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Section Start / End Time Page Item Description Presenter Action/

DiscussionIT Support Available Remote participants are encouraged to dial/video any time after 9:00 AM to ensure connectivity is established before the meeting begins at 10:00 AM.

11.1 10:00 AM Call to Order

An adjourned regular meeting of the Partnership HealthPlan of California will be called to order on June 24, 2020 via Webex and at PHC video conference locations

1.2 Roll Call Board Clerk1.3 Agenda Approval or Modifications Nancy Starck, Chair Action1.4 4-13 Approval of Board Meeting Minutes

This action approves the Board meeting minutes for April 22, 2020

1.5 Commissioner CommentsAt this time, Commissioners may provide comments and announcements.

1.6 Public CommentsAt this time, members of the public may address the Board on any non-agenda item of interest to the public that is within the subject matter jurisdiction of the Board Members of the public will have the opportunity to address the Board on a scheduled agenda item during the Board's consideration of that item. Speakers will be limited to three (3) minutes.

1.7 Correspondence Board Clerk Information1.8 14-23 CEO Report Liz Gibboney Information

2

2.1 10:30 AM24-26

Resolution to Ratify Finance Committee's approval to amend PHC's FY 2019-2020 Budget

This resolution approves amendments to the FY 2019-2020 Budget

2.2 10:40 AM27-34

Resolution to Ratify Finance Committee's approval of PHC's Preliminary Health Care Budget for FY 2020-2021

This resolution approves PHC's Preliminary Health Care Budget developed from the assumptions approved by the Board on 04-22.20.

PHC IT Support9:00 AM- 10:00 AM

Action

Opening

Consent Calendar - Ratification of Finance Committee ActionAll matters listed on the Consent Calendar are to be approved with one motion unless a member of the Board removes an item for separate action. Any Consent Calendar item for which separate action is requested shall be heard as the next Agenda item.

Nancy Starck, Chair Action

Commissioners Information

Public Information

Nancy Starck, Chair

Conflict of Interest Reminder - Commissioners should abstain from voting on any agenda item where they might have a conflict of interest.

PHC Mission Statement is "to help our members, and the communities we serve, be healthy"

Public and Guest Reminder - Public comment is welcome during designated "Public Comments" time frames.

Board of Commissioners Meeting AgendaVia Webex

June 24, 2020: 10:00 a.m. – 2:00 p.m.In-person Locations:

PHC’s Southeast Region Office located at 4605 Business Center Drive, Fairfield, CAPHC's Northeast Office located at 2525 Airpark Drive, Redding, CA

Per Governor Newsom Executive Order, N-25-20 that relates to social distancing measures being taken for COVID-19. The Executive Order authorizes public meetings with Brown Act requirements to be held via teleconference or telephone. It waives the Brown Act requirement for physical

presence at the meeting for members, the clerk, and/ or other personnel of the body as a condition of participation for a quorum. Executive order N-33-20 directs all residents to immediately heed current State public health directives to stay home, except as needed to maintain continuity of operations of essential critical infrastructure sectors and additional sectors as the State Public Health Officer may designate as critical to protect the health and

well-being of all Californians.

Liz Gibboney / Patti McFarland /

Jeff Ingram

Action

Liz Gibboney / Patti McFarland /

Jeff IngramAction

PHC Board Meeting Packet for 6-24-20 | of 120


Discussion

3

3.1 11:10 AM 35-36 Resolution to Accept all PHC Committee Minutes and Department Operating Reports. As well as Approving all PHC Policies, Program Descriptions and PCP QIP Changes Approved by PAC.

Nancy Starck, Chair Accept

This resolution provides commissioners with links toall PHC committee packets and departmentaloperating reports for their acceptance. It also providesthem with all PHC policies and program descriptionspreviously approved by PAC in May and June fortheir approval. Operational Reports PAC Approved Policy Updates 340B Advisory Committee - N/A (No meeting sinceMarch 2020)Consumer Advisory Committee North - June 2020

Consumer Advisory Committee South - June 2020Finance Committee - May 2020Finance Committee - June 2020Physician Advisory Committee for May 2020

Quality and Utilization Advisory Committee (Q/UAC)Internal Quality Improvement (IQI)Provider Advisory GroupCredentialing Committee

Physician Advisory Committee for June 2020Quality and Utilization Advisory Committee (Q/UAC)Internal Quality Improvement (IQI)Provider Advisory GroupCredentialing Committee

3.2 37-39 Resolution to Approve Physician Advisory Committee Membership Changes This resolution approves the resignation of S. Fuller, MD, appointment of T. Shinder, MD and change inrepresentation of D. Gorchoff, MD to the PhysicianAdvisory Committee.

Resolution to Approve Utilization Management Program Description, MPUD3001

Utilization Management Program Description RedlinesUtilization Management Program Description FinalResolution to Approve Board Reappointment of Kathie PowellThis resolution approves the reappointment of Kathie Powell, representing Sonoma County.

4

4.1 11:15 AM 46-63 Resolution to Aprove Final Budget FY 2020-2021This resolution approves PHC's final budget for ourbusiness.

4.2 64-68 Resolution to Approve the Repurposing ofUnearned 2019 QIP FundsThis resolution approves repurposing of unearned PCPQIP funds.

4.3 69-70 Resolution to Approve Recognizing 2019 PCP QIP RecipientsThis resolution recognizes the recipients of PHC's2019 PCP QIP.

Committee MeetingMinutes and Material are

available on PHCWebsite (click on links)

Consent CalendarAll matters listed on the Consent Calendar are to be approved with one motion unless a member of the Board removes an item for separate action. Any Consent Calendar item for which separate action is requested shall be heard as the next Agenda item.

3.3 40-42

Peggy Hoover Action

Regular Agenda Items

This resolution approves updates to the UtilizationManagement Program Description approved by PACin June 2020.

3.4 43-45

Liz Gibboney /Robert Moore, M.D.

Liz Gibboney Action

Action

Liz Gibboney Action

Liz Gibboney /Patti McFarland Action

Liz Gibboney Action


http://www.partnershiphp.org/About/Documents/BoardPackets/2020/Documents/June2020OperationsReports.pdf

http://www.partnershiphp.org/About/Documents/BoardPackets/2020/Documents/June2020PACPolicySummary.pdf

http://www.partnershiphp.org/Members/Medi-Cal/Documents/CAC/NR_CAC_June2020-AgendaPacket.pdf

http://www.partnershiphp.org/Members/Medi-Cal/Documents/CAC/SR_CAC-June2020-AgendaPacket.pdf

http://www.partnershiphp.org/About/Documents/FinanceCommittee/2020/FinanceCommittee_5.20.20_Packet.pdf

http://www.partnershiphp.org/About/Documents/FinanceCommittee/2020/FiComm_6.17.20-Packet-FINAL.pdf

http://www.partnershiphp.org/Providers/HealthServices/Documents/Physicians%20Advisory%20Committee%20-%20PAC/2020/May%202020/PACPacket_05-13-20_Final2.pdf

http://www.partnershiphp.org/About/Documents/QUAC/2020/QUAC%20Meeting%20Packet%2005_20_20%20FINAL.pdf

http://www.partnershiphp.org/Providers/HealthServices/Documents/Physicians%20Advisory%20Committee%20-%20PAC/2020/June%202020/PACPacket_06-10-20_Rev.Post-Mtg.pdf




http://www.partnershiphp.org/About/Documents/QUAC/2020/QUAC%20Meeting%20Packet%2006_17_20%20FINAL.pdf




http://www.partnershiphp.org/About/Documents/BoardPackets/2020/Documents/UMProgramDescriptionRedline.pdf

http://www.partnershiphp.org/About/Documents/BoardPackets/2020/Documents/UMProgramDescriptionFinal.pdf


Discussion5

5.1 11:45 AM 71-86 Metrics and Financial Update for June Patti McFarland Information5.2 87-92 Operations Update Sonja Bjork Information5.3 External & Regulatory Affairs Update

93 Legislative Tracking Chart94 Press Releases

5.4 CMO Report on Quality Dr. Robert Moore Information

6

6.1 12:45 PM Wellness & Recovery Benefit Overview Margaret Kisliuk Information6.2 Employee Survey Regina Littlefield /

Amy AgleInformation

6.3 2020 Claims Department Summary Lisa Malvo / Nikki Rotherham / Michelle Dunham

Information

6.4 95-120 Grievance and Appeals Update La Rae Banks Information

7 Upcoming Board Meetings

10/28/2020 - Main location is Fairfield12/2/2020 - Main location is Santa Rosa

Government Code §54957.5 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 Board Clerk as the contact for Partnership HealthPlan of California located at 4665 Business Center Drive, Fairfield, CA 94534, for the purpose of making those public records available for inspection. The Board Meeting Agenda and supporting documentation is available for review from 8:00 AM to 5:00 PM, Monday through Friday at all PHC regional offices (see locations above). It can also be found online at www.partnershiphp.org.PHC meeting rooms 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 Board Clerk at least ten (10) days prior to the scheduled meeting at (707) 863-4516 or by email at [email protected]. Notification in advance of the meeting will enable the Board Clerk to make reasonable arrangements to ensure accessibility to this meeting and to materials related to it.

Educational Session

Other Reports

Dustin Lyda / Amy Turnipseed Information

This agenda contains a brief description of each item to be considered. Except as provided by law, no action shall be taken on any item not appearing on the agenda.

8/26/2020 - Main location is Redding (pending location/may convert to virtual


http://www.partnershiphp.org/




mailto:[email protected]




MINUTES OF THE MEETING OF PARTNERSHIP HEALTHPLAN OF CALIFORNIA (PHC)

Meeting held via Webex In person locations:

PHC’s Southeast Office located at 4665 Business Center Drive, Fairfield PHC’s Northeast Office located at 2525 Airpark Drive, Redding, CA

On April 22, 2020

Commissioners Present: Jonathon Andrus, Aimee Brewer, Mary Kay Brooks, Lewis Broschard, M.D., Amby Burum, Tammy Moss Chandler, Paula Cohen, Greta Elliott, Donnell Ewert, Dean Germano, Alicia Hardy, Gerald Huber, Dave Jones, Karen Larsen, Viola Lujan, Melissa Marshall, M.D., Gary Pace, M.D., Mitesh Popat, M.D., Kathryn Powell, William Remak, Heather Snow, Tory Starr, Nancy Starck, Kimberly Tangermann, and Jennifer Yasumoto

Commissioners Excused: Matthew Willis, M.D.

