San Francisco Respectfully submitted: C. Burgess C. Burgess Clerk of the Commission Page 5 of 5 CMC Advisory Committee Minutes September 15, 2017

45 CMC Dashboard CMC Advisory Committee September 15, 2017 Today s discussion Objectives Quality withhold update MLR dashboard Transitions measure

46 Performance on DY 2 and 3 Quality Withhold Measures Updated as of 9/15 Indicator Target 2016 Performance Recent Performance/Notes CW6 Plan all-cause readmissions 11% 15.19% overall 10.48% STAR Metric (2016) 14.85% overall for rolling 12 months through 1Q 2017 CW7 Annual flu vaccine 69% 73% (2016) 77% (2017) CW8 Follow-up after hospitalization for mental illness 30 day 56% Improvement = 40.8% 64.84% (2016) Quarterly report in process CW10 Reducing the risk of falling 55% 77% (2016) 2017 data available in 2018 CW11 Controlling blood pressure 53% 64.37% (2016) Medical record based, no interim reporting CW12 Medication adherence for diabetes 73% 84% (2016) 94% for 2017 to date medications CW13 Encounter Data monthly 80% 92% submitted within 180 days (2016) 94% for 2017, up to August Reduction in emergency room use for seriously mentally ill and substance use disorder enrollees TBD 1075 per 1000 member months (2016) 1071 per 1000 overall for rolling 12 months through Q CAW4 - Percentage of members who have a care coordinator and at least one care team contact (CA 1.12) CAW1 - Number of members with at least one documented discussion of care goals in the individualized care plan (CA 1.6) CAW3 Mental Health Shared Accountability ICP with Primary Mental Health Provider (CA 1.7) TBD - Probably 88.4%; Improvement might be 78.2% TBD - Probably 90%; Improvement might be 29.4% TBD - Highest scoring state plan minus 10 points 76.9% (2016) 88.3% - Rolling 12 months as of 5/31/ % (2016) Monthly report in process Measure suspended for 2014, 2015, and 2016 Development of baseline report in process Performance on Financial measures UPDATED 9/15/2017 Category Proposed Indicator Budget Target Most Recent Performance Revenue Enrollment 9,628 9,628 9,241 as of 9/1 Continue to lose more members than new enrollments 91 new enrollments from August report 71/127 regained from deeming as of 9/1 Revenue RAF (2016 DOS) as of 9/15 (1.337 as of 8/15) Notes Based on estimate of final. Only includes RAPS Final RAF for 2016 was 1.3. Future Revenue Medical cost RAF Capture (2017 DOS) Acute Inpatient PMPM N/A 75%* 34.3% for Q2 (14.6% for Q1) $383 $384 $449 as of 7/31 ($464 as of 6/30) Medical cost SNF PMPM $79 $78 $93 as of 7/31 ($96 as of 6/30) Medical cost Physician, OP, and Other PMPM $530 $530 $501 as of 7/31 ($501 as of 6/30) Admits per 1000 at 306 (target of 275). Average paid per admission at $17,595 (target of $16,921) Overall inpatient at $565, relative to $560 in June Days per 1000 at 1,815 (target of 1500) and paid per day at $615 due to systems issue (target of $558 per day) Includes Landmark through May $514 in June 2016 Medical cost Pharmacy PMPM $505 $446 $478 as of 7/31 ($476 as of 6/30) Offsets Pharmacy rebates PMPM $22 $43 $48 PMPM for 2016 Cost per scrip at $115 and utilization at 4.15 Rx PMPM Generic Dispensing rate = 83% $473 as of June 2016 Lagging indicator Q not yet complete and data from 2017 being compiled. Q was $63.59 PMPM

47 Transitions of Care: 84% of our members have an ambulatory care follow-up visit within 30 days of discharge Q1 Q2 Q3 Q4 Q CA Average Source: CA 1.11 Ambulatory f/u after discharge; CA Average from Q

48 WiderCircle Connect. For Life. HPSM Pilot Status September 2017

49

50

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52 WiderCircle dual-eligible experience matches HPSM baseline

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54 QUALITY IMPROVEMENT COMMITTEE MEETING September 20, 2017, 6:00 p.m. 7:30 p.m. Health Plan of San Mateo 801 Gateway Blvd., Boardroom South San Francisco, CA AGENDA ITEM: 4.4 DATE: December 13, 2017 Members Present: Chair, Barbara Erbacher; Dr. Jeanette Aviles; Dr. Hung-Ming Chu; Dr. Nancy Morioka-Douglas; Dr. Maria Osmena and John Ferrelli HPSM Members Present: Dr. Cynthia Cooper; Nicole Ford; Leticia Mora; Vicky Perez and Kati Phillips HPSM Members Excused: Maya Altman and Dr. Margaret Beed 1. Call to Order The meeting was called to order by Commissioner Barbara Erbacher. A roundtable of introduction was provided by the QIC members. 2. Approval of QIC minutes from Jun 21, 2017 The QIC minutes was approved and seconded by the committee members. 3. Approval of the Clinical Quality Committee (CQC) minutes from Sep 11, The CQC minutes was approved and seconded by the committee members. 5. Approval of the Service Quality Improvement Committee (SQIC) minutes from Aug 25, 2017 The SQIC minutes was approved as presented and seconded by the committee members. 6. Approval of Utilization Management Committee (UMC) minutes from Aug 28, 2017 The UMC minutes was approved and seconded by the committee members. 7. Approval of Agenda The QIC agenda was approved as presented. 8. Clinical Guidelines for the Diagnosis and Management of Asthma Ms. Ford stated HPSM has an asthma guideline already approved by this committee earlier this year from Institute of Clinical Systems and Improvement (ICSI) website. To date, HPSM is pursuing a more comprehensive asthma guideline, which is through the U.S. Department of Health Care Human Services, National Heart, Lung and Blood Institute. Comment from Dr. Aviles if the asthma guideline from 2007 is for both adult and children, which was confirmed by Ms. Ford. Comment from Dr. Chu inquiring for a more current update. Ms. Ford stated the issue with the 2007 asthma guideline could supplement and/or replace from 2016 guideline through the Global Imitative for Asthma. Dr. Chu stated part of the recommendation in terms of medications might be slightly different from the standard practice in the United States. HPSM was looking to research a more comprehensive guideline in the standard medication Page 1 of 3 QIC Minutes September 20, 2017

55 practice in the U.S. Comment from Mr. Ferrelli inquiring how is the guideline presented to the committee; e.g., internal notification whether one product is better over the other product or not? Ms. Ford stated we have inquired with other Plans; there might be other possible guidelines available; and internal recommendation by HPSM medical directors to be approved by a committee for review. Comment from Dr. Chu concerning the 2016 global initiative guideline, the issue is whether the medication recommended is available in the United States. In addition, would the tables listed in the global initiative are compatible in the United States or not. Ms. Ford stated there is an updated guideline from ICSI for global initiative. Dr. Aviles will send to Nicole the NHLVI website endorsed by SMMC, which is a quick and a comprehensive reference. In addition, asthma is more of an issue in pediatrics versus adults. The committee will continue to search further for current guidelines. Ms. Ford recommended if the committee is not prepared to review the clinical guidelines at this time, we will defer at the next quarterly meeting. Additional suggestions were also recommended to research for other studies. Motion was deferred until next meeting. 9. Performance Improvement Programs 9.1. Post-Partum Care Leticia Mora is the Quality Improvement specialist to report on the results of the post- partum compliance. Separate presentation slides were provided in the program overview for postpartum care: Background Intervention Intervention results Lesson learned Feedback/discussion 9.2. Asthma Medication Ratio Ms. Mora reported on the asthma medication ratio where HPSM was slightly above the (MPL) minimal performance level. HPSM is currently focusing on an intervention if we should fall below the MPL. Ms. Mora is currently in the early stage of reviewing the data; identifying effective interventions and how to increase HEDIS rates around asthma medication compliance. Asthma medication ratio is controlled medications over total asthma medication by looking at controlled medications regularly versus by looking at emergency medications. HPSM has developed outreach scripts for the disease management program that could be used in an intervention to improve asthma medication adherence Cervical Cancer Screening Ms. Vicky Perez is the Quality Improvement specialist to report on the Cervical Cancer Screening data in the strategy for overall cervical cancer screening population. The eligible population is between 21 years old and 65 years old, which are divided into two sub-groups 1) members with PCP visit at SMMC clinic since 2014 and 2) members without PCP visit at SMMC clinic since For 2017, HPSM is looking at subgroups within the population by focusing Page 2 of 3 QIC Minutes September 20, 2017

56 on those assigned to 25 PCPs due for their pap tests in the last three years. Also for those women assigned to SMMC clinics. HPSM is required to do the process improvement project (PIP) by DHCS in the disparity group. DHCS requires a vigorous process to identify a health disparity. Quality looked for disparities in timely prenatal and postpartum care, asthma medication adherence and cervical cancer screenings. A statistically significant disparity was identified in the cervical cancer screening rates between English speaking women and non-english speaking women, where English speakers had statistically significant lower screening rates. Further analysis revealed that the majority of English speaking women who have not had cervical cancer screening in the recommended timeframe are eligible for Medi-Cal under Medi-Cal Expansion (MCE). Thus, the PIP program to improve cervical cancer screening rates among English speaking women will focus on the MCE population. 10. Nurse Advice Line Vendor Update Ms. Perez reported on the Nurse Advice Line (NAL) where HPSM has been using the same vendor since We recently concluded an RFP process and are currently in discussion with a new vendor to sign a contract soon. The new vendor is called Team Health based out of Tennessee. We will be presenting at the next Commission meeting to approve the contract with Team Health to take over NAL services January 1, Quality will be working with our Marketing and Provider Services departments. Meanwhile, members may continue to call the old number but will eventually be redirected to call the new number. 11. Texting Programs Ms. Ford stated HPSM will continue to use text messaging going forward as well as expanding to use for different quality improvement projects. 12. Cal MediConnect Quality Withhold Measures Ms. Ford reported on the performance on Demonstration Year 1, 2 and 3 Quality withhold measures from April 2014 through 2015 in the process measures for assessments and documentations for care goals. Separate presentation slides were provided in the program overview for Cal MediConnect Quality Withhold Measures. 13. Hospitalist Program & SNFist Program No update was provided at this time. 14. Next Meeting December 20, Adjourn the meeting adjourned at 7:30 p.m. with no further business. Page 3 of 3 QIC Minutes September 20, 2017

57 PHYSICIAN ADVISORY GROUP Meeting Minutes October 4, :30 a.m. San Mateo Medical Center 222 W. 39 th Avenue, Boardroom, 2 nd Floor San Mateo, CA AGENDA ITEM: 4.5 DATE: December 13, 2017 Committee Members Present: Committee Members Excused: HPSM Members Present: HPSM Members Excused: Drs. Hung-Ming Chu, Leland Luna, Vincent Mason, Kenneth Tai, Kamal Shamash, Janet Chaikind Drs. Roberto Diaz, James Hutchinson, Randolph Wong, Tom Stodgel Drs. Cynthia Cooper and Richard Moore Rhonda Bibbins, Pat Curran, Paul de la Cruz Maya Altman and Dr. Margaret Beed 1. Call to Order Dr. Janet Chaikind (Chair) called the meeting to order at 7:35am 2. Public Comment No public comment was offered. 3. Approval of April 2017 Meeting Minutes Meeting Minutes for August were approved by all committee members. 4. Approval of Agenda Dr. Mason made a motion to approve the October 4, 2017 meeting agenda and Dr. Chu seconded the motion. The agenda was approved unanimously. 5. New Business 5.1 Announcements Dr. Cooper notified the PRC/PAG members that there has been an improvement with the prior authorization process since the implementation of DocuStream. This has reduced the time it takes for the authorization assistants to process them. 5.2 Provider Services Announcements Rhonda stated that we continue to move forward with the first phase of the implementation of HealthTrio to be effective 1/1/2018 for the SB137 on-line provider directory. Page 1 of 2 Physician Advisory Minutes October 4, 2017

58 6. HPSM Update Pat stated that we are currently reviewing the payment models for primary care providers and will be updating by July of Adjournment The meeting adjourned to PRC Closed Session at 8:10 a.m. The next meeting of the Physician Advisory Group is scheduled for December 6. Page 2 of 2 Physician Advisory Minutes October 4, 2017

59 MEMORANDUM AGENDA ITEM: 4.6 DATE: December 13, 2017 DATE: November 2, 2017 TO: FROM: RE: San Mateo Health Commission Maya Altman, Chief Executive Officer Michael Smigielski, Chief Financial Officer Amendments to agreements with San Mateo County Public Authority and the City of San Mateo for HealthWorx Recommendation Authorize the Chief Executive Officer to execute amendments to agreements with the San Mateo County Public Authority and the City of San Mateo extending the HealthWorx insurance product; and increasing the monthly premium charged to the San Mateo County Public Authority and the City of San Mateo. The agreement terms are January 1, 2018 through December 31, Background In July 2001, the department of Managed health Care (DMHC) licensed HPSM s HealthWorx product to serve eligible In-Home Supportive services (IHSS) workers whose employer of record is the San Mateo County Public authority. IHSS workers provide personal care services for IHSS clients. Coverage was effective August 1, 2001 for the first enrolled IHSS workers. In January 2009, the DMHC approved a second expansion of eligibility for HealthWorx to include per diem employees of the City of San Mateo. HealthWorx has been provided to per diem city employees since March There are currently 1,056 HPSM members insured under HealthWorx. Discussion The HealthWorx premium schedule is renewed annually and is subject to premium rate adjustments based on benefit utilization experience, general medical inflation, and regulatory changes, including mandates required under the Affordable Care Act. The proposed premium increase has been discussed with and agreed to by officials from the Public Authority and the City of San Mateo. These increases will permit HPSM to sustain the program over the next year. Fiscal Impact The current monthly premium for the City of San Mateo is $235 and $242 for the San Mateo County Public Authority. Effective January 1, 2018, the monthly premium for both contracts will increase to $ for each member enrolled. The rates will remain in effect through December HPSM s HealthWorx program has been operating at a loss; this increase will bring the program closer to the breakeven point.

60 DRAFT RESOLUTION OF THE THE SAN MATEO COMMUNITY HEALTH AUTHORITY IN THE MATTER OF APPROVE AN AMENDMENTS TO AGREEMENTS WITH CITY OF SAN MATEO & SAN MATEO COUNTY PUBLIC AUTHORITY FOR HEALTHWORX RESOLUTION RECITAL: WHEREAS, A. The San Mateo Community Health Authority has entered into agreements with the City of San Mateo and the San Mateo County Public Authority to render covered services and supplies to members covered under the HealthWorx Program that are set forth in the HealthWorx Program Evidence of Coverage; B. The premium rates are subject to potential premium rate adjustments based on conformity to Affordable Care Act regulations and are analyzed by the Chief Financial Officer to ensure rates are appropriate and reasonable given claims experience; and C. All the parties wish to extend the HealthWorx insurance product through December 31, NOW, THEREFORE, IT IS HEREBY RESOLVED AS FOLLOWS: 1. The San Mateo Community Health Authority approves the proposed premium rate increase of $ for both City of San Mateo and the San Mateo County Public Authority and contract term extensions through December 31, 2018; and 2. Authorizes the Chief Executive Officer to execute said amendments. PASSED, APPROVED, AND ADOPTED by the San Mateo Community Health Authority this 13th day of December, 2017 by the following votes: AYES: NOES: ABSTAINED: ABSENT: Barbara Erbacher, Chairperson ATTEST: APPROVED AS TO FORM: BY: C. Burgess, Clerk Kristina Paszek DEPUTY COUNTY COUNSEL

61 MEMORANDUM AGENDA ITEM: 4.7 DATE: December 13, 2017 DATE: November 20, 2017 TO: FROM: RE: San Mateo Health Commission Maya Altman, Chief Executive Officer Amendment to Agreement with Delta Dental for the Healthy Kids Program Recommendation Approve an amendment to the Delta Dental agreement for the Healthy Kids Program to extend the agreement one year through 12/31/2018 Background Healthy Kids is a local insurance program serving lower income children from birth through age 18 who do not qualify for Medi-Cal. To be eligible for Healthy Kids, children must reside in San Mateo County and live in families with a household income above 266 percent and up to 322 percent of the federal poverty level (FPL). Healthy Kids provides medical, dental, and vision services. Discussion In 2003, HPSM began offering comprehensive dental services to Healthy Kids members, contracting with Delta Dental to manage a provider network, adjudicate and pay dental claims, perform utilization and medical management for dental services, and operate a member services call center. Historically it has been demonstrated that low income children have lower utilization of dental services, poorer oral health status, and more untreated oral disease as compared to privatelyinsured children. The partnership between Delta Dental and HPSM for Healthy Kids members has been very successful. This public-private collaboration has helped increase access to dental care for this underserved population. Healthy Kids members receive care anywhere in the county of San Mateo, thus eliminating the need to have to travel long distances to receive care. As of October 2017, 1,391 members Healthy Kids members benefit from this effective collaboration. In August 2016, the majority of Healthy Kids members transitioned to Medi-Cal with the implementation of new legislation providing Medi-Cal coverage for undocumented children. This action decreased Healthy Kids membership by approximately 2,000 children. Fiscal Impact This amendment extends the agreement with Delta Dental one year through December 31, The monthly premium paid to Delta Dental remains $22.94, the same as the prior year.

62 DRAFT RESOLUTION OF THE THE SAN MATEO COMMUNITY HEALTH AUTHORITY IN THE MATTER OF APPROVAL OF AN AMENDMENT TO THE AGREEMENT WITH DELTA DENTAL FOR THE HEALTHY KIDS PROGRAM RECITAL: WHEREAS, RESOLUTION A. The Health Plan of San Mateo has previously entered into an agreement with Delta Dental to provide dental benefits to Healthy Kids Members; B. A high number of children have been able to access dental care and receive needed dental treatment through Delta Dental s network; and C. Both parties wish to continue this agreement. NOW, THEREFORE, IT IS HEREBY RESOLVED AS FOLLOWS: 1. The San Mateo Community Health Authority approves the amendment to the agreement with Delta Dental for the Healthy Kids Program to continue the term of the agreement through December 31, 2018 at a per member per month rate of $22.94; and 2. Authorizes the Chief Executive Officer to execute said amendment. PASSED, APPROVED, AND ADOPTED by the San Mateo Health Commission this 13th day of December, 2017 by the following votes: AYES: NOES: ABSTAINED: ABSENT: Barbara Erbacher, Chairperson ATTEST: APPROVED AS TO FORM: BY: C. Burgess, Clerk Kristina Paszek DEPUTY COUNTY COUNSEL

63 MEMORANDUM AGENDA ITEM: 4.8 DATE: December 13, 2017 DATE: November 21, 2017 TO: FROM: San Mateo Health Commission Maya Altman, Chief Executive Officer Eben Yong, Chief Information Officer RE: Waive Request for Proposal Process and Ratify Approval of Technology Procurements through CDW Government, LLC. Recommendation Waive the RFP process and ratify approval of technology procurement with CDW Government, LLC, for software licenses and computer equipment, and professional services rendered, from January 1, 2017 December 31, Background CDW Government, LLC (CDWG) is a Fortune 500 global provider of software and computer equipment. HPSM has done business with CDWG for 15 years. CDWG is the Enterprise Software Advisor for our existing Microsoft Enterprise Agreements, in which they facilitate renewals, manage our contract and service our accounts. Discussion Software, equipment and services with CDWG for 2017 are, as follows: 1. IT Security Assessment - $36, Software Licenses (Adobe Acrobat, Symantec Encryption Suite) - $12, CISCO network equipment maintenance contracts - $8, Software Licenses (Microsoft: Office Suite, SQL Server, Windows Server) - $ 173, Software Licenses (Mobile Device Management) - $16, DELL Storage - $6,500 Fiscal Impact The technology products and licenses described herein are critical components of HPSM s IT infrastructure and are used on a daily basis by HPSM staff. The total amount requested for approval for 2017 is not to exceed $253,000.