Commissioners Absent: Richard Fogg, John Reeves III, Barbie Robinson

Staff Present Benjamin Amparo, La Rae Banks, Kaylee Baquiax, Danielle Biasotti, Sonja Bjork, Dell Coats, Marisa Dominguez, Kim Fillette, David Glossbrenner, M.D., Patty Hayes, Peggy Hoover, Jeff Ingram, Kirt Kemp, Mary Kerlin, Margaret Kisliuk, Leslee Kitzman, Marshall Kubota, M.D., Stan Leung, Pharm.D., Regina Littlefield, Dustin Lyda, Melissa McCartney, Lisa Malvo, Nancy McAdoo, Patti McFarland, Robert Moore, M.D., Amenda Namin, Lisa O’Connell, Jose Puga, Erika Robinson, Nikki Rotherham, Lynn Scuri, Tahareh Daliri Sherafat, Kevin Spencer, Lyle Smith, Nancy Steffen, Amy Turnipseed, Andrew Torge, Colleen Valenti, Wendi West, Liz Gibboney, CEO, and Ashlyn Scott, Clerk

Guests Present Lisa Fowler, Matt Gal

AGENDA ITEM 1.0 OPENING

AGENDA ITEM 1.1 CALL TO ORDER Commissioner Nancy Starck, Board Chair, called the bi-monthly meeting to order via Webex video conference and welcomed everyone to the meeting. Board members and attendees were told Governor’s Executive Order N-25-20, which relates to social distancing measures being taken for COVID-19, waives the Brown Act requirement for physical presence at the meeting for members, the clerk, and/ or other personnel of the body as a condition of participation for a quorum.


Board members were reminded to abstain from voting on any agenda item where they might have a conflict of interest, and to state their name before asking questions or making motions. As a reminder, Commissioner Starck read the PHC Mission Statement that is, “to help our members, and the communities we serve, be healthy”. She also mentioned that guests would have an opportunity to speak at designated times throughout the agenda. AGENDA ITEM 1.2 ROLL CALL Ashlyn Scott, Clerk of the Commission, called the roll indicating there was a quorum. AGENDA ITEM 1.3 AGENDA APPROVAL OR MODIFICATION Commissioner Starck asked if anyone had changes for the agenda. Hearing no requests, she asked for a motion to approve the agenda.

MOTION: Commissioner Germano moved to approve the agenda as presented, seconded by Commissioner Cohen.

Commissioner Starck asked for commissioner or public comments. Hearing no requests, she called for a vote. The clerk summarized the vote as follows. BOARD ACTION SUMMARY: 25 yes, 0 no, 0 abstention. Motion carried with Commissioner Willis absent. Commissioners Fogg, Reeves and Robinson were absent during the vote. AGENDA ITEM 1.4 TO APPROVE THE NEW BOARD MEMBER APPOINTMENT OF TORY STARR Ms. Gibboney stated that this resolution approves the appointment of Tory Starr, the new Chief Executive Officer of Open Door Health, replacing Cheyenne Spetzler on the PHC Board. Ms. Gibboney then asked Mr. Starr to introduce himself to the Board. Mr. Starr said he is delighted to be a part of the PHC Board and he looks forward to meeting everyone in person in the near future. He has been at Open Door since January 2020 and mentioned what a strange time it has been in the wake of COVID-19. Commissioner Starck inquired whether anyone had questions or comments for Ms. Gibboney. Commissioner Germano thanked Ms. Spetzler for her contributions to the PHC Board. Hearing no further questions or comments, Commissioner Starck asked for a motion to approve resolution 1.4.

MOTION: Commissioner Brewer moved to approve resolution 1.4 as presented, seconded by Commissioner Germano.

Commissioner Starck asked for commissioner or public comments. Hearing no requests, she called for a vote. The clerk summarized the vote as follows. BOARD ACTION SUMMARY: 25 yes, 0 no, 0 abstention. Motion carried with Commissioner Willis excused. Commissioners Fogg, Reeves and Robinson were absent. AGENDA ITEM 1.5 APPROVAL OF FEBRUARY 26, 2020 MINUTES Commissioner Starck inquired whether anyone had questions, corrections, or comments regarding the minutes. Hearing no requests, she asked for a motion to approve.

MOTION: Commissioner Jones moved to approve the Board meeting minutes for February 26, 2020 as presented, seconded by Commissioner Yasumoto.


Commissioner Starck asked for commissioner or public comments. Hearing no requests, she called for a vote. The clerk summarized the vote as follows. BOARD ACTION SUMMARY: 25 yes, 0 no, 0 abstention. Motion carried with Commissioner Willis excused. Commissioners Fogg, Reeves and Robinson were absent. AGENDA ITEM 1.6 COMMISSIONER COMMENTS Commissioner Starck asked if there were any commissioner comments or announcements. Commissioner Cohen reminded the Board that the U.S. Census deadline has been extended to October 31, 2020. The census is critical for health care funding, especially during a pandemic. She asked that the group to support the census and encourage health centers to support it as well. Hearing no more comments, Commissioner Starck moved on to public comments. AGENDA ITEM 1.7 PUBLIC COMMENTS Commissioner Starck asked if there were any public comments. Hearing no requests, she moved on to correspondence. AGENDA ITEM 1.8 CORRESPONDENCE Commissioner Starck asked if there was any correspondence. Ashlyn Scott, Clerk of the Commission, replied yes. On March 2, 2020, an email was received from a non-contracted Physical Therapist who occasionally treats patients with Partnership HealthPlan as a secondary insurance. When he treats patients with PHC as a secondary insurance, he receives a letter of non-payment from PHC. He is concerned about the cost of postage and suggested PHC send these notices electronically. Ms. Bjork, COO, stated that PHC does offer electronic billing, however the process requires some testing with the provider and our Claims team, to ensure the notices will be received. Smaller providers or providers we don’t often bill, will usually not take the necessary steps to complete the online billing process. Though this provider is not contracted, our Provider Relations team will reach out to offer our online billing services. AGENDA ITEM 1.9 CEO REPORT Ms. Gibboney began her report by highlighting some topics not related to COVID-19, since that will be the main topic for discussion throughout the meeting. California Healthcare, Research and Prevention Tobacco Tax (“Prop 56”) – The Prop 56 behavioral health integration grant applications were due to DHCS in February. PHC had an overwhelming response from providers. We helped apply for over $50M for providers and there is $140M available statewide. Funding is delayed due to COVID-19 and will begin July 1. Wellness and Recovery Program/Drug MediCal – DHCS and CMS have finally given PHC a firm go-live date of July 1, 2020 for the launch of our regional drug treatment benefit, which is a large component of our Wellness and Recovery Program. Trinity County recently notified us that have decided not to participate in the pilot, so we will go forward with the remaining seven counties and look forward to launching this benefit, which we have prepared for over four years. Managed Care Organization (“MCO”) Tax – California’s re-worked MCO Tax proposal was approved in early April, which includes approximately $1.5 billion in funds that were not included in the FY 19-20 Budget. DHCS Annual Medical Audit – PHC had an excellent annual DHCS Medical Audit this year as DHCS reported no findings. Ms. Gibboney extended her appreciation to the entire team for their excellent preparation, collaborative working relationship with DHCS and follow-through.


Commissioner Starck inquired whether anyone had additional questions for Ms. Gibboney. Hearing no requests, she moved on to the Featured Topic: PHC’s response to COVID-19. AGENDA ITEM 1.10 COVID-19: PHC RESPONSE Ms. Gibboney began the discussion by stating the PHC team has done a great job at interpreting the various shelter-in-place orders across our counties and getting employees deployed. Deployed employees were sent home with almost entire workstations. Our goal is to maintain 90% of staff teleworking and for those who continue to come into the office to maintain appropriate social distancing. We have been holding weekly Virtual Executive Briefings with staff via Webex to connect with deployed staff and to openly discuss public health, emergency response and internal matters. PHC has been able to maintain service levels in our call centers for our members. PHC has also began outreach to 60,000 high risk members to check in on their health and provide necessary information. We have also sent information via mail and post frequently on our external website. PHC has released FY2018-2019 $130M IGT funds early to forty eligible entities and waived admin costs. We are pleased we are in the position to continue funding providers during these times. Physical therapists, occupational therapists and CBAS facilities have been able to bill for video visits with patients to assist with cash flow. Capitation also helps with cash flow, however there were a number of weeks where provider had lower patient volume which causes some concern. Later in the meeting, we will request the Board’s approval to refurbish unearned PCP QIP funds to provide PHC with more opportunities to pay providers. Internally, our strategic planning process is delayed to focus on COVID-19 response efforts. PHC also awaits a surge of a conservative estimated 60,000 new members in our counties. We also are assessing internal goals to determine if they will need to shift due to COVID-19. As for the CalAIM waiver renewal process, DHCS has stated they are not currently focusing on these efforts and do not currently have a timeline of when they will resume, though a revised calendar will be released this summer. Plans continue to execute the pharmacy carve out, per Governor Newsom’s Executive Order. The fourth federal stimulus bill was approved in the Senate and there is a fifth bill being proposed. Though the Public Charge Final Rule is not currently being enforced, the administration has not changed their position on the matter. Dr. Moore began his portion of the presentation by stating there are currently 869 COVID-19 cases in PHC counties, with a growth rate of 3.3% per day and a doubling time of seventeen days. PHC counties have reported thirty COVID-19 related deaths, two of which were PHC members. PHC also has eight members hospitalized due to COVID-19. We continue to monitor long term care facilities, as COVID-19 spreads quickly in these types of settings. The overall goal should be a 60-70% immunity rate but the U.S. is still far from reaching that goal. Santa Clara County performed a randomized sample serology test and found about 3-3.5% had antibodies, which is similar to the estimated national average. The order to stay home has two main goals: prevent transmission of infection and prevent travel from place to place. Some of PHC’s counties have zero cases but if people continue to travel, the virus will spread. As restrictions ease, traveling should still remain limited to prevent new outbreaks. Elective surgeries were stopped to preserve personal protective equipment (PPE), in order to prepare for a potential surge in hospital patients. However, hospitals in California still have a large capacity for patients. Though some elective surgeries are non-emergency, they are still extremely important (e.g. chemotherapy and colonoscopies). It is important to not increase risk by stopping important elective surgeries. Outpatient settings can adjust safely with strict measures to continue to see patients at this time. Patients have felt uneasy about in-office appointments due to COVID-19, and have neglected being seen for potentially serious issues. It is our responsibility to