64 DRAFT RESOLUTION OF THE SAN MATEO HEALTH COMMISSION and THE SAN MATEO COMMUNITY HEALTH AUTHORITY IN THE MATTER OF WAIVER OF REQUEST FOR PROPOSAL PROCESS AND RATIFY THE APPROVAL OF TECHNOLOGY PROCUREMENTS THROUGH CDW GOVERNMENT, LLC. RECITAL: WHEREAS, RESOLUTION A. The technology products and licenses described herein are critical components of HPSM s IT infrastructure and are used on a daily basis by HPSM staff. B. CDW Government, LLC (CDWG) is a Fortune 500 global provider of software and computer equipment. HPSM has done business with CDWG for 15 years. NOW, THEREFORE, IT IS HEREBY RESOLVED AS FOLLOWS: 1. The San Mateo Health Commission waives the request for proposal process and ratifies the approval of technology procurement through CDW Government, LLC as described in the attached memorandum in an amount not to exceed $253,000. PASSED, APPROVED, AND ADOPTED by the San Mateo Health Commission this 13th day of December, 2017 by the following votes: AYES: NOES: ABSTAINED: ABSENT: ATTEST: Barbara Erbacher, Chairperson APPROVED AS TO FORM: BY: C. Burgess, Clerk Kristina Paszek DEPUTY COUNTY COUNSEL

65 AGENDA ITEM: 4.9 MEMORANDUM DATE: December 13, 2017 DATE: December 4, 2017 TO: FROM: San Mateo Health Commission Maya Altman, Chief Executive Officer RE: Commission Meeting Schedule for 2018 The San Mateo Health Commission meetings will be held on the 2 nd Wednesday of the month at 12:30 p.m. at the Health Plan of San Mateo, 801 Gateway Blvd., 1 st Floor Boardroom, South San Francisco. Generally, the Commission meets nine times a year. Below are the meeting dates planned for 2018, unless notified otherwise. Please note there will be no meeting scheduled for the months of February, June, or September. January 10, 2018 March 14, 2018 April 11, 2018 May 9, 2018 July 11, 2018 August 8, 2018 October 10, 2018 November 14, 2018 December 12, 2018

66 RESOLUTION OF THE DRAFT SAN MATEO HEALTH COMMISSION and THE SAN MATEO COMMUNITY HEALTH AUTHORITY IN THE MATTER OF SAN MATEO HEALTH COMMISSION MEETING DATES FOR 2018 RECITAL: WHEREAS, RESOLUTION A. The San Mateo Health Commission meets on the 2 nd Wednesday of the month at 12:30 p.m. at its offices in South San Francisco; and B. The Commission wishes to adopt a schedule for 2018 for its scheduled meetings. NOW, THEREFORE, IT IS HEREBY RESOLVED AS FOLLOWS: 1. The San Mateo Health Commission adopts the schedule to meet on the 2 nd Wednesday of each month at 12:30 pm with the exception of February, June and September PASSED, APPROVED, AND ADOPTED by the San Mateo Health Commission this 13 th day of December, 2017 by the following votes: AYES: NOES: ABSTAINED: ABSENT: Barbara Erbacher, Chairperson ATTEST: APPROVED AS TO FORM: BY: C. Burgess, Clerk Kristina Paszek DEPUTY COUNTY COUNSEL

67 DRAFT SAN MATEO HEALTH COMMISSION and SAN MATEO COMMUNITY HEALTH AUTHORITY Meeting Minutes November 8, :30 p.m. Health Plan of San Mateo - Boardroom 801 Gateway Blvd., Suite 100 South San Francisco, CA AGENDA ITEM: 4.10 DATE: December 13, 2017 Commissioners Present: Jeanette Aviles, M.D. Don Horsley David J. Canepa Peggy Jensen Barbara Erbacher, Chair George Pon, R.Ph. Si France, M.D. Ligia Andrade Zuniga Commissioners Absent: Counsel: Staff Present: Teresa Guingona Ferrer Kristina Paszek Maya Altman, Gabrielle Ault-Riche, Chris Baughman, Margaret Beed, M.D., Corinne Burgess, Pat Curran, Karen Fitzgerald, Robert Fleming, Nicole Ford, Francine Lester, Ian Johansson, Colleen Murphey, Khoa Nguyen, Sophie Scheidlinger, Melora Simon, Vicki Simpson, Michael Smigielski, Katie-Elyse Turner, and Lia Vedovini. 1. Call to order/roll call The meeting was called to order at 12:30 p.m.by Commissioner Erbacher. A quorum was present. 2. Public Comment Ms. Erbacher introduced Si France, M.D., who was appointed to the Commission in July Dr. France provided some information about his professional background as a physician and a health care business entrepreneur. There was no public comment. 3. Approval of the Agenda Commissioner Horsley moved approval of the agenda as presented. M/S/P. 4. Approval of Consent Agenda Commissioner Horsley moved approval of the consent agenda as presented. M/S/P. 5. Specific Discussion/Action Items 5.1 Update on Cal MediConnect and Coordinated Care Initiative Ms. Altman noted that the consent agenda includes the ratification of an amended threeway agreement between HPSM, DHCS and CMS extending the Cal MediConnect (CMC) program for another two years through It was originally scheduled to end December Ms. Altman introduced Melora Simon, Director of Adult Demonstration Projects, who presented a CMC program and financial update. 1 of 6 November 8, 2017 Commission Meeting Minutes

68 Ms. Simon reviewed the attached presentation: Background of CareAdvantage Cal MediConnect and beneficiary demographics; Program extension through December 2019 but beginning in January 2018 IHSS fiscal responsibility reverts to the County; HPSM performance based on national customer survey rating showing HPSM as third in the nation relative to other health plans; HPSM membership reaching about 60% of the eligible market with current enrollment at 9,200 and another 6,000 who have Medi-Cal with HPSM but have Medicare covered somewhere else (predominantly fee-for-service); and approximately 1,500 with Kaiser Dual Eligible Special Needs Plan (D-SNP); Membership declining about 10% since 2015 mostly due to members moving out of the area, passing away, or losing Medi-Cal coverage. Previous HPSM D-SNP included a six month rather than a two month deeming period, allowing more time for recovery of Medi-Cal coverage before Medicare disenrollment triggered; 75% of members over 65 years of age; half in North County and remainder split between central and south county ; Timely Health Risk Assessments (HRAs) performed on about 50% of new members, with about one-third unwilling to participate; new vendor starting and new strategies for reaching more difficult populations being developed; Individualized Care Plans (ICPs) developed with member input; new vendor consolidating ICP and HRA implementation; Engagement with primary and ambulatory care network high; nearly 90% of members have seen a PCP in the last year and 84% have some kind of ambulatory care follow up visit 30 days after discharge from a hospital; HomeAdvantage program, team based care in the home for members with five or more chronic illnesses, launched one year ago and growing quickly; Growth in IHSS case load, adult day health care participation, and continued engagement with MSSP, together with a general decline in long term care institutionalization (one time growth in 2017 due to developmentally disabled members who live in care facilities transitioning to CMC); 100% of quality withholds earned back for 2014 and 50% for 2015; HPSM appears to be doing well for 2016 quality performance; Lost money since 2014 and budgeted for a loss in 2017; initially experienced losses in Medicare with surpluses for CMC Medi-Cal; however, rates restated earlier this year by State and now losses for both Medicare and Medi-Cal CMC. Year to date budgeted CA Medicare medical loss ratio (MLR) is 103% but actual YTD is 98.7%; revenue is down $4.6 million due to membership losses and due to member mix and risk scores; Medical expenses lower than expected partly due to reduced membership but also due to better than expected pharmacy expenses; Savings opportunities identified or implemented in 2017 to reduce Medicare losses, including description of initiatives, owners, and timeframes; benefits may not be realized until 2018; MLR Dashboard for monthly tracking of initiatives relative to 2017 budget targets; and 2 of 6 November 8, 2017 Commission Meeting Minutes

69 Expected issues in 2018 including continued downward pressure on revenues, new payment arrangements with PCPs, and continued work on savings initiatives. Ms. Altman added that HPSM, together with the other CMC plans in California, has submitted a rate restructuring proposal to DHCS that will improve CMC Medi-Cal revenues. Commissioner Aviles commented that as a provider it is difficult to determine if a patient is in CMC. Costs could be higher and support for the member more problematic if a patient is not a CMC member. 5.2 Presentation on California Children s Services Demonstration Pilot Ms. Altman noted that HPSM is the only health plan in the state involved in a CCS pilot. However, the pilot program is scheduled to expand to several other health plans in She introduced Sophie Scheidlinger, the Pediatric Health Manager in Health Services who oversees the CCS Pilot. Ms. Scheidlinger reviewed the presentation included in the Commission packet. She covered the background of the CCS program, which began in 1927 and has traditionally been a partnership between the State and counties. HPSM s pilot began in April The pilot, now known as the Whole Child Model, brings treatment and management of a child s CCS and non-ccs conditions together, including utilization management, care coordination, and claims payment, under one accountable entity. Prior to the pilot, County CCS was responsible for authorizing services and care coordination for the child s CCS condition while HPSM was responsible for all non-ccs related health care. This fragmented approach created confusion for the families and often did not allow for the most effective care to be provided. The pilot goals are to reduce fragmentation of care; preserve quality of care and access to specialized providers ; explore new strategies to improve health outcomes, access, and quality of care, provider satisfaction and support; and decrease financial/operational inefficiencies. Major 2017 initiatives included implementation of new technology systems for authorizations and care coordination; development of a value based purchasing program for private duty nursing agencies to increase access/quality for children requiring these services; and exploring delegation of care coordination with Lucile Packard Children s Hospital and Kaiser. In 2018, HPSM will implement of the State s new Whole Child Model (which is slightly different than the HPSM pilot) along with the other County Organized Health Systems approved for implementation in legislation approved in In addition to implementing the LPCH delegated care coordination model, the Pilot will work with other community partners to provide improved care coordination. 3 of 6 November 8, 2017 Commission Meeting Minutes

70 Commissioner Aviles asked if the new Care Coordination system (MedHOK) is for HPSM internal use only. Ms. Scheidlinger explained that it is; however, County partners that are co-located with HPSM, such as County CCS staff, work in the system as well. Ms. Altman added that the Pilot advisory committee and family sub-committee are very active and provide important feedback. Initiatives to improve access to private duty nursing, improve timely access to medications, and enhance customer services for families whose children need incontinence supplies were all driven by concerns expressed by the ten or so family members participating in the committee. Commissioner Erbacher asked about increasing payment to home care nurses. Dr. Beed explained this was part of the private duty nursing value based payment initiative; HPSM increased payments to the agencies in return for access and quality guarantees. The increased payment helps these agencies recruit nurses by paying higher wages. 5.3 Discussion/Action on Grant Agreement with Lucile Packard Children s Hospital Ms. Altman explained the recommendation is to approve a two year agreement under which LPCH will provide care coordination for eligible HPSM members. The agreement total is $790,000 and the program begins on December 1, This agreement is directly related to the CCS Pilot project. Lucile Packard is the largest CCS provider for San Mateo County; over 80% of CCS the kids go to LPCH specialty providers. In 2014, Packard received an innovation award from CMS to test the impact of care coordination for children with complex medical conditions. About a third of those involved were HPSM members. While we are still reviewing evaluation results, the preliminary information is positive. We also believe the most effective care coordination happens closest to where care is actually delivered. Also, the State s Health Homes project is scheduled in begin in 2019; health plans will be required to contract with providers to offer care coordination at care delivery sites. This program will help us prepare for Health Homes. Commissioner Aviles asked if other funders are involved in this program. Ms. Scheidlinger explained LPCH has other funding; HPSM funds will be used to cover HPSM members. Commissioner Jensen moved approval of the grant agreement as presented. M/S/P. 5.4 Report on 2017 HEDIS Results Ms. Altman introduced Ms. Nicole Ford, Quality Improvement Manager, who presented the 2017 HEDIS results. A copy of her presentation is attached: In 2014, HPSM was ranked ninth among state health plans based on a HEDIS aggregated quality factor score; in 2017, HPSM moved up to seventh place. HPSM performed 8,813 chases of medical record locations and 4,612 record abstractions and reviews in an eight week period for this year s HEDIS effort. No HPSM measures were below the Minimum Performance Level (MPL). Two measures were above the High Performance Level (HPL). For the Cal MediConnect program, all HEDIS measures were above the CMS core quality withhold benchmark. 4 of 6 November 8, 2017 Commission Meeting Minutes

71 For childhood immunizations, HPSM was above the HPL at 82.99% and scored second highest among all plans in the state for this measure. Cervical cancer screening is a measure of considerable focus for HPSM. The eligible population went from 6,000 women to 20,000 between 2014 and 2017 due to the ACA and Medi-Cal Expansion. Results for this measure were above the MPL for 2017 despite the large increase in membership. Timely prenatal care was at 82.63%, midway between the MPL and HPL. Postpartum care was closer to the HPL at 67.11% The score for controlling high blood pressure (BP) decreased in the past year but is still above the benchmark. A possible reason for the decrease is difficulty accessing medical records since this information is not in claims data. Also, the result is based on the last BP reading of the year. A pilot using home BP monitoring units is being tested with the results flowing directly to the member s electronic medical record. Diabetes care has improved in most measures with significant improvement in AbA1c control, which can have a meaningful impact on overall health. Plan all-cause readmissions tracks readmissions within 30 days of initial hospital discharge. A lower rate indicates fewer readmissions. HPSM scored a slight increase compared to the prior year; however, the score is still below the CMS benchmark (a lower score is better). Follow-up after hospitalization for mental illness requires a follow up appointment with a behavioral health provider within 30 days of a hospital discharge; HPSM s score improved markedly compared to the prior year, bringing us above the CMS benchmark. Commissioner Zuniga noted there are many barriers for people with disabilities that may prevent access to cervical cancer screening. She recommended HPSM examine these equipment and access issues. Ms. Ford said HPSM staff conducts medical office assessments that focus on these types of issues. Commissioner Aviles noted that CAIR (California Immunization Registry) was updated this year, creating significant challenges for providers. The data is likely incomplete for this year. Ms. Ford said that staff may need to do more chart reviews to find the data. Commissioner Pon noted that the standards for appropriate BP levels are changing. Dr. Beed responded while standards may be changing the NCQA HEDIS measure has not yet changed. 5.5 Annual Fraud, Waste, Abuse (FWA) and Compliance Training Mr. Ian Johansson presented the annual trainings required by the state and federal government. His presentation was included in the Commission packet. He provided an overview the Commission s role as the oversight body of the Health Plan of San Mateo for compliance and fraud, waste and abuse prevention and monitoring. He reviewed the relevant laws and regulations, as well as the seven core elements of an effective compliance program, including policies and procedures, a code of conduct, a Compliance Officer, a Compliance Committee, Commission oversight, training and education, 5 of 6 November 8, 2017 Commission Meeting Minutes

72 appropriate lines of communication, and publicized disciplinary standards. Mr. Johansson also reviewed reporting lines, including the corporate structure and how appropriate reporting is achieved throughout the organization and to our state and federal governing agencies. Related to FWA, Mr. Johansson outlined prevention strategies and the various types of FWA, how they are detected, and what should occur based on HPSM policies and procedures. He reviewed the major federal laws and civil law processes; anti-kickback laws; HIPAA regulations; and how HPSM ensures that organizations and individuals on government exclusion lists are prevented from contracting with or working for HPSM. Finally, Mr. Johansson reviewed the compliance life cycle: Prevent, Detect, Report, Correct, and Monitor/Audit. He described how HPSM works through these steps. 6. Report from Chairman/Executive Committee Commissioner Erbacher had no report. 7. Report from Chief Executive Officer Ms. Altman reported that John Ferrelli has left his position as CEO of Seton Medical Center and has resigned from the Commission. HPSM will host its 30 th anniversary celebration on Monday, December 4, Congresswoman Anna Eshoo, who helped found HPSM, Jennifer Kent, Director of the State Department of Health Care Services, and other elected officials are expected to attend. HPSM s 2018 budget will be presented for approval at the December Commission meeting. 8. Other Business There was no other business. 9. Adjournment The meeting was adjourned at 2:11 p.m. Respectfully submitted: C. Burgess C. Burgess Clerk of the Commission 6 of 6 November 8, 2017 Commission Meeting Minutes

73 CareAdvantage Cal MediConnect Update November 8, 2017 Today s discussion: CareAdvantage CMC Overview of CareAdvantage Cal MediConnect Background: Launched in April 2014, as part of a federal alignment demonstration in 10 states that integrates benefits for members who are dually eligible for Medicare and Medicaid. HPSM context: Rolled D-SNP members in starting in January 2015 and closed the D-SNP at the end of 2016, once special legislation to include the developmentally disabled was enacted. Demonstration has been extended to the end of 2019, but as of January 1, 2018, the responsibility for In-Home Supportive Services has reverted to the county. Beneficiaries are among our most vulnerable, with high needs: Average age is 72 72% have high blood pressure 45% have arthritis 43% have a mental health diagnosis 25% receive In-Home Supportive Services 7% of membership but 30% of expenditures Lots of names/acronyms for the same program: CareAdvantage, CMC, MMP, DDP

74 Overall, CareAdvantage CMC outperforms other Duals (MMP) plans in California and across the country Overall Rating of Health Plan 2016 Growth in rating of 9 or 10 relative to %* 6% 85% 8% 86% 8% HPSM was ranked 3 rd in the nation! *Note: Our score for 2016 was 88%, based on a case-mix adjustment applied by CMS. 12/6/ Membership: We have about 60% of the reachable market and enrollment has declined by 10% since CA CMC has experienced a 30% increase in disenrollments relative to the D-SNP, likely due to shorter deeming period (2 mos. vs 6 mos.) Other plans have also experienced declining enrollment since launch, though IEHP and LA Care have recently seen growth 12/6/2017 4

75 Demographics: ~75% of CMC members are over 65 Average monthly membership Under Overall, membership is aging Conversion of the developmentally disabled population to CA CMC accounts for the rise in Under 65s in Q Average age Half of CMC membership is in North County with the rest roughly split between Central and South Average monthly membership OOC Coast Central South North Q1 2017

76 Assessments: We conduct timely assessments on about 50% of new members, with about a third not willing to participate HRA Completion within 90 days (CM 2.1) 2016 and % 39% 42% 38% 51% 60% Members unwilling to participate (CM 2.1) 2016 and % 26% 31% 36% 23% 9% Q2 Q3 Q Q1 Q2 CA Avg Q2 Q3 Q Q1 Q2 HRAs completed CA Avg Health plan unable to locate (CM 2.1) 2016 and 2017 Selected a new vendor for HRAs who started on October 1 Source: Core Measure 2.1; CA Average from NORC using Q data. 12/6/ % 29% 25% 27% Q2 Q3 Q Q1 23% 24% Q2 CA Avg Care plans: We brought on a vendor to support Care Plan completion in Q which resulted in improvements Number of HRAs completed High risk members Low risk members Timely High Risk Member ICPs completed (CA 1.2) % 60% 38% 43% 21% Q1 Q2 Q3 Q4 CA Avg 73% 55% Q1 Q Q1 Q2 Q3 Q4 Q1 17 Q2 Timely Low risk member ICPs completed (CA 1.4) Consolidated vendors as of October 1 st 2017 in order to sustain and improve performance 47% 67% 45% 52% 23% Q1 Q2 Q3 Q4 CA Avg 75% 56% Q1 Q Source: CA 1.2 and CA 1.4; CA Average from NORC using Q data. 12/6/2017 8

77 Engagement with Primary and Ambulatory Care is high, including our HomeAdvantage program Members who have seen any PCP in the last year % Members with an ambulatory care follow-up visit within 30 days of discharge % Members engaged by HomeAdvantage team 2017 January 99 Q % 84% February 171 March 247 Q % 83% April May June 457 Q % 82% July 498 August 611 California Average is 70% September October /6/ Overall, utilization of LTSS has rebalanced towards home and community based services Number of unique members using services, 2016 and 2017 IHSS CBAS Q1 Q2 Q3 Q Q1 MSSP Q2 88 Long Term Care Q1 Q2 Q3 Q Q Q2 IHSS and CBAS continues to rise MSSP was down in Q1 and Q due to shortstaffing Rise in LTC in Q due to transition of the developmentally disabled into CMC Q1 Q2 Q3 Q Q1 Q2 Q1 Q2 Q3 Q Q1 12/6/ Q2