make patients feel safe to ensure they receive proper care. Hospitals also need steady revenue streams in order to provide quality care. Sonja Bjork added that PHC’s Population Health Management team is contacting 60,000 high-risk members by sending post cards and conducting live outreach calls, not robo-calls. Our Member Services staff is assisting with the calls, since there has been a decrease in Call Center volume. All staff conducting outreach call have been trained, including executive staff. The goals of these calls include: ensuring members know where to get prescriptions, educating on the availability of the advice nurse and providing information on additional resources such as food assistance and mental health services. Commissioner Germano inquired whether there is capacity to loosen restrictions around providing in-home equipment such as high blood pressure monitors. Ms. Gibboney replied that PHC is working with a supplier and has secured at-home equipment for monitoring blood pressure and oximeters. Once PHC received the order, we will work with providers to distribute to members. Dr. Moore added that the blood pressure cuffs would be covered via pharmacy, however PHC is looking to increase the cost that is covered. Commissioner Brewer stated that February and March were brutal for NorthBay but through surge planning, ordering an ample supply of PPE, and increasing testing capabilities, NorthBay is now slowly opening imaging and elective surgeries beginning April 24. NorthBay also has a team of nurses contacting 4,500 high-risk patients to deliver prescriptions, groceries and supplies. This has assisted in decreasing the number of patients in the emergency rooms. Commissioner Andrus added that his clinic is looking to open elective surgeries and outpatient services but it is difficult when there is limited testing. There is no access to the antibody testing, making it difficult to open while keeping patients safe. Dr. Moore agreed that testing is essential and though it has increased, it is not enough to open services completely. Testing needs to be available for all healthcare workers and first responders. Commissioner Huber asked Dr. Moore’s thoughts on the Santa Clara study which indicated COVID-19 spread may have begun in the area as early as October. Dr. Moore responded that he hasn’t seen a report from a reliable source that indicated October spread of COVID-19. Commissioner Germano asked if PHC’s payments to hospitals has decreased due to the decrease of surgeries. Mr. Ingram replied that PHC has not seen a lag in claims yet but expects to in the next month. Commissioner Lujan inquired what PHC’s message for members in outreach calls is regarding how to connect with primary care physicians. Ms. Bjork stated that our staff is directed to ask if the member knows who their PCP is and how to contact them. Commissioner Popat added that his clinic quickly converted to telehealth, with 80-90% of their appointments now being virtual and the majority of those being via phone. The transition has gone relatively smoothly, though getting our population to use video conferencing has been a barrier. Having patients install and navigate a phone application can be challenging. There has


been a large surge in behavioral health appointments. Now we begin to look ahead to what is next with a blended community and the virus still circulating. How do we triage those carrying COVID-19 and prevent them from coming into the office? We are thinking we may need telephone screenings before in-person visits. PHC can help providers by recommending best practices and consistent messaging to circulate in our communities. Commissioner Starr stated that COVID-19 is a marathon that had a sprint start. Open Door is doing mostly telephone visits and there have been difficult technical issues. He also added there is a lot they have learned from COVID-19 that we can be carried into the future. Commissioner Germano said his health center is requiring patients to bring masks for in-person appointments. Those who do not bring masks are provided with one, which equals about 500 masks a day. Commissioner Powell added that her health center has been reaching out to high-risk patients, providing an outdoor vaccine clinic and administering drive-up dental services for children. Everyone is being creative and trying to provide services in whatever ways they can. It is also important to be aware of employee needs. Ninety employees are receiving CalFresh benefits, due to a family member losing their job. Everyone is busy providing quality care to 5,000 patients. Commissioner Burum thanked the group for their efforts, especially as a person with medical issues. Telehealth helps patents a lot as it decreases the necessity to travel. Ms. Gibboney added that the COVID-19 crisis has forced providers to use telehealth which greatly improves access across our region and we hope these efforts continue. AGENDA ITEM 3.0 CONSENT CALENDAR Commissioner Starck stated that all items on the consent calendar would be approved with one motion unless someone wants to pull an item for further discussion. Hearing no requests, she asked for a motion to approve resolutions 3.1-3.7. 3.1 Resolution to Approve Committee Minutes 3.2 Resolution to Approve Board Reappointment of Richard Fogg and Paula Cohen 3.3 Resolution to Approve Board Strategic Planning Retreat Summary 3.4 Resolution to Approve Utilization Management Program Description, MPUD3001 3.5 Resolution to Approve the Care Coordination Program Description, MPCD2013 3.6 Resolution to Approve the Population Health Management Strategy, MCCD2027 and

Population Needs Assessment 3.7 Resolution to Approve HR Policies and the Personnel Committee Minutes for April 15, 2020

MOTION: Commissioner Andrus moved to approve resolutions 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, and 3.7 as presented, seconded by Commissioner Lujan.

Commissioner Starck asked for commissioner or public comments. Hearing no requests, she called for a vote. The clerk summarized the vote as follows. BOARD ACTION SUMMARY ON RESOLUTIONS 3.1, 3.2, 3.4, 3.5, 3.6, and 3.7: 24 yes, 0 no. Motion carried with Commissioner Willis absent and Commissioner Cohen abstaining from Resolution3.2. Commissioners Fogg, Reeves and Robinson were absent. . AGENDA ITEM 4.0 REGULAR AGENDA ITEMS


AGENDA ITEM 4.1 TO APPROVE BUDGET ASSUMPTIONS FOR FY 2020-2021 Mr. Ingram stated that the Finance Committee already reviewed this resolution in-depth at the meeting last week and they have recommended its approval to the Board. PHC’s budget process - In April, the Finance Committee and Board approves the “draft” budget assumptions, in May, the Finance Committee approves the preliminary Health Care budget, and then in June, the Finance Committee and the Board approve the final budget that includes previously reviewed components and a fully developed administrative budget. Mr. Ingram mentioned that PHC is working with many unknowns in making budget assumptions, such as COVID-19 and the potential economic fall-out. PHC will react quickly and adjust models accordingly. Commissioner Germano asked if there is any indication the State is continuing work in the pharmacy carve-out during the COVID-19 crisis. Ms. Gibboney replied the State maintains that it will continue in the pharmacy carve-out process. Commissioner Starck inquired whether anyone had additional questions for Mr. Ingram Hearing no requests, she asked for a motion to approve resolution 4.1.

MOTION: Commissioner Jones moved to approve resolution 4.1 as presented, seconded by Commissioner Germano.

Commissioner Starck asked for commissioner or public comments. Hearing no requests, she called for a vote. The clerk summarized the vote as follows. BOARD ACTION SUMMARY: 25 yes, 0 no, 0 abstention. Motion carried with Commissioner Willis excused. Commissioners Fogg, Reeves and Robinson were absent. AGENDA ITEM 4.2 RESOLUTION TO APPROVE APPOINTMENT OF ASHLYN SCOTT AS CLERK OF THE COMMISSION AND AGENDA ITEM 4.3 RESOLUTION TO APPROVE COLLEEN VALENTI AS ASSISTANT CLERK OF THE COMMISSION Ms. Gibboney stated that Cynthia McCamey, Clerk of the Commission retired in April, so PHC requests to appoint Ashlyn Scott as the new Clerk to the Board and Colleen Valenti as the Assistant Clerk to the Board. Commissioner Starck inquired whether anyone had questions for Ms. Gibboney Hearing no requests, she asked for a motion to approve resolution 4.2 and 4.3.

MOTION: Commissioner Huber moved to approve resolution 4.2 and 4.3 as presented, seconded by Commissioner Remak.

Commissioner Starck asked for commissioner or public comments. Hearing no requests, she called for a vote. The clerk summarized the vote as follows. BOARD ACTION SUMMARY: 25 yes, 0 no, 0 abstention. Motion carried with Commissioner Willis excused. Commissioners Fogg, Reeves and Robinson were absent. AGENDA ITEM 4.3 RESOLUTION TO APPROVE COMMENDATION SAND APPRECIATION FOR LYNN HUDGEN’S SERVICE TO PHC Ms. Gibboney thanked Lynn Hudgens for his contributions to the PHC Board and wished him well in retirement. Wendi West will work on filling his Board seat.


Commissioner Starck inquired whether anyone had questions for Ms. Gibboney Hearing no requests, she asked for a motion to approve resolution 4.4.

MOTION: Commissioner Germano moved to approve resolution 4.4 as presented, seconded by Commissioner Larsen.

Commissioner Starck asked for commissioner or public comments. Hearing no requests, she called for a vote. The clerk summarized the vote as follows. BOARD ACTION SUMMARY: 25 yes, 0 no, 0 abstention. Motion carried with Commissioner Willis excused. Commissioners Fogg, Reeves and Robinson were absent. AGENDA ITEM 4.5 RESOLUTION TO APPROVE REALLOCATION OF UNEARNED 2019 PCP QIP FUNDS FOR PRIORITY PROJECTS Ms. Gibboney said PHC rewards primary care providers with PCP QIP funds based on a variety of indicators. These funds are budgeted for annually and this year’s measure were more difficult based on new standards from the Governor and State. There was $9.7M of unearned PCP QIP funds for 2019 and PHC would like to repurpose these funds to invest in our primary care network. PHC wants to invest in improving quality, access and workforce in an impactful way. Investments will be presented to Finance Committee for approval and will be allocated in three areas: virtual care, workforce development and quality metrics. Commissioner Broschard asked how much money was awarded via PCP QIP funds. Mr. Ingram stated $24.1M was distributed in PCP QIP funds. Commissioner Marshall thanked PHC for recognizing and helping with the difficulties provider are experiencing. Commissioner Remak asked if resources for patient and provider will be covered in funds invested in virtual care. Ms. Gibboney replied PHC would like to help on both ends to help member and provider connect as easy as possible. Commissioner Remak questioned if investments made to the workforce includes both current and future workforce. Ms. Gibboney said both. PHC just hired a Director of Workforce Development, Andrew Torge, to implement workforce initiatives and education support. PHC has a physician and nurse recruiting incentive program but we are looking to expand to other in-demand positions. Commissioner Starr thanked PHC for looking out for provider needs. AGENDA ITEM 5.0 OTHER REPORTS AGENDA ITEM 5.1 FINANCIAL UPDATE Mr. Ingram began his report by highlighting various information included in his written financial report. For the month ending February 28, 2020, PHC reported a surplus of $2.5 million, bringing the year-to-date deficit to $9.5 million. PHC has earmarked $10 million in reserves for COVID-19 related expenses and will continue to monitor the situation accordingly. At the conclusion of Mr. Ingram’s report, Board members had an opportunity to ask questions and make comments.


ACTION: No action required.

Commissioner Starck inquired whether anyone had additional questions for Mr. Ingram Hearing no requests, she moved on to Sonja Bjork for the Operations Update. AGENDA ITEM 5.2 OPERATIONS UPDATE Ms. Bjork began by giving her appreciation for the calm leaders at PHC during such a chaotic time. Claims have been paid on time, with regular, clean claims paid within ten days of submittal. Claims that have had a SIF, have been processed within thirty days. PHC did have an issue with one vendor struggling with submitting claims during the pandemic. They were having technical and staffing issues, however, after having daily conversations, they have returned to submitting claims in a timely manner. There are many providers learning to bill with staff working from home. With the potential of gaining 60,000 new members, PHC is beginning to prepare. Onboarding of Member Service Representatives was on hold due to the deployment of staff to telework. However, onboarding will resume virtually in May. The new hires will come into the office to receive equipment and take a training course with IT, then will be deployed to telework. PHC is concerned about the heavy workload for our county-eligibility partners as we know they are inundated with CalFrash and Medi-Cal applications. We thank safety net providers who will see individuals new to Medi-Cal. Member Services calls have decreased by 35%, likely due to members avoiding calling because they believe they cannot see their doctor. Commissioner Huber asked where the figure of 60,000 projected member growth came from. Ms. Gibboney replied PHC analyzed the statewide model of new Medi-Cal applicants and calculated PHC’s share of new members. At the conclusion of Ms. Bjork’s report, Board members had an opportunity to ask questions and make comments.

ACTION: No action required. Commissioner Starck asked anyone had additional questions for Ms. Bjork. Hearing no requests, she moved on to Amy Turnipseed for her update. AGENDA ITEM 5.3 PRESS RELEASES, COVID-19 STATE AND FEDERAL LEGISLATION UPDATE, COVID-19 EXECUTIVE ORDERS RELATED TO HEALTH SERVICES Ms. Turnipseed overviewed the written press release update included in the packet. PHC sent press releases last week regarding the early payout of IGT and PCP QIP funds. Currently the Legislature is due to reconvene on May 4, however, this date may be extended, as the State tries to navigate handling business remotely. There have been two informational hearings and the only government actions made were related to COVID-19. The June budget will be limited will not include anything but homelessness, COVID-19 and wildfire prevention. A summary of healthcare-related COVID-19 executive orders was included in the Board packet. The Federal Legislature has passed four COVID-19 legislative packages, with the CARES Act being the largest.

ACTION: No action required.


AGENDA ITEM 5.4 REGULATORY AFFAIRS AND COMPLIANCE DASHBOARD Q1 2020 Ms. Turnipseed highlighted the Q1 2020 Regulatory Affairs and Compliance Dashboard, which is reported to the Board every quarter. PHC had a great quarter, quickly and appropriately reporting any instances of HIPAA and fraud, waste and abuse violations. AGENDA ITEM 6.0 EDUCATIONAL SESSION AGENDA ITEM 6.1 PHARMACY UPDATE Dr. Moore and Mr. Leung provided an update on the Pharmacy Department and the department’s goals and objectives to help better serve our members. They discussed the importance of formulary management to drive down costs and provided a comparison on the cost of non-specialty drugs versus specialty drugs from 2019. PHC’s Managing Pain Safely program has been a great education tool for community pharmacies. Dr. Moore and Mr. Leung discussed planned activities for 2019-2020 which includes continual efforts towards National Committee of Quality Assurance (NCQA) accreditation, preparing for the Medi-Cal Rx-Pharmacy Carve-Out and increasing clinical activities aligned with HEDIS goals. DHCS will take all necessary steps to transition all pharmacy services for Medi-Cal managed care to a fee-for-service benefit by January 2021. This will have an impact on member experience, quality improvement, medication safety, 340B program, medication safety and care coordination. Following the presentation, Board members had an opportunity to ask questions and make comments. Commissioner Remak inquired if the carve-out will implicate changes to programs such as stroke-prevention programs. Mr. Leung replied that it is important the State address whether there will be changes to these programs before the carve-out process begins. Guest Matt Gal questioned if PCP QIP measures will be re-examined in light of COVID-19. Dr. Moore stated PHC has an advisory group making recommendations and putting together comments for providers regarding PCP QIP and COVID-19.

ACTION: No action required. AGENDA ITEM 7 ADJOURNMENT Commissioner Starck asked whether anyone had additional business, hearing no requests she adjourned the Board meeting at 12:30 PM. Minutes respectfully submitted by: Colleen Valenti, Assistant Clerk Board Approval Date: Signed:

Colleen Valenti, Assistant Clerk Nancy Starck, Chair


Report from the Chief Executive Officer

June 2020

COVID-19 Response. Our continued response to the pandemic includes several components, including our work with PHC staff, providers and on behalf of our members. Most PHC staff continue to work remotely with the expectation that we will be doing so at least through the end of July. We monitor our network daily, to report to DHCS on office closures/reduced hours. Some had reduced office hours or closures during protests. We are nearing the end of our “TLC4C19” outbound call campaign to 60,000 high-risk PHC members. Our service levels overall have not been diminished through the pandemic.

Racism, Equity and Protests. With the unprecedented and continued civil protests regarding police brutality and systemic racism, we are working with our internal Health Equity Team, created about a year ago, to lead our efforts with regard to member health disparities, PHC employees and external partner support. Efforts are currently underway to hold a series of staff forums for employees who wish to speak about their experiences. These conversations will inform future internal and external actions and policies with regard to health equity.

FY 2020-2021 State Budget. As of the date of this report, the California State Legislature has approved their version of the State Budget for the upcoming fiscal year, and are in continued negotiations with Governor Newsom’s Administration to complete the budget by June 30th. The Legislature and Administration have taken very different positions when it comes to assumptions about the amount of the deficit and expectations for further federal financial assistance, in light of the COVID pandemic.

The Governor has proposed “trigger” cuts that happen in January, with the assumption that the State will not get additional aid. The Legislature, conversely, assumes that aid will come, and has set forth a different list of cuts to become effective in October, if the aid does not materialize this summer. Several large reductions in revenue, namely a retroactive rate cut and required (but unfunded by the State) rate increase for long term care facilities, are driving our projected deficit for FY 20-21. The State Budget remains very fluid and additional negotiations are expected later this summer, even after an agreement is likely reached this month.

Department of Health Care Services (DHCS) Leadership Change. After just four months in his new role, Dr. Brad Gilbert left his post as Director of DHCS, effective June 12th. After several years as CEO of Inland Empire Health Plan, the local MediCal plan in Riverside/San Bernardino Counties, Dr. Gilbert came out of a brief retirement this winter to lead the Department through the CalAIM Waiver implementation. The


Administration announced his successor, Mr. Will Lightbourne, this week. He is the former Director of California’s Department of Social Services, under Governor Jerry Brown.

Long Term Care at Home Program. In late May, DHCS announced its intention to develop this new program for launch in early 2021, aimed at “decompressing” skilled nursing facilities and residential care facilities during the COVID-19 pandemic as well as flu seasons. While details about the program are still limited, it appears to dovetail with objectives of the CalAIM waiver and similar “hospital at home” initiatives where members are given the option to stay at home with additional supports, remote monitoring, etc. PHC intends to actively participate in the program planning.

CalRx (the Governor’s Executive Order on Pharmacy). So far, the carve-out is proceeding as planned on January 1, 2021. We continue to participate in various state meetings and work groups on the actual implementation. Our FY 20-21 budget assumptions will reflect the carve-out taking place as stated.

CalAIM Waiver Proposal. Just after DHCS accepted final comments on the CalAIM Waiver proposal, the COVID-19 pandemic hit. This followed many months of stakeholder and public participation in the development process. DHCS has announced that the January 1st 2021 effective dates, to various parts of the waiver proposal, have been delayed. No additional dates are available yet.

US Department of Health and Human Services (HHS) Final Rule on Discrimination. On Friday, June 12th, the Trump administration announced it was overturning an Obama-era rule banning discrimination against patients based on gender identity, a protection grounded in the Affordable Care Act. The Health and Human Services Agency said it would enforce the provision (Section 1557) of the ACA by “returning to the government’s interpretation of sex discrimination according to the plain meaning of the word ‘sex’ as male or female and as determined by biology.” The California Department of Health Care Services immediately issued a statement saying that California law, regardless of federal regulation changes, prohibits discrimination on a variety of bases, including sexual orientation. This includes, but is not limited to, the MediCal program.