78 Performance on Initial Quality Withhold measures (2014 and 2015) Measure Source Benchmark 2015 Passed? CW1 Assessments CMS defined process measure % (Highest scoring state plan minus 10 points) 77% N CW2 Consumer Governance Board CMS defined process 100% 100% Y measure 5.3 CW3 Customer service CAHPS 86% 82% N CW4 Encounter Data MMP Encounter Data 80% within 180 days of date of service 95% Measure excluded CW5 Getting Appointments and Care Quickly CAHPS 74% 75% Y CAW1 Documentation of Care Goals CAW2 BH Shared Accountability MOU and P&Ps CAW3 Mental Health Shared Accountability ICP with Primary Mental Health Provider CAW4 Interaction with Care Team CAW5 Ensuring Physical Access to Buildings, Services and Equipment State defined process measure CA 1.6 State defined process measure CA 2.2 State defined process measure CA 1.7 State defined process measure CA 1.12 State defined process measure CA % 3.7% N 100% 100% Y Highest scoring state plan minus 10 points Measure suspended 90% 75% N 100% 100% Y n/a 2014: Earned 100%, worth $519k 2015: Earned back 50%, $1.2 million 12/6/ Performance on Ongoing Quality Withhold Measures (2016 onwards) Indicator Target 2016 Performance Recent Performance/Notes CW6 Plan all-cause readmissions 11% 15.19% overall 10.48% STAR Metric (2016) CW7 Annual flu vaccine 69% 73% (2016) 77% (2017) CW8 Follow-up after hospitalization for mental illness 30 day 56% Improvement = 40.8% 14.85% overall for rolling 12 months through 1Q % (2016) Quarterly report in process CW10 Reducing the risk of falling 55% 77% (2016) 2017 data available in 2018 CW11 Controlling blood pressure 53% 64.37% (2016) Medical record based, no interim reporting CW12 Medication adherence for 73% 84% (2016) 94% for 2017 to date diabetes medications CW13 Encounter Data monthly 80% 92% submitted within 180 days for Medicare (2016) 94% for 2017, up to July CAW 7 - Reduction in emergency room use for seriously mentally ill and substance use disorder enrollees CAW 9 - Percentage of members who have a care coordinator and at least one care team contact (CA 1.12) CAW 8 - Number of members with at least one documented discussion of care goals in the individualized care plan (CA 1.6) CAW3 Mental Health Shared Accountability ICP with Primary Mental Health Provider (CA 1.7) Proposed benchmark: 83.6 per 1000 member months Proposed 2016 and 2017: 78% Proposed 2016 and 2017: 55% TBD - Highest scoring state plan minus 10 points 89.6 per 1000 member months (2016) 89.2 per 1000 overall for rolling 12 months through Q % (2016) 88.3% - Rolling 12 months as of 5/31/ % (2016) Estimate may be revised Measure suspended for 2014, 2015, and 2016 Monthly report in process Development of baseline report in process 12/6/

79 We have lost money on CA CMC since it began in 2014 and budgeted for a loss in 2017 CareAdvantage CMC Medi-Cal CMC* $ Millions MLR $ Millions MLR % % % % % % 2017 Budget % % Source: February 2017 Finance Committee Reports, restated using most recently updated Medi-Cal rates applied to actual dates of service. 12/6/ September YTD 2017 Snapshot: CA CMC only Membership Monthly average % 9386 Capitation revenue $, PMPM Healthcare expenses $, PMPM Budget 1577 Budget 1618 Actual 1562 Actual -1.0 % -4.7 % YTD MLR is 98.7% (Budget was 103%) Revenue was unfavorable to budget by $4.6 M ($3.4 M membership, $1.2M member mix) Medical expenses were favorable to budget by $10M $3.5M due to lower than expected membership Remaining $6.5 M due to better than expected Rx expenses 1542 Budget Actual 12/6/

80 Estimated sizing of opportunities implemented or identified in 2017 Conversion of 2017 budgeted CA-CMC losses to PMPM targets 90% MLR target $212 PRELIMINARY ESTIMATES Quality Withhold (100%) More accurate risk adjustment Inpatient cost Rx unit cost Rebates and other Rx initiatives Gap to get to 90% $75 $21 $0.37 $58 $22 $36 Started by converting the 90% MLR goal to a PMPM amount based on 2017 budget Created estimates of identified opportunities if realized, these would get us to a 95% MLR Meeting the quality withhold would get us almost all the way there on the Medi-Cal side, so we have focused on the Medicare side Source: 2017 Budget; Cost of Healthcare Savings Goals; PopHealthCare May report; Internal analysis. 12/6/ Overview of 2017 initiative implementation and realization timeframe Description of initiatives Owner(s) Implementation timeframe Realization timeframe QW Sustain high performance on existing measures Continue to refine processes to improve performance on Care Team Contacts (CA 1.12) and Documented Discussion of Care Goals (CA 1.6) and Care coordination with mental health provider (CA 1.7) Shared accountability with BHRS Nicole (HEDIS) Marwan/Dr. Beed (Rx) Terry (Encounters) Leilani (MOC) Ed (BHRS) Ongoing Q for 1.12 and Q4 for 1.6 and months after year end RA Continued optimization of our risk adjustment program Integration of Landmark s efforts for their engaged members Katie-Elyse Miriam (Landmark) Ongoing Data in; Analysis of impact by Q for 2017 DOS IP Acute Inpatient Increase time spent on concurrent review and early discharge planning Strengthen program support (Landmark) Enhance handoff between IP and Care Coordination teams DRG Outlier payment work Skilled Nursing/LTC Introduce SNFist program for short and long term stays SNF Value-Based Payment Continued expansion of CCSP Marwan/Dr. Beed (All) Matt (Outliers) Pat (SNF rates) Preston (CCSP) Acute Ongoing SNFist by Q SNF payment by Q CCSP as of Q2 End of 2018 Rx Vendor management to ensure price and rebate targets met PCP outreach to improve Generic Dispensing Rate and Generic switching Continued focus on PDE Reconciliation Strengthening of DUR efforts Marwan/Dr. Beed Q End of 2018 E/DE Birthday campaign (goal of 125 new enrollments per month) Karen (Sales) Continued efforts to keep deeming success rate at 50% with Charlene (Deeming) potential focus on institutional members Continued efforts to keep voluntary disenrollment low Ongoing Ongoing 12/6/

81 We have developed an MLR Dashboard for monthly tracking Category Proposed Indicator 2017 Budget Mid-2017 Target Most Recent Performance Revenue Enrollment 9,628 9,628 9,241 as of 10/1 YTD Average 9,386 Revenue Final RAF (2016 DOS) as of 10/15 (1.360 as of 9/15) Notes UPDATED 10/30/2017 Continue to lose more members than new enrollments 76 new enrollments from September report 69/123 regained from deeming as of 10/1 Based on estimate of final. Only includes RAPS Final RAF for 2016 was 1.3. Future Revenue Medical cost RAF Capture (2017 DOS) Acute Inpatient PMPM N/A TBD 67% for Q2 (28% for Q1) $383 $384 $424 as of 9/30 ($436 as of 8/31) Medical cost SNF PMPM $79 $78 $99 as of 9/30 ($96 as of 8/31) 2016 Q2 was 64%; 2016 Q1 was 28%: Q3 was 82% in 2016 Admits per 1000 at 307 (down from 314 last month, target of 275). Average paid per admission at $16,563 (down from $16,645 last month, target of $16,921) Days per 1000 at 1,948 (up from 1,871 last month, target of 1500) and paid per day at $610 due to systems issue (down from $613 last month, target of $558 per day) Medical cost Physician, OP, and Other PMPM $530 $530 $506 as of 9/30 ($502 as of 8/31) Medical cost Pharmacy PMPM $505 $446 $477 as of 9/30 ($479 as of 8/31) Offsets Pharmacy rebates PMPM $22 $43 $35 PMPM for 1Q 2018 as of 9/15 wire; $66.27 for 2016 Cost per scrip at $115 and utilization at 4.16 Rx PMPM Generic Dispensing rate = 83% Lagging indicator 9/15 wire is only the first payment for Q12017, so it is incomplete 12/6/ On the horizon for Continued downward pressure on revenues 4% savings built in to demonstration offsets increase in Part C revenue Changes to risk adjustment 6% reduction in Part D premium 2. Exploring new payment arrangements for PCPs 3. Continuing to identify additional opportunities for savings 12/6/

82 HEDIS 2017 Results San Mateo Health Commission November 8, 2017 HEDIS Health Effectiveness Data Information Set Performance metrics that assess the effectiveness and access/availability of care Measured and reported annually: Submitted mid-june for prior calendar year s membership and services Compared across health plans nationally Most measures based on claims, pharmacy and laboratory data (Administrative), some require the use of medical record review as well (Hybrid) All submissions require passing NCQA audit prior to reporting

83 Benchmarks Medi-Cal: Minimum performance level (MPL) is the lower 25 th percentile and High performance level (HPL) is the upper 90 th percentile Based on prior year s HEDIS reporting from all NCQA s national Medicaid plans DHCS requires plans to perform above MPL for a mandatory set of HEDIS measures (29 in total) CareAdvantage Cal MediConnect (CMC) CMS Core Quality Withhold Measures Can meet benchmark or gap improvement target to pass measure (10% improvement or at least 1% rate change)

84

85 HEDIS Submissions to NCQA: Medi-Cal, CareAdvantage CMC Vendor for medical record abstraction, staffed oversight and project coordination 8,813 chases (medical record locations) 4,612 medical records abstracted and reviewed 8 weeks Medi-Cal Results: No measures below MPL 2 measures above HPL: Childhood Immunization Status, combination 3 (CIS-3) Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) CareAdvantage CMC Results: All HEDIS measures above CMS core quality withhold benchmarks

86 Childhood Immunizations Percentage of Medi-Cal children fully immunized by the age of 2 (Combo 3: all doses of DTaP, IPV, MMR, HiB, HepB, VZV, PCV) 90.0% 80.0% 80.3% 75.56% 82.11% 81.60% 78.08% 82.99% 70.0% 60.0% HPL MPL 50.0% 40.0% Reporting Year Pay for Performance (P4P) incentive of $1 per pediatric member per month for PCPs who utilize and actively participate in the California Immunization Registry 90% 80% 82.99% Childhood Immunizations - Combination 3 for all MCOs HEDIS % 60% 50% 40% 30% SFHP- San Francisco HPSM - San Mateo Kaiser SoCal- San Diego CCAH- Monterey/Santa Cruz Kaiser NorCal- KP North SCFHP- Santa Clara CenCal - Santa Barbara CCHP- Contra Costa Health Net- Los Angeles ABC- San Francisco Health Net - San Diego Partnership - Southeast Alameda Alliance for Health- Alameda Health Net- Tulare ABC- Santa Clara ABC- Tulare IEHP- Riverside/San Bernardino ABC- San Benito ABC- Madera CalOptima- Orange County CalViva- Madera County ABC- Region 1 LA Care - Los Angeles ABC- Kings ABC- Fresno Care First- San Diego ABC- Alameda CenCal - San Luis Obispo CHG- San Diego CHW- Region 1 CalViva- Kings Partnership - Southwest ABC- Sacramento CCAH- Merced CHW- Imperial Molina- San Diego ABC- Region 2 CalViva- Fresno GCHP- Ventura KFHP- Kern ABC- Contra Costa Molina - Riverside/San Bernardino Molina - Imperial Health Net- Sacramento HPSJ- San Joaquin Partnership - Northwest Molina - Sacramento Health Net - Kern Health Net - Stanislaus CHW- Region 2 HPSJ- Stanislaus Partnership- Northeast Health Net - San Joaquin Rate MLP HPL Wt Ave

87 Cervical Cancer Screening: Percentage of women ages with Medi-Cal who received a pap test in the last 3 years or a pap test and HPV test within the last 5 years: 90.0% % % 60.0% 50.0% 40.0% 62.0% 66.33% 61.80% 55.10% 54.79% 55.26% Eligible Members ( Thousands) HPL 30.0% Reporting Year 0 MPL EP Increase in eligible population with Medi-Cal Expansion (MCE) Quality improvement efforts targeting younger (20-30s) female members that are now more prevalent in the eligible population Developing a performance improvement program (PIP) targeting MCE women 90% Cervical Cancer Screening for all MCOs HEDIS % 70% 60% 55.26% 50% 40% 30% Kaiser NorCal (KP Cal LLC) Kaiser SoCal (KP Cal LLC) SFHP - San Francisco PHC - Southeast CenCal - Santa Barbara Health Net - Tulare Anthem Blue Cross - Tulare CalViva - Fresno CHW - Imperial Alameda Alliance for Health ABC - San Francisco Molina - San Diego LA Care - Los Angeles PHC - Southwest CenCal - San Luis Obispo IEHP - Riverside/San Bernardino CCHP - Contra Costa KFHP - Kern CareFirst - San Diego CalViva - Kings CalViva - Madera SCFHP - Santa Clara CCAH - Merced ABC - Region 2 HPSM - San Mateo CHG - San Diego CCAH - Monterey/Santa Cruz GCHP - Ventura ABC - Madera CalOptima - Orange CHW - Region 2 PHC - Northeast ABC - Santa Clara Molina - Sacramento ABC - Alameda HPSJ - Stanislaus ABC- San Benito Molina - Riverside/San Bernardino Molina - Imperial ABC - Sacramento ABC - Kings ABC - Fresno ABC - Region 1 PHC - Northwest Health Net - Stanislaus Health Net - Los Angeles CHW - Region 1 HPSJ - San Joaquin Health Net - Sacramento ABC - Contra Coasta Health Net - Kern Health Net - San Diego Health Net - San Joaquin Rate MPL HPL Wt Ave

88 Prenatal Care: Percentage of Medi-Cal deliveries that received a prenatal care visit within the first trimester or 42 days of enrollment if the member became enrolled after the first trimester 95.0% 90.0% HPL MPL 85.0% 80.0% 81.9% 84.18% 82.66% 77.89% 79.95% 82.63% 75.0% 70.0% 65.0% 60.0% Reporting Year Regularly monitoring timely access to OB providers via secret shopper calls Working to maintain and expand OB provider network through enhanced reimbursement and promotion of performance incentives 100% Timely Prenatal Care for all Medi-Cal MCOs HEDIS % 90% 85% 82.63% 80% 75% 70% 65% 60% 55% 50% CenCal - Santa Barbara Kaiser SoCal (KP Cal LLC) Kaiser NorCal (KP Cal LLC) CenCal - San Luis Obispo CCHP - Contra Costa ABC - San Benito PHC - Southwest ABC - Tulare Health Net - Tulare ABC - Region 1 CalViva - Fresno CHW - Region 2 CalViva - Kings ABC - San Francisco ABC - Santa Clara PHC - Southeast SFHP - San Francisco CalOptima - Orange CCAH - Monterey/Santa Cruz Alameda Alliance for Health PHC - Northwest ABC - Sacramento GCHP - Ventura CHW - Region 1 ABC - Region 2 CHW - Imperial IEHP - Riverside/San Bernardino Molina - San Diego HPSM - San Mateo SCFHP - Santa Clara CalViva - Madera Health Net - Stanislaus Health Net - Sacramento PHC - Northeast CCAH - Merced ABC - Contra Coasta CHG - San Diego Health Net - Kern ABC - Kings Health Net - Los Angeles ABC - Fresno Care First - San Diego Molina - Riverside/San Bernardino Health Net - San Joaquin Molina - Imperial Health Net - San Diego ABC - Alameda HPSJ - San Joaquin HPSJ - Stanislaus ABC - Madera KFHP - Kern Molina - Sacramento LA Care - Los Angeles Rate MPL HPL Wt Ave

89 Postpartum Care: Percentage of Medi-Cal deliveries with a postpartum visit between 21 and 56 days after delivery 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 61.2% 59.18% 59.55% 63.07% 64.84% 67.11% HPL MPL 50.0% 45.0% 40.0% Reporting Year Continuing our Prenatal Care program that outreaches to pregnant members and provides incentives for receiving timely care during and after their pregnancy Collaborating with SMMC 39 th Ave. OB clinic on a PIP to increase postpartum visits that occur within the 21 to 56 days post-delivery timeframe 90% Postpartum Care for all Medi-Cal MCOs HEDIS % 70% 67.11% 60% 50% 40% 30% Kaiser SoCal (KP Cal LLC) CCAH - Monterey/Santa Cruz CCHP - Contra Costa CenCal - Santa Barbara Kaiser NorCal (KP Cal LLC) PHC - Southeast ABC - Tulare SFHP - San Francisco ABC - Region 1 Care First - San Diego PHC - Southwest Molina - San Diego CHW - Region 2 CalOptima - Orange SCFHP - Santa Clara ABC - Santa Clara Health Net - San Diego CalViva - Fresno ABC - Region 2 ABC - San Benito Alameda Alliance for Health HPSM - San Mateo CenCal - San Luis Obispo Health Net - Tulare GCHP - Ventura PHC - Northwest CHW - Region 1 IEHP - Riverside/San Bernardino CalViva - Madera Health Net - Stanislaus CHW - Imperial KFHP - Kern Health Net - Kern ABC - San Francisco CCAH - Merced HPSJ - San Joaquin PHC - Northeast ABC - Fresno CalViva - Kings HPSJ - Stanislaus ABC - Madera Health Net - Sacramento ABC - Sacramento Health Net - San Joaquin CHG - San Diego ABC - Alameda ABC - Contra Coasta LA Care- Los Angeles Health Net - Los Angeles Molina - Riverside/San Bernardino ABC - Kings Molina - Imperial Molina - Sacramento Rate MPL HPL Wt Ave

90 Controlling High Blood Pressure: Percentage of CareAdvantage/CMC members with hypertension whose blood pressure was controlled during the measurement year 80.00% 70.00% 60.00% 61.46% 60.34% 70.32% 64.37% 50.00% 50.51% 40.00% 30.00% 29.20% 20.00% Reporting Year CMS Core Measure Benchmark = 53% Measure relies completely on medical record review, using only the last BP taken in measurement year Expanding home blood pressure monitoring pilot to CMC members with hypertension assigned to NEMS Controlling High Blood Pressure for all Medi-Cal MCOs HEDIS % 90% 80% 70% 66.39% 60% 50% 40% 30% Kaiser SoCal (KP Cal LLC) Kaiser NorCal (KP Cal LLC) CalOptima - Orange SFHP - San Francisco CHW - Imperial LA Care - Los Angeles Care First - San Diego SCFHP - Santa Clara CenCal - San Luis Obispo CHW - Region 1 HPSM - San Mateo Molina - Imperial Alameda Alliance for Health Health Net - Los Angeles PHC - Southwest Health Net - San Diego PHC - Northeast ABC - San Francisco CHW - Region 2 PHC - Southeast Health Net - Tulare Health Net - Stanislaus CenCal - Santa Barbara ABC - Region 1 HPSJ - Stanislaus CalViva - Madera CCHP - Contra Costa IEHP - Riverside/San Bernardino ABC - Tulare Molina - Sacramento KFHP - Kern ABC - Kings CalViva - Fresno Molina - San Diego CHG - San Diego CalViva - Kings ABC - Santa Clara ABC - Region 2 HPSJ - San Joaquin Health Net - Sacramento Health Net - San Joaquin ABC - Madera ABC - Contra Coasta Health Net - Kern CCAH - Merced CCAH - Monterey/Santa Cruz ABC - Fresno ABC - Alameda Molina - Riverside/San Bernardino ABC - Sacramento ABC - San Benito PHC - Northwest GCHP - Ventura Rate MPL HPL Wt Ave

91 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% Diabetes Care: Percentage of CareAdvantage/CA CMC members years of age with diabetes who had each of the following tests or results within the measurement year 0.00% HbA1C Test HbA1C >9% HbA1C <8% Eye Exam Nephropathy Scn BP< 140/ % 38.69% 55.23% 60.58% 87.10% 69.34% % 35.52% 57.91% 65.69% 86.13% 64.48% % 33.09% 60.83% 67.40% 90.27% 45.50% % 37.96% 54.26% 70.56% 86.13% 55.47% % 48.91% 46.23% 72.51% 94.65% 65.45% % 31.87% 59.37% 71.53% 93.92% 62.77% Significant improvements in HbA1c control Continue to promote comprehensive diabetes care through our Pay for Performance Program Plan All-Cause Readmissions: Percentage of CareAdvantage/CA CMC inpatient stays with an unplanned acute inpatient stay for any diagnosis within 30 days of the initial hospital discharge 20.00% 16.89% 17.26% 14.17% 13.57% 16.11% 14.27% 15.19% 10.00% 0.00% Reporting Year Lower rates are better HPSM CMS STAR metric performance rate = 10.07% CMS Core Measure Benchmark = 11% Strengthening Care Transitions program Implementing SNFist program in 2018 to reduce readmissions from skilled nursing facilities