Wellness and Recovery Program/Drug MediCal. We are very pleased and proud to launch the regional drug treatment component of our Wellness and Recovery Program on July 1, 2020. Margaret Kisliuk, our Behavioral Health Administrator, will present an overview of the program at the June Board meeting.

NCQA Accreditation/HEDIS Scores. NCQA has issued some modified guidance relative to those plans seeking accreditation during the COVID-19 pandemic, and we are making some minor changes to our file review “look back” period in accordance with those flexibilities. We are not, however, requesting a delay in our November, 2020 First Survey date.

We continue to watch for updated requirements from DHCS Managed Care Branch on their expectations for primary care provider performance during the pandemic, and into next year.

Staff Count. We currently have 903 employees.

Upcoming Board Functions/Meetings (pending COVID-19 status and need for remote participation):

• Wednesday, August 26, 2020 – “main” meeting in Redding • Wednesday, October 28, 2020 – “main” meeting in Fairfield • Wednesday, December 2, 2020 – “main” meeting in Santa Rosa


Local Innovations Grants on Housing

Board Update

June 24, 2020


PHC Funds Leveraged to Support 26 Housing Projects


Local Innovations Grants on Housing


CountyGrant Funds

Allocated For This County

Unspent Grant Funds For This Project Grantee Project Description Status and New Activity Update

Del Norte $493,118 $493,118 Del Norte County Department of Health & Human Services

New construction of approximately 30 supportive housing units for homeless people with serious mental illness in Del Norte County; PHC grant will be used in combination with funds from No Place Like Home and

other state programs.

County has not yet secured NPLH funding.

Humboldt

$2,316,486

$119,295 Redwood Community Action Agency

Rehabilitation of existing housing sites and new construction in Eureka, CA to result in 40 new

additional beds of for families with children and homeless individuals with substance use disorders

and/or mental health diagnosis.

Blue Vic is still undergoing renovation construction. Onyx Partnership Apartments are

fully leased.

Humboldt $0 Community Revitalization and Development Corporation

New Construction of 25 supportive housing units for low-income families, chronically homeless individuals and homeless families in Rio Del, CA; PHC grant will be used in combination with California Low-Income

Housing Tax Credit funds.

Construction project is complete.

Lake $1,330,904 $830,904 Adventist Health Clear Lake

Rehabilitation of existing structure in Clearlake, CA targeted to result in 26 new additional beds in

supportive housing for adults without children that are experiencing homelessness.

Demolition began. Contractor bids obtained.

Lassen $323,225 $323,225 Lassen County Health & Social Services Scattered-site subsidized rental properties serving low-income households in Susanville, CA.

Housing case managers started conducting intakes for the program with potential clients.

Project Descriptions and Activity Update


Marin $1,717,065

$112,500 Ritter Center

Facilitation of Comprehensive Care project utilizing Registered Nurse Case Manager and master leased housing assistance to serve

the medically-complex individual experiencing homelessness w/emergency housing to meet goals of reducing inpatient hospital

stays.

RN was hired to assist with COVID pandemic and shelter in place

protocols.

$567,065 Homeward Bound of Marin

New Construction of 15 supportive housing units for chronically homeless adults prioritized by quantified vulnerability; PHC grant will be used in combination with funds from No Place Like Home

and other community programs.

City Council approved environmental review, legislative actions, and project

approvals.

Mendocino $1,646,196

$0 Health and Human Services of Mendocino County

Project targeted to expand access to affordable housing in Ukiah, CA.

Supported the housing needs of 3 children and 2 adults. We anticipate a

sharp increase in demand for this component of our project in the next

reporting period.

$177,792 Redwood Community Services

New construction of 10 single resident occupancy units for individuals experiencing chronic homelessness in the city of Ukiah; PHC grant will be used in combination with Redwood Community Services' resources. Construction completion targeted for Winter

2020.

Paid off the remaining balance on the property.

Modoc $133,239 $0 T.E.A.C.H., Inc. Purchase and rehabilitation of an 8 unit apartment complex to provide Permanent Supportive Sober Living for PHC members. MOU Finalized.

Napa

$1,260,820

$310,000 Peter A. & Vernice H. Gasser Foundation

New construction of 53 supportive housing units for Napa residents experiencing homelessness, mental health disabilities and other barriers to housing; PHC grant will be used in combination with

funds from No Place Like Home and other state programs. Project implementation supported by Burbank Housing, County of Napa

HHSA and the City of Napa.

Received City Council approval for the project and EIR at the Public Hearings.

Development of constructiondocuments.

Napa $65,205 Abode Services

Flexible housing funds targeted to eliminate housing barriers for 18-24 vulnerable, high-need homeless households in need of move-in

assistance and other critical housing supports.

Provided rental assistance to two participants and support with utility

payments to another resident. Additionally, Abode used the funds to

prevent one participant from being evicted.

Project Descriptions and Activity Update Cont.


Shasta

$2,627,376

$0 Shasta Women's Refuge, Inc. (One Safe Place)

Transitional Housing with Case Management, Rapid Rehousing and Permanent Housing Serving an estimated

50-70 members that are victims of domestic violence; PHC grant is leveraged with a funding award from the

Federal Victims of Crime Act program.

MOU Finalized.

Shasta $0 Hill Country Community Clinic(The Center of Hope)

New construction of a housing complex offering primary medical care, mental health treatment, substance abuse

treatment, dental care and case management for 16 transitional age homeless youth (ages 16-24) and 30

adults with complex housing needs; PHC grant will be used in combination with funds from No Place Like

Home and other state programs.

MOU Finalized.

Shasta $0 Hill Country Community Clinic (Youth Without A Home)

Case Management and housing support funds to house 15 Transitional Aged Youth (TAY) experiencing

homelessness identified by local educational partners: Shasta College and California Heritage YouthBuild

Academy.

MOU Finalized.

Shasta $0 Northern Valley Catholic Social Service, Inc.

Flexible housing funds targeted to eliminate housing barriers for approximately 50 high-need homeless

households in need of move-in assistance and other critical housing supports, that agree to participate in case

management.

The grant funds are being expanded to cover staff and administration costs and provide financial

assistance to referred clients needing permanent housing.

Shasta $435,376 Northern Valley Catholic Social Service, Inc.

New Construction of 15 supportive housing units for adults with severe mental illness in the town of Burney, CA; PHC grant will be used in combination with state

and federal housing funds.

Submitted draw requests.



Siskiyou

$779,949

$197,954Siskiyou County Health & Human Services Agency - Social Services

Division - Rapid Re-Housing Project

Rapid Re-Housing services for 36 individuals and families; PHC grant will be utilized with funding as an expansion to the existing

Siskiyou County CalWORKs Housing Support Program.

Increased collaboration with motels; ongoing communication with PCP's

and clinics.

Siskiyou $560,000 Siskiyou County Health & Human

Services Agency - Behavioral Health Services Division

Project targeted for grantee to identify a Development Sponsor through an RFP process contingent upon a state-approved project

plan for the use of No Place Like Home funding.

The Request for Qualifications (RFQ) for a Developer Sponsor was

developed by Housing Tools, approved by County Counsel and distributed to

potential contractors

Solano $4,913,964 $4,863,964

CAP Solano Joint Powers Authority Subcontract with Berkley Food and

Housing

Expansion of established Rapid Re-Housing program: Funding to support 75 Solano County households with rental assistance and case

management in Permanent Supportive Housing

Berkeley Food & Housing Project does not have the resources to carry out

proposed project.

CAP Solano Joint Powers Authority Subcontract with Caminar For

Mental Health

Supportive Housing Program providing rental assistance and supportive services to Solano County adults with serious mental

illness. Funding to support 38 individuals.

The project is still in the unit acquisition and lease up phase and are

still identifying units and tenants.

CAP Solano Joint Powers Authority Subcontract with MP 1700 Santa Monica Associates,

L.P.

New Construction Project a 71-Unit Affordable Rental Community for individuals and families with special needs, located in Fairfield.

The building permit application was submitted to City of Fairfield for plan check review. The general contractor

provided subcontractor hard cost estimates. A Disposition, Development

and Loan Agreement was executed with the Fairfield Housing Authority,

which includes $2.2M loan, land donation and $1M Fee Credit. A Low Income Housing Tax Credit funding

application was submitted.



Sonoma

$4,917,538

$1,304,242 Sonoma County Community Development - Facilitation

In partnership with Catholic Charities, Committee on the Shelterless, Drug Abuse Alternatives Center, Reach of Home

and West County Community Services; this facilitation project is for the placement of PHC members into permanent housing

and sober living environments while connecting them with health and social services. Project scope is targeted to serve at

least 140 PHC members.

CenterPoint/DAAC: They had very good housing retention rates in the time period of the grant. SCHA Housing Navigation: two households were placed in permanent housing. Catholic Charities: Are having

challenges due to the pandemic.

Sonoma $1,304,242Sonoma County

Community Development Commission - Capital Innovation

In partnership with Committee on the Shelterless, Reach of Home and West County Community Services; the scope of this

work includes 3 acquisition-rehabilitation projects that will result in 20 PSH units and 16 medical respite beds.

COTS: The MIC PSH program currently has 12 clients in residence. The Recuperative Care program officially opened in January and has provided care to five. Reach for Home: Rehabilitation to the Permanent Supportive Housing Program through PHC was completed. West County Community Services: WCCS has acquired and

placed 4 units in Sebastopol.Catholic Charities/Burbank: The Caritas Homes, Phase 1, project

is in the predevelopment stage. DanCo: Construction has not started yet. Community Support Network: Four former foster youth and one chronically homeless youth

were housed.

Trinity $195,390 $195,390 Trinity County Behavioral Health Department

New construction of 20 units of permanent affordable housing for persons who are seriously mentally ill and homeless or at risk of homelessness. PHC grant will be used in combination

with funds from No Place Like Home and other state programs.

The County is working through site acquisition details, including soil sampling, transportation studies and

rezoning prior to taking site control.

Yolo

$2,344,729

$700,313 Davis Community Meals and Housing

Multi-functional housing service facility with 18 units of PSH, 10 transitional units, and 4 emergency shelter beds. PHC grant will be used in combination with funds from Sutter's Getting to

Zero Initiative and other fundraising efforts from Davis Community Meals and Housing.