92 Follow-up after Hospitalization for Mental Illness: Percentage of CareAdvantage/CA CMC mental health discharges with subsequent outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner 80.00% 70.00% 68.26% 66.89% 69.66% 64.84% 30 Days 7 Days 60.00% 50.00% 40.00% 50.90% 52.32% 49.44% 58.64% 37.65% 39.16% 42.97% 30.00% 20.00% 19.58% 10.00% Reporting Year CMS Core Measure Benchmark for follow-up within 30 Days = 56% Gap improvement target = 40.84% Worked with BHRS to monitor follow-up activities and revise reporting practices Questions? Nicole Ford Quality Improvement Manager nicole.ford@hpsm.org

93 MEMORANDUM AGENDA ITEM: 5.1 DATE: November 27, 2017 DATE: December 13, 2017 TO: FROM: RE: San Mateo Health Commission Maya Altman, Chief Executive Officer Mike Smigielski, Chief Financial Officer HPSM 2018 Budget Recommendation Attached is the 2018 budget overview and the 2018 budget summary (see slide 6). HPSM anticipates total revenues of $776,481,582 and total expenses of $772,888,346 (including Strategic Investment offsets), for an overall deficit of $(3,593,236). Impact of 2017 There were several events that impacted our 2017 financial experience and inform our thinking for 2018 Implementation of a Non-Medical Transportation (NMT) benefit effective 7/1/17 Change in Medi-Cal to APR/DRGs effective 7/1/17 Updated Sutter agreement effective 8/1/17 Continued rate decreases for the MCE population Outlook for 2018 Expect improvement around Landmark program, extent of savings is uncertain Reimbursement increases for SMMC LTC facility (Burlingame) and other facilities IHSS program will be carved out of HPSM financials (will still remain a benefit) Implementation of risk sharing arrangement with SMMC(1/1/18), Brown & Toland (7/1/18) and NEMS (7/1/18); no financial impact booked in 2018 budget Continuing uncertainty around federal program support Health Care Program Budget Methodology Each health care program budget includes projections for membership (if applicable), revenue, and medical expenses. Revenue and expenses in the budget are projected and reported on the accrual basis of accounting in accordance with Generally Accepted Accounting Principles. The capitation revenue, reinsurance and medical expense budgets are also presented on a per member per month (PMPM) basis.

94 The 2018 medical expense budget was developed using HPSM s actual medical and utilization expense for 2016 and 2017 and then creating modeling assumptions for end of year 2016 and budget year These assumptions included anticipated cost inflation factors, known premium changes, utilization trends, any known or anticipated provider increases or decreases and any known or anticipated utilization management initiatives. HPSM s claims information system segregates, tracks and reports medical claim expenditures for the major expense categories. General and Administrative Expenses The general and administrative budget starts with the base of actual expenditures incurred for the current fiscal year, with additions and deletions as appropriate. This includes a review of the continued appropriateness of all previous and current expense items. Each department director is required to submit departmental budgets which reflect the resources (including staffing levels) they believe are necessary to adequately carry out their responsibilities. All departmental budget proposals are reviewed and approved by the department director and receive review and revisions by the Chief Financial Officer, the Deputy Chief Executive Office and the Chief Executive Officer. Administrative expenditures for 2018 are projected to be $54,059,558 resulting in an administrative ratio of 7.0%.

95 DRAFT RESOLUTION OF THE SAN MATEO HEALTH COMMISSION and THE SAN MATEO COMMUNITY HEALTH AUTHORITY IN THE MATTER OF ADOPTION OF OPERATING BUDGET FOR 01/01/18-12/31/18 RECITAL: WHEREAS, RESOLUTION A. The Finance Committee has reviewed details and assumptions for the budget for CFY2018; and B. The Committee recommends the approval of a budget which is based on the current available financial information; NOW, THEREFORE, IT IS HEREBY RESOLVED AS FOLLOWS: 1. The San Mateo Health Commission approves the operating budget for CFY 2018 as presented and attached. PASSED, APPROVED, AND ADOPTED by the San Mateo Health Commission this 13th day of December, 2017 by the following votes: AYES: NOES: ABSTAINED: ABSENT: Barbara Erbacher, Chairperson ATTEST: APPROVED AS TO FORM: BY: C. Burgess, Clerk Kristina Paszek DEPUTY COUNTY COUNSEL

96 Health Plan of San Mateo 2018 Financial Budget December 13, 2017 San Mateo Health Commission

97 HPSM Mission Statement To ensure access to high-quality services and supports that help San Mateo County s vulnerable and underserved residents live the healthiest lives possible.

98 2018 Programs Medi-Cal (MC) Medi-Cal Expansion (MCE) Cal MediConnect (CMC) Healthy Kids (HK) CCS (CCS Pilot) HealthWorx (HW) ACE

99 Impacts of 2017 Implementation of a Non-Medical Transportation (NMT) benefit effective 7/1/17 Change in Medi-Cal to APR/DRGs effective 7/1/17 Updated Sutter agreement effective 8/1/17 Continued rate decreases for the MCE population

100 Consolidated Budget 2018 Budget 2017 Budget Variance Revenues (net of IGT) $776,481,582 $857,286,860 ($80,805,278) Health Care Costs $688,513,821 $770,638,539 $82,124,718 Administrative Expenses $54,059,558 $53,968,120 ($91,438) MCO Tax $59,835,725 $60,797,130 $961,405 Net Income (Loss) ($25,927,522) ($28,116,929) $2,189,407 Strategic Investments $15,590,299 $21,153,212 $5,562,913 Final Surplus (Loss) ($3,593,236) ($6,963,717) $3,370,481 *Medical Loss Ratio 93.0% 90% (3.4%) Administrative Ratio 7.0% 6.3% (0.7%) IHSS Revenue and expenses are removed in 2018 *Actual Medical Loss Ratio is 93.4%; $3.6M from the strategic reserves will supplement the 2018 projected revenue

101 HEALTH PLAN OF SAN MATEO CONSOLIDATED Budget 2018 Consolidated HPSM Medi-Cal CCS Pilot MCE CMC HealthWorx Healthy Kids ACE Est. Annual Member Months 1,502, ,880 19, , ,796 12,672 17, ,242 Est. Avg. Monthly Membership 125,232 75,740 1,605 36,158 9,233 1,056 1,440 21,604 OPERATING REVENUES: Capitation & Premium Revenue (Net of IGT) $ 776,481,582 $ - $ 319,368,400 $ 28,154,735 $ 188,325,997 $ 233,560,219 $ 3,807,445 $ 3,264,786 Total Operating Revenue $ 776,481,582 $ - $ 319,368,400 $ 28,154,735 $ 188,325,997 $ 233,560,219 $ 3,807,445 $ 3,264,786 $ - HEALTH CARE EXPENSE: Provider Capitation Expense $ 43,593,247 $ - $ 18,916,021 $ 498,346 $ 18,518,888 $ 5,659,992 Professional Svs Non-Capitated 73,666,124-26,529,034 1,530,400 17,805,313 26,723, , ,334 Other Professional Svs - Non-Capitated 132,407,664-45,225,382 7,694,693 29,445,610 48,581, , ,713 Inpatient Services 145,512,624-49,621,249 6,215,771 30,832,342 57,820, , ,479 Pharmacy 143,848,841-42,760,511 6,756,041 43,732,685 48,997,780 1,359, ,385 Long Term Care 123,146,422-66,699, ,266 9,805,942 45,939,725 Dental 396, ,250 UM / QA Costs 20,322,767-6,323,760 3,604,842 4,465,925 5,771, ,967 40,964 Reinsurance 1,128, ,288 14, ,585 83,233 9,533 12,916 Bad Debt & Recovery - Health Care Claims 100,000-33,967 4,202 26,031 34, Incentive Pool Adjustment 1,361, ,884 9, , ,971 MLTSS (CBAS & MSSP) 3,030, ,903 87,399 2,041,081 Total Health Care Expenses $ 688,513,821 $ - $ 258,192,488 $ 27,029,549 $ 155,380,820 $ 242,170,599 $ 3,942,076 $ 1,798,289 $ - ADMINISTRATIVE EXPENSES $ 54,059,558 $ - $ 17,651,142 $ 2,183,388 $ 13,527,318 $ 18,107,761 $ 366,950 $ 129,621 $ 2,093,379 MCO Tax $ 59,835,725 $ - $ 39,763,050 $ 842,625 $ 18,982,950 $ - $ 104,544 $ 142,556 Total Operating Expense $ 802,409,104 $ - $ 315,606,680 $ 30,055,562 $ 187,891,088 $ 260,278,359 $ 4,413,570 $ 2,070,466 $ 2,093,379 Net Income/Loss from Operations $ (25,927,522) $ 3,761,720 $ (1,900,827) $ 434,909 $ (26,718,140) $ (606,125) $ 1,194,320 $ (2,093,379) NON-OPERATING REVENUES: Interest $ 3,500,000 $ 3,500,000 $ - $ - $ - $ - $ - $ - Rental Income 1,040,430 $ 1,040,430 Misc. Other Income 2,203, $ 2,203,557 Total Non-Operating Revenue $ 6,743,987 $ 4,540,430 $ - $ - $ - $ - $ - $ - $ 2,203,557 PROJECTED SURPLUS / (DEFICIT) $ (19,183,535) $ 4,540,430 $ 3,761,720 $ (1,900,827) $ 434,909 $ (26,718,140) $ (606,125) $ 1,194,320 $ 110,178 APPROVED STRATEGIC INVESTMENTS : IOA / Brilliant Corners $ 2,100,000 Clinical Partnerships 300,000 Member Access 240,000 Landmark 7,618,088 Physician Reimbursement Enhancements 5,332,211 SURPLUS / (DEFICIT) Excluding Strategic Investments $ (3,593,236) APPLY REVENUE USING RESERVES 3,593,236 RETAINED EARNINGS BALANCE 0