Fundraised $2.7 million. Began to move forward with city planning department and the city council to get

necessary entitlements and begin construction is Aug/Sept 2020.

Yolo $0 City of West Sacramento

In partnership with Mercy Housing, the City of West Sacramento, the Yolo County HHSA and the Yolo County

Housing Authority, this is a new construction project that will result in 75 Permanent Supportive Multi-Family Housing Units

in a mixed-use commercial zone that has prioritized Multi-Family use. PHC funding will be used in combination with funds from No Place Like Home and other state programs.

MOU Finalized.

Yolo $679,972 City of Woodland

New construction of 60 permanent housing units for those who are homeless or unstably housed. 40 of the units are intended

for Medi-Cal qualified individuals and will provide permanent supportive housing to the residents. 20 of the units are intended

for Medi-Cal qualified individuals and provide supportive services to residents.

Dignity Health awarded the permanent supportive housing development a $1.5 million grant.



AGENDA REQUEST FOR RATIFICATION for

PARTNERSHIP HEALTHPLAN OF CALIFORNIA

Board / Finance Committee (when applicable) Agenda Item Number: Meeting Date: June 17, 2020 2.1 Board Meeting Date: June 24, 2020

Resolution Sponsor: Liz Gibboney, Partnership HealthPlan of CA

Recommendation by: Finance Committee

Topic Description: To amend the Health Plan’s FY19-20 budget to account for the DHCS mandated fiscal changes to the Health Plan. In response to COVID-19, the State will reduce the Health Plan’s capitation rate retroactive to July 1, 2019 through December 31, 2020. Additionally, DHCS is increasing the Long Term Care (LTC) per diem rate by 10 percent. The LTC rate increase is effective March 1, 2020 and the end date is to be determined by DHCS.

Reason for Resolution: To obtain Board approval to amend the Health Plan’s FY19-20 budget for decreased State Capitation Revenue and increased Long Term Care expenses as required by DHCS.

Financial Impact: The impact to the Health Plan is estimated to include a $30M reduction to revenue and a $12M increase to healthcare costs in FY19-20.

Requested Action of the Board: Based on the recommendation of staff, the Board is asked to approve the Health Plan’s FY19-20 budget amendment.



PARTNERSHIP HEALTHPLAN OF CALIFORNIA Board / Finance Committee (when applicable) Agenda Item Number: Meeting Date: June 17, 2020 2.1 Board Meeting Date: June 24, 2020

Resolution Number: 20-1990

IN THE MATTER OF: APPROVING THE AMENDMENT TO THE FY2019-2020 HEALTHPLAN BUDGET Recital: Whereas, A. The Board has responsibility for establishing budget policy and specific budget

approval. B. In prior meetings, PHC staff, the Finance Committee and the Board have provided

direction and input into the development of the budget.

Now, Therefore, It Is Hereby Resolved As Follows: 1. To obtain approval to amend the HealthPlan’s annual FY2019-2020 budget for the

DHCS mandated fiscal changes in response to COVID-19.

PASSED, APPROVED, AND ADOPTED by the Partnership HealthPlan of California this 24th day of June, 2020 by motion of Commissioner, seconded by Commissioner, and by the following votes: AYES: Commissioners: NOES: Commissioners: ABSTAINED: Commissioners: ABSENT: Commissioners: EXCUSED: Commissioners:

Nancy Starck, Chair

Date


ATTEST: BY:

Colleen Valenti, Assistant Clerk




Board / Finance Committee (when applicable) Agenda Item Number: Meeting Date: May 20, 2020 2.2 Board Meeting Date: June 24, 2020

Resolution Sponsor: Liz Gibboney, Partnership HealthPlan of CA


Topic Description: On April 22, 2020, the Board approved Budget Assumptions for FY 2020-2021 and directed staff to prepare a full operational budget. The Preliminary Health Care Budget for FY 2020-2021 was developed. If approved, the full Board will ratify the Finance Committee’s approval on June 24, 2020.

On June 17, 2020, the Finance Committee will review and approve the Final Budget. The full Board will review and approve it on June 24, 2020.

Reason for Resolution: The purpose of this resolution is to provide the Preliminary Health Care Budget prepared for FY 2020-2021 for review and approval.

Financial Impact: The financial impact is significant.

Requested Action of the Board: Based on the approval of the Finance Committee, the Board is asked to ratify the Preliminary Health Care Budget for FY 2020-2021.



PARTNERSHIP HEALTHPLAN OF CALIFORNIA Board / Finance Committee (when applicable) Agenda Item Number: Meeting Date: May 20, 2020 2.2 Board Meeting Date: June 24, 2020


IN THE MATTER OF: RATIFYING THE FINANCE COMMITTEE’S APPROVAL OF THE PRELIMINARY HEALTH CARE BUDGET FOR FY 2020-2021 Recital: Whereas, A. The Board has responsibility for establishing budget policy and specific budget

approval. B. In prior meetings, PHC staff, the Finance Committee and the Board have provided

direction and input into the development of the budget.

Now, Therefore, It Is Hereby Resolved As Follows: 1. To ratify the Finance Committee’s approval of the Preliminary Health Care Budget

for FY 2020-2021.


Nancy Starck, Chair


Date ATTEST:

BY: Colleen Valenti, Assistant Clerk


FY 2020-21

Preliminary Health Care Budget

May 2020


Introduction As part of the PHC budget process, the next phase is to present and seek approval from the Finance Committee, the preliminary health care budget. PHC Staff has outlined the major expense categories and highlighted the risks and opportunities assumed in the first draft of the health care costs. Estimates may materially change prior to the final presentation of the full operating budget in June 2020.

Health Care Expenses Due to the COVID-19 pandemic and the unknown future of both the economy and society’s behavioral trends, accurately budgeting health care costs for the upcoming fiscal year poses a real challenge. There are many benchmarks, models, budgets, studies, and theories dedicated to COVID-19 and the new realities that may follow. PHC Staff has been reviewing these materials, breaking down data sources, and cross checking with the Plan’s experience for validity. Many of the theories make logical sense. High unemployment claims should inevitably result in high Medi-Cal enrollment. Deferred services should drastically reduce health care spending for the remainder of the 2020 calendar year. The systemic disruption to our economy should lead to a stock market crash and subsequent recession. However, the impacts surrounding each one have yet to be seen within the Plan’s experience. The small increases in membership have been a result of freezing redeterminations as Medi-Cal applications, so far, are below prior year trends. Claims receipts are only down an average of 20,000 claims a week from prior years and the weekly payment amounts have been similar to seasonal trends as well. The stock market has already begun the rebound and investor sentiment continues to be positive as local governments begin relaxing restrictions and the world attempts to get back to normal life. That said, PHC Staff believes the best approach to the 2020-21 budget is to base assumptions on the known impacts the Plan has experienced thus far and exclude, though continue to track, the variables tied to the more draconian type scenarios.

Health care cost projections for fiscal year 2020-21 were based on the Plan’s historical claims experience for all counties. Cost experience from January 2019 through April 2020 will serve as the base data for budget development. COVID impacts realized in April and May 2020 are modeled to alter the timing of health care costs, deferring varying percentages within cost categories to later in the year. Although the monthly expenses will vary, the full year health care costs will not reflect material COVID-19 impacts. If new information becomes available prior to the final budget submission, staff will make adjustments where necessary. Information surfacing after June 2020, will be evaluated and material impacts not covered as part of the flex budget process will need to be incorporated in a full budget refresh.

The first draft of the health care budget assumes an overall expense of $2.5 billion, which is $125.9 million, or 4.7%, less than the forecasted 2019-20 spend. Considerations and estimates by cost category are presented in more detail, below.


Global Sub-Capitation & Capitated Medical Groups 2020-21: $198.5 million 2019-20 : $296,059 or 0.1%

The first pass of the health care budget assumes no year-to-year change for provider capitation rates. Membership decreases have reduced the global sub-capitation expense and since the provider is not accepting new members, the potential increase to PHC membership will not have a material impact. Capitated medical groups, however, should have variability tied to overall plan enrollment. Variances tied to membership will be accounted for as part of the flex budget process. Similar to prior years, contract negotiations pose a risk of increased cost pressures if PHC is unable to keep rates at their current levels.

Inpatient Hospital 2020-21: $820.8 million 2019-20 : ($15.4) million or (1.8%)

The Inpatient Hospital line item includes inpatient fee-for-service, hospital capitation, and stop loss expenses. PHC experienced an increase in average cost for high dollar cases throughout 2019-20 fiscal year, driving a modest increase to the forecasted stop loss expenses for the upcoming budget. PHC will continue to evaluate the thresholds for the stop loss provision as higher inpatient trends drastically increase the number of qualifying cases. Hospital capitation has a relatively small increase, with minimal rate increases and moderate membership increases. The remainder of the decrease is tied to inpatient fee-for-service. PHC accrued $10.0 million in 2019-20 for potential COVID-19 direct expenses that is not expected to occur in 2020-21. Staff will continue to evaluate hospital contracts relative to revenue. If DHCS continues to reimburse at levels lower than cost, PHC will need to continue to push the reductions downstream.

Physician Services 2020-21: $418.6 million 2019-20 : ($12.2) million or (2.8%)

Physician Services line item includes proposition 56 (prop 56), specialty capitation, primary capitation, and physician fee-for-service expenses. The slight decrease is largely attributable to a prior year adjustment, made in 2019-20, related to 2017-18 and 2018-19 physician services prop 56 program updates. Staff will continue to monitor paid claims for the month of May 2020 and will make material adjustments where necessary.

Long Term Care 2020-21: $359.8 million 2019-20 : $14.4 million or 4.2%

Early in each calendar year, DHCS releases rate adjustments for long term care facilities effective retroactively to the prior August. PHC Claims Department staff subsequently adjust all prior paid claims for the effective period, ensuring payment accuracy. This delayed process inherently increases the budgeting risk for this line item, as the total amount paid by date of service is unknown for a large part of the year. The increase of $14.4 million for the 2020-21 budget is largely based on prior year rate trends and potential increases tied to new mandates on safety. There could be additional COVID-19 impacts


related to behavioral changes as members will likely be hesitant to enter congregate living settings. Staff does anticipate changes to this estimate prior to the final budget.

Pharmacy 2020-21: $167.7 million 2019-20 : ($124.0) million or (42.5%)

The large reduction of $124.0 million is directly tied to the State’s pharmacy carve-out from managed care plans. Effective January 1, 2021, PHC will no longer be responsible for the pharmacy benefit. For the first half of the fiscal year, Staff estimated expenses using prior period trending. The utilization trend analysis considered membership, generic vs brand, non-drug, and specialty drugs.

Ancillary Services 2020-21: $429.0 million 2019-20 : $7.1 million or 1.7%

Ancillary Services is comprised of fee-for-service and capitated ancillary services. The budget assumes a modest increase of $7.1 million mainly tied to fee-for-service claims trends. This is another category that could be impacted by any drastic changes to claims patterns. Staff will continue to monitor the paid claims for the month of May 2020 and will make material adjustments where necessary.

Other Medical 2020-21: $79.3 million 2019-20 : $3.7 million or 4.9%

The Other Medical category includes transportation, quality assurance, health care investment fund (HCIF), nurse advice line, and Health Insurance Premium Payments (HIPP). Transportation expenses will continue to increase due to increasing utilization and contracting pressures. Staff also expects the quality assurance, medical administrative expenses, to increase from the 2019-20 forecasted levels due to the timing of Health Services staff hiring. These two categories are offset by timing of strategic use of reserve (SUR) payments, tied to housing, that were recognized in 2019-20. Over the past few years, PHC has flagged the housing SURs as a non-budget variance due to the timing of grant accounting. This upcoming budget will continue to carry the timing caveat as there are still unspent housing funds.

Quality Improvement Programs (Incentives) 2020-21: $75.9 million 2019-20 : $0.0 or 0.0%

PHC anticipates maintaining the same overall levels of funding for the incentive programs, subject to final revenue projections when rates from DHCS are received. There is some budgetary risk involved in estimating the exact overall payment level, which is dependent on the actual performance of participating providers. COVID-19 introduces its own level of complexity with major disruptions to normal day-to-day activities for measurement year 2020. Staff will continue to use historical performance along with more recent leading indicators to predict the estimated payout of all programs. Budget funding may shift between programs as each QIP has its own set of participants, guidelines, and performance.


Health Care Budget Comparison


CONSENT AGENDA REQUEST for


Board Meeting Date: Agenda Item Number: June 24, 2020 3.1

Resolution Sponsor: Liz Gibboney, CEO, Partnership HealthPlan of CA

Recommendation by: PHC Advisory Groups and Committees

Topic Description: Partnership HealthPlan of California (PHC) has a number of advisory groups & committees established by the Commission (known as the Board) with direct reporting responsibilities. These are the 340B, Compliance, Consumer Advisory, Finance, Personnel, Policies and Benefits, Physicians Advisory, Substance Use Services, Provider Advisory, and Strategic Planning.

The Physician’s Advisory Committee (PAC) has responsibility for oversight and monitoring for the quality and cost-effectiveness of medical care provided to PHC’s members. A number of other PHC advisory groups & committees have direct reporting responsibilities to PAC. These are the Credentialing, Cultural & Linguistics & Health Education, Internal Quality Improvement, Member Grievance Review, Over/Under Utilization Workgroup, Peer Review, Pharmacy & Therapeutics, Provider Grievance Review, Quality/Utilization Advisory, Substance Use Services Internal Quality Improvement, and Substance Use Services.

The Board is responsible for reviewing and accepting all minutes and packets approved by the various PHC advisory groups & committees, and approving the policies, program descriptions, and QIP policy changes that were approved by the PAC, from February 2020 through April 2020. In addition, the Board reviews and accepts PHC’s Claims, Health Services, Human Resources, Member Services, and Provider Relations department operating reports.

Reason for Resolution: To provide commissioners with all PHC committee minutes, committee packets, and departmental operational reports. In addition, to provide commissioners with all PHC policies and program descriptions approved by PAC and recommended for approval.

Financial Impact: Any financial impact to the HealthPlan is included in the budget assumptions.

Requested Action of the Board: Based on the recommendation of PHC’s advisory groups & committees, the Board is asked to accept receipt of all PHC committee minutes, committee packets, and the departmental operational reports. In addition, to approve all PHC policies and program descriptions approved by PAC linked to the packet.



PARTNERSHIP HEALTHPLAN OF CALIFORNIA Board Meeting Date: Agenda Item Number: June 24, 2020 3.1

Resolution Number:

20-1992 IN THE MATTER OF: ACCEPTING ALL PARTNERSHIP HEALTHPLAN OF CALIFORNIA (PHC) COMMITTEE MINUTES, COMMITTEE PACKETS, AND DEPARTMENTAL OPERATING REPORTS. IN ADDITION, TO APPROVE ALL PHC POLICIES AND PROGRAM DESCRIPTIONS APPROVED BY THE PHYSICIANS ADVISORY COMMITTEE (PAC) Recital: Whereas,

A. The Board has fiduciary responsibility for the operation of the organization.

B. The Board has responsibility to review and accept all PHC committee minutes, packets, and departmental operational reports. In addition to review and approve all PHC policies and program descriptions approved by PAC.

Now, Therefore, It Is Hereby Resolved As Follows:

1. To accept receipt of all PHC committee minutes, committee packets, and departmental operational reports.

2. To obtain approval for all PHC policies and program descriptions approved by PAC and recommended for Board approval.

PASSED, APPROVED, AND ADOPTED by the Partnership HealthPlan of California this 24th day of June 2020 by motion of Commissioner, seconded by Commissioner, and by the following votes: AYES: Commissioners: NOES: Commissioners: ABSTAINED: Commissioners: ABSENT: Commissioner: EXCUSED: Commissioners:

Nancy Starck, Chair

Date ATTEST: BY:

Colleen Valenti, Assistant Clerk PHC Board Meeting Packet for 6-24-20 | of 120





Recommendation by: The Physician Advisory Committee

Topic Description:

Resignation: Shandi Fuller, MD, Solano Family Health Services, submitted her resignation to the Physician Advisory Committee, due to changes in her responsibilities.

Appointment: Teresa Shinder, MD, Chief Medical Officer, OLE Health requested appointment to the Physician Advisory Committee. Dr. Shinder is Board Certified in Pediatrics.

Change in Representation: David Gorchoff, MD, Interim Chief Medical Officer, Marin City Health and Wellness, is the predecessor to Dr. Shinder at OLE Health. He will continue his membership with the Physician Advisory Committee.

Reason for Resolution: To obtain approval for membership changes to the Physician Advisory Committee.

Financial Impact: There is no financial impact to the HealthPlan.

Requested Action of the Board: Based on the recommendation from the Physician Advisory Committee, the Board is asked to approve the membership changes to the Physician Advisory Committee due to the resignation of Shandi Fuller, MD, the appointment of Teresa Shinder, MD and the change in representation of David Gorchoff, MD.





IN THE MATTER OF: APPROVING PHYSICIAN ADVISORY COMMITTEE MEMBERSHIP CHANGES Recital: Whereas, A. Shandi Fuller, MD, has resigned from the Physician Advisory Committee. B. Teresa Shinder, MD, requested appointment to the Physician Advisory Committee. C. David Gorchoff, MD will continue his membership on the Physician Advisory

Committee, with a change in representation. D. The Board has authority to appoint committee members.

Now, Therefore, It Is Hereby Resolved As Follows: 1. To obtain approval of the membership changes to the Physician Advisory

Committee.

PASSED, APPROVED, AND ADOPTED by the Partnership HealthPlan of California this 24th day of June by motion of Commissioner, seconded by Commissioner, and by the following votes: AYES: Commissioners: NOES: Commissioners:

ABSTAINED: Commissioners: ABSENT: Commissioners: EXCUSED: Commissioners:

Nancy Starck, Chair

Date


ATTEST: BY:







Recommendation by: Quality/Utilization Advisory Committee & Physician Advisory Committee

Topic Description: The Utilization Management (UM) Program Description serves to implement a comprehensive integrated process that actively evaluates and manages utilization of health care resources delivered to all members, and to pursue identified opportunities for improvement.

Reason for Resolution: To obtain approval for recommended changes to the Utilization Management Program Description, MPUD3001.

Financial Impact: There is no measurable financial impact to the HealthPlan.

Requested Action of the Board: Based on the recommendation of the Quality/Utilization Advisory Committee and Physician Advisory Committee, the full Board is asked to approve the Utilization Management Program Description, MPUD3001.





IN THE MATTER OF: APPROVING THE UTILIZATION MANAGEMENT PROGRAM DESCRIPTION, MPUD3001 Recital: Whereas, A. The Board has the authority and responsibility for ensuring PHC has a

comprehensive and integrated Utilization Management program. B. The Board has ultimate responsibility for approving the Utilization Management

Program.

Now, Therefore, It Is Hereby Resolved As Follows: 1. To approve the Utilization Management Program Description, MPUD3001



Nancy Starck, Chair

Date


ATTEST: BY:







Recommendation by: Sonoma County Board of Supervisors and PHC Staff

Topic Description: The Sonoma County Board of Supervisors met on June 9, 2020 and reappointed Kathryn Powell to the PHC Board for another 4-year term of office. Ms. Powell will continue serving as the Sonoma County Community Health Center Representative. Ms. Powell’s new term commences on May 22, 2020 and terminates on May 21, 2024.

Reason for Resolution: To obtain approval for membership changes to the PHC Board due to the Sonoma County reappointment.

Financial Impact: There is no financial impact to the HealthPlan.

Requested Action of the Board: Based on the recommendation of the Sonoma County Board of Supervisors and PHC Staff, the full Board is being asked to approve Board membership changes due to the Sonoma County reappointment of Kathryn Powell.