102 Outlook for 2018 Expect improvement around Landmark Program, extent of savings is uncertain Increases in SMMC LTC facility (Burlingame) and other facilities IHSS program will be carved out of HPSM financials (will still remain a benefit) Implementation of risk sharing arrangement with SMMC (1/1/18), Brown &Toland (7/1/18) and NEMS (7/1/18); no financial impact booked in 2018 budget Continuing uncertainty around federal program support

103 Budget Development Premium Revenue Base Membership Known Premium Changes Quality Measure Recoupments Health Care Expenses 2017 Actual (Jan-June) Utilization Trends Provider increases Savings from Landmark General & Administrative Salaries & Benefits Services & Supplies

104 Membership 2018 Total 2018 Average Membership Projected 125,232

105 2018 Membership Assumptions Medi-Cal: Assumed stable numbers based on 2017 historical trends Medi-Cal Expansion (MCE): Assumed a 200 member decrease from 2017 levels in January and then stable through the rest of the year Duals: Stable, no growth CCS: Stable no growth

106 Revenue 2018 HW HK 0.5% 0.4% ACE 0.3% CMC 30.0% MC 41.0% MCE 24.2% CCS 3.6% Total Revenue: $776,481,582 (with ACE, $778,685,139)

107 Medical Expense 2018 Professional Svs Non-Capitated 11% Provider Capitation Expense 6% Other 4% Inpatient Services 21% Long Term Care 18% Pharmacy 21% Other Professional Svs - Non-Capitated 19% Total Medical Expenses: $688,513,821

108 Strategic Investments Initiative Resolution Description $$$ Landmark Delivers in-home care and services to the most chronically ill members Specialty Physician Reimbursement Increases provider reimbursement equivalent to Medicare to attract new specialty physicians and increase access to care IOA/Brilliant Corners Establishing a Performance Incentive and New Programming Pool for the CCSP Program Clinical Partnership ; Forms a primary care collaborative with goal of developing a new care model and payment methods Member Access program Provides funding to encourage creative ways to improve access to care $7,618,088 $5.332,211 $2,100,000 $300,000 $200,000

109 Medi-Cal Summary $319,68,400 $258,192,488 Revenue Health Care Expenses Assumes a 3.5% increase in base rates from FY17/18 rates, effective 7/1/18 MLTSS supplement based on FY 17/18 rates IHSS services will be carved out of the premium (and expense side) BHT supplemental payment flat from 17/18 rates Hep C supplemental payment based on 1-6/18 rates IP Cost increases: $3.9M (full impact of Sutter increase, APR-DRG increases effective 7/1/17, Seton to DRG 1/1/18) IP Utilization decrease of (4.2%) due to Health Services efforts. LTC: Facility increases of $6.2M, ($1.7M) decrease due to CCSP efforts RX: 7.6% increase in utilization, $3.0M increase $17,651,142 Admin Expenses Based on 2018 admin budget with LOB allocations based on health care costs Admin as a % of revenue = 5.5% MCO Tax is $39,763,050, ~$43.75PMPM, $40PMPM for all products Projected Surplus of $3,761,720

110 Medi-Cal Expansion (MCE) Summary $188,325,997 $155,380,820 Revenue Health Care Expenses Assumes a (2%) decrease in base rates from FY17/18 rates, effective 7/1/18 MLTSS supplement based on FY 17/18 rates IHSS services will be carved out of the premium (and expense side) Hep C supplemental payment based on 1-6/18 rates IP Cost increases: $2.4M (full impact of Sutter increase, APR-DRG increases effective 7/1/17, Seton to DRG 1/1/18) IP Utilization: $2.6M increase due to 9.5% increase in utilization LTC: Facility cost increases of $1.3M RX: 7.8% increase in utilization, $3.2M Physician & OP Services: $3.7M due to cost/utilization trends, transportation benefit $0.6M increase $13,527,318 Admin Expenses Based on 2018 admin budget with LOB allocations based on health care costs Admin as a % of revenue = 7.1% MCO Tax is $18,982,950, ~$43.54PMPM, $40PMPM for all products Projected Surplus of $434,909

111 Cal MediConnect Summary $233,560,219 Revenue Assumes a 5.4% increase in premium: excluding IHSS premium, 2018 $2,108.02PMPM, 2017 $2, % increase in risk scores from (expected 2017 final) to (expected final 2018) Assumes 50% return in withhold measures (total withhold is 3% of premium) $242,170,599 Health Care Expenses IP: Decrease of ($6.0M) primarily attributed to Landmark Home Advantage and SNFist programs RX: $1.6M increase due to 3.1% increase in cost and utilization LTC: Facility costs increases of $5.3M offset by a ($1.2M) decrease due to the CCSP program Professional & OP expenses: $0.9M due to dialysis recontracting, $0.3M due to increase in transportation, $0.6M due to increases in cost with Landmark $18,107,761 Admin Expenses Based on 2018 admin budget with LOB allocations based on health care costs Landmark programs: $5.7M (offsets savings in Health Care Expenses) Admin as a % of revenue = 7.7% Projected Deficit of ($26,718,140)

112 CCS Pilot $28,154,735 Revenue Assumes a 5% decrease in revenue effective 1/1/18 (due to profitability in CY 2016) $27,029,549 Health Care Expenses IP: $0.8M increase due to a 13.5% increase in utilization $2,183,388 Admin Expenses Based on 2018 admin budget with LOB allocations based on health care costs Admin as a % of revenue = 7.8% MCO Tax is $842,625 ~$43.75PMPM, $40PMPM for all products Projected Deficit of ($1,900,827)

113 HealthWorx $3,807,445 Revenue Assumes a 24% increase to $300.46PMPM $3,942,076 Health Care Expenses 5.9% increase in cost and utilization, +$0.2M $366,950 Admin Expenses Based on 2018 admin budget with LOB allocations based on health care costs Admin as a % of revenue = 9.6% MCO Tax is $104,544~$8.25PMPM, $40PMPM for all products Projected Deficit of ($606,125)

114 Healthy Kids $3,264,786 Revenue Premium remains flat at $ $2,070,466 Health Care Expenses (4.2%) decrease in cost and utilization. (2017 saw one costly case that affected the results) $129,621 Admin Expenses Based on 2018 admin budget with LOB allocations based on health care costs Admin as a % of revenue = 4.0% MCO Tax is $142,556~$8.25PMPM, $40PMPM for all products Projected Surplus of $1,194,320

115 ACE TPA arrangement with County Flat fee based on membership, no increase projected Membership projected to be flat Budget projects a surplus of $110,178

116 Projected Financial Position Current Financial Position $ (3,593,236) Projected Deficit before Strategic Initiatives $ (19,183,535) 1 Landmark Additional Improvement $ 3,809,044 2 Premium Improvements due to increases in LTC $ 12,800,000 3 Risk Adjustment Part D $ 1,000,000 Variance $ (1,574,491) Additional Initiatives TBD Current Landmark has been assigned an ROI of 1.0. Assuming an ROI of 1.5, we would see an additional improvement of $3.8M The increases due to SMMC and other facilities assumes zero increases from the State. Assuming 100% full reimbursement would be a $12.8M gain Part D improvements in the budget were not included. There was a 9.5% decrease in Part D risk score. Assuming a 9.5% increase would be a $1.0M gain Finance is holding quarterly cost committee meetings to uncover additional opportunity for savings. There is also a quarterly meeting focused on the performance of the CMC product.

117 General and Administrative (G&A) Salaries and Benefits 1 position eliminated; other positions repurposed to meet operational needs HPSM average total positions of 301 Services and Supplies $0.5M approved for capital projects $1.8M approved for new software Total Administrative budget of $54,059,588

118 G&A bridge Projected Budget Variance Revenue $ 797,281,550 $ 776,481,582 $ (20,799,968) Admin $ 50,400,973 $ 54,059,558 $ 3,658,585 Admin as % of Revenue 6.3% 7.0% Percentage Dollar Value Item Budgeted admin % of revenue 7.0% 1 Open Positions (~42.5 FTEs) 0.7% $ 5,619,151 2 Captial Improvements (Approved) 0.1% $ 500,000 3 New Software (Approved) 0.2% $ 1,800,000 4 Variance due to Premium decrease 0.2% $ 20,799,968 Net 5.8% This table shows how HPSM is expecting an increase from the HPSM internal target of 5.5% of revenue Item 1: We currently have 42.5 open positions, filling all of these would cause an increase of 0.7% Item 2 and 3: These are items previously approved Item 4: We expect an $80.6 M decrease in revenue. Had revenue been at 2017 levels, admin as % of revenue would have decreased by 0.2%

119 As a Percentage of Revenue, the administrative budget equates to 7.0% Admin 7.0% Health Care 93.0% 93.0% of every dollar goes toward the healthcare costs of our members

120 AGENDA ITEM: 5.2 DATE: December 13, 2017 Technology Priorities San Mateo Health Commission December 13, 2017

121 Why Technology Projects High impact High dollar Long lead time Cross-department functions

122 Completed Projects* HEALTHsuite Core system for health plan operations MedHOK Care Coordination Grievance and Appeals Provider Dispute Resolutions Pharmacy Authorizations and Appeals * Implementation completed. Ongoing enhancements/upgrades 3

123 In-process Implementations DocuStream Authorization Entry HealthTrio Provider Directory Provider Portal Member Portal Cactus Provider Credentialing Contract Management System

124 In-process Projects Website Redesign Intranet Redesign DocStar Upgrade Phone System Upgrade - Callback Assist

125 Up-Coming Projects Compliance Program Management System Human Resources Management System

126 Integrated Approach Determine priority for project Project Priority List Updated and Reviewed Monthly by Senior Managers Inclusion of impacted departments Determined by nature of the project Led by Business Systems Integration Team

127 Business Systems Integration Supervisor 3 Business Systems Analysts 2 Project Managers Lead Project Implementations Support Business Units with workflows Conduct Root Cause Analyses

128 Business Systems Integration A Link

129 Thank You