IN THE MATTER OF: APPROVING THE BOARD REAPPOINTMENT OF KATHRYN POWELL Recital: Whereas, A. Certain agencies have responsibility for appointing Board members. B. Kathryn Powell is a Sonoma County PHC Board representative and her term

expired on May 21, 2020. She requires a reappointment to serve a new 4-year term of office.

C. On June 9, 2020, the Sonoma County Board of Supervisors reappointed Kathryn Powell to the PHC Board for another 4-year term of office.

D. The Board has the authority to appoint committee members.

Now, Therefore, It Is Hereby Resolved As Follows: 1. To approve the reappointment of Kathryn Powell as the Sonoma County

Community Health Center Representative for a new 4-year term of office, May 22, 2020-May 21, 2024.



Nancy Starck, Chair

Date


ATTEST: BY:



REGULAR AGENDA REQUEST for





Topic Description: On April 22, 2020, the Board approved Budget Assumptions for FY 2020-2021 and directed staff to prepare a full operational budget. On May 20, 2020, the Finance Committee approved the Preliminary Health Care Budget for FY 2020-2021, so a final Budget could be prepared.

Reason for Resolution: To give the Board the opportunity to review and approve the final Budget for FY 2020-2021 that includes PHC’s core business: administration, health care, capital and updated assumptions for review and approval.

Financial Impact: The impact to the HealthPlan is implicit in the budget.

Requested Action of the Board: Based on the recommendation of the Finance Committee and PHC Staff, the Board is asked to approve the final budget for FY 2020-2021.



PARTNERSHIP HEALTHPLAN OF CALIFORNIA Board / Finance Committee (when applicable) Agenda Item Number: Meeting Date: June 17, 2020 4.1 Board Meeting Date: June 24, 2020


IN THE MATTER OF: APPROVING THE FINAL BUDGET FOR FY 2020-2021 Recital: Whereas, A. The Board has responsibility for establishing budget policy and specific budget

approval. B. In prior meetings, PHC staff, the Finance Committee and Board provided direction

and input. C. The final Budget conforms to general assumptions established.

Now, Therefore, It Is Hereby Resolved As Follows: 1. To obtain approval for the final Budget for FY 2020-2021.


Nancy Starck, Chair

Date


ATTEST:



1

FY 2020‐21

Annual Operating & Capital Budget

June 2020


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Table of Contents Introduction ............................................................................................. 3 Outlook for 2020‐21 ................................................................................. 3 Membership ............................................................................................. 3 Revenue .................................................................................................... 4 Medi‐Cal Base Capitation .......................................................................................................................... 4

Interest Income ......................................................................................................................................... 4

Other Income ............................................................................................................................................ 5

Healthcare Expense .................................................................................. 5 Global Sub‐Capitation & Capitated Medical Groups ................................................................................ 5

Inpatient Hospital ..................................................................................................................................... 5

Physician Services ..................................................................................................................................... 6

Long Term Care ......................................................................................................................................... 6

Pharmacy .................................................................................................................................................. 6

Ancillary Services ...................................................................................................................................... 6

Other Medical ........................................................................................................................................... 7

Quality Improvement Programs (Incentives) ............................................................................................ 7

Administrative Expense ............................................................................ 7 Workforce ................................................................................................................................................. 7

Employee .................................................................................................................................................. 8

Occupancy ................................................................................................................................................. 8

Operating .................................................................................................................................................. 8

Professional Services ................................................................................................................................. 8

Computer & Data ...................................................................................................................................... 8

Profit & Loss Statement ........................................................................... 9 Fund Balance .......................................................................................... 10 Capital Projects ...................................................................................... 12 Version History ....................................................................................... 15


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Introduction The next phase of the PHC budget process is to present the 2020‐21 Operating & Capital Budget to the Finance Committee and Board of Directors for final approval. PHC Staff has consolidated the prior components of the budget into one comprehensive summary. A version history has been provided at the conclusion of this report to walk between the healthcare assumptions presented in May 2020 and the final healthcare costs presented below.

Outlook for 2020‐21 As the Plan prepares for the upcoming 2020‐21 fiscal year, PHC, along with the rest of the world, is still facing many unknowns due to the COVID‐19 pandemic. The developing situation will inevitably impact the Plan in many aspects which covers membership, rate development, non‐operating income, healthcare trends, and administrative loads.

Prior to the pandemic, the sustained strong economy and low unemployment continued to drive State‐wide reductions in Medi‐Cal enrollment. Membership and base program revenues may increase if an economic fallout eventually materializes. Base capitation rates are subject to change depending on the outcome of the State budget process and potential Federal stimulus. PHC continues to monitor and implement changes to managed care rules and regulations, new benefits required by DHCS, and also continue to pursue NCQA accreditation.

PHC plans to sustain a $70.1 million deficit for the twelve months ending June 30, 2021. As mentioned in the prior presentations, the unknowns surrounding the 2020‐21 fiscal year will likely lead to a re‐budgeting exercise mid‐year.

Membership The Plan experienced membership losses, excluding retro eligibility, thru January 2020, consistent with statewide trends, due to a number of factors, including a generally strong economy. February 2020 showed a slight increase due to the expanded benefits to include the undocumented adults ages 19 to 26. As part of the COVID‐19 response, the State froze redeterminations beginning March 2020. This resulted in four consecutive months of increased membership despite the absence of increased Medi‐Cal applications. The unemployment claims across California has not yet translated to the volume of increased caseloads the Staff expected. Initial evidence points to coverage remaining for furloughed workers and increased utilization of COBRA. Additionally, some anecdotal evidence assumes the newly uninsured will not enroll to Covered California or Medi‐Cal because they view this period as only temporary and expect to secure employment within the next few months. Due to the overall uncertainty, PHC has decided to model a few flat months of enrollment followed by a resumed, though softened, negative trend. This relatively flat trend approach attempts to mitigate any actual volatile enrollment trends and aims to more accurately forecast the full year’s average, or total member months.


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Revenue PHC budgeted overall revenues at $2.7 billion for a year‐to‐year decrease of $80.0 million. The budget utilized draft rates for the 18 month bridge period provided by DHCS, estimated revenue cuts as part of the May Revise, up‐to‐date market analysis, and existing ancillary revenue streams. DHCS will provide the Plan with the final 2019‐20 18 month bridge period rates and draft CY 2020 rates sometime during the fiscal year. Variances caused by rate differences can be provided as part of the monthly financial performance reporting once the rate changes have been recorded.

Medi‐Cal Base Capitation 2020‐21: $2.7 billion 2019‐20 : decrease of $70.7 million or 2.6% The Medi‐Cal Base Capitation includes offsetting variances driven by base revenue, membership trends, proposition 56 (prop 56), and other supplemental revenues. As part of the May Revise, DHCS reduced the 2019‐20 18 month bridge period rates by 1.5 percent for Adult, Child, SPD, and MCE aid categories. Additionally, the CY 2021 rate period is expected to have a 0.5 percent reduction to the underwriting gain component of the base rates for all aid categories. These two cuts combined represent roughly $45.0 million of reduced base capitation. The removal of the pharmacy component, beginning January 2021, represents an additional $155.0 million of decreased capitation. The continuance of prop 56 programs has been openly debated at the State level, but as of early June, the programs are slated to be in place for the 2020‐21 FY. Prop 56 represents an increase of roughly $29.8 million in base capitation. Supplemental revenues increased from prior year’s budget by $36.1 million, primarily driven by increased utilization. The remaining offsetting variance of $63.4 million is driven by the increase in average membership from prior year’s expectations.

Interest Income 2020‐21: $1.4 million 2019‐20 : decrease of $4.8 million or 77.8% In the wake of the COVID‐19 outbreak and its disruption to the economic market, the Federal Open Market Committee (FOMC) on March 15, 2020 voted to reduce the federal funds target rate to a range of 0.0 to 0.25 percent, a drop of 100 basis points. This was in addition to the 50 basis point drop that occurred on March 4, 2020. The Committee met again on June 10, 2020, projecting no plans to raise interest rates through 2022. While there is not a direct correlation between the federal funds rate and the interest rate earned on deposits or investments held, the overall yield tends to follow a similar


5

direction. The Plan will assume an annual rate of return of 0.5 percent. PHC will revise the rate accordingly based on any future actions taken from the Federal Reserve.

Other Income 2020‐21: $7.7 million 2019‐20 : decrease of $4.5 million or 37.2% Currently, PHC leases space to 11 tenants in Fairfield and one tenant in Redding. Tenants are being sought for previously leased vacant space and for the newly available space on the third floor of 4605 in Fairfield. Rental income is estimated based on existing and anticipated lease agreements. For anticipated leases, rental income was projected using lease rates that are approximately 90 percent of current market rates. Building maintenance costs associated with the leased space will be included in administrative costs. Tenant improvements, greater than $10,000, for the leased space will be included in capital expenditures. Other income also includes the fee collected by the Plan to administer the Intergovernmental Transfer Program (IGT), which has been budgeted at 3 percent for 2020‐21 which is a decrease of ($3.7) million from the prior year.

Healthcare Expense PHC Staff believes the best approach to the healthcare expense budget is to base assumptions on the known impacts the Plan has experienced thus far and exclude, though continue to track, the variables tied to COVID‐19 and the economic outlook.

Healthcare cost projections for fiscal year 2020‐21 were based on the Plan’s historical claims experience for all counties. Cost experience from January 2019 through May 2020 served as the base data for budget development. COVID impacts realized in April and May 2020 are modeled to alter the timing of healthcare costs, deferring varying percentages within cost categories to later in the year. Information surfacing after June 2020, will be evaluated and material impacts not covered as part of the flex budget process will need to be incorporated in a full budget refresh.

The final budget assumes an overall expense of $2.6 billion, which is $30.7 million, or 1.2 percent, less than the 2019‐20 annual budget. Considerations and estimates by cost category are presented in more detail, below.

Global Sub‐Capitation & Capitated Medical Groups 2020‐21: $195.4 million 2019‐20 : decrease of $8.1 million or 4.0%

The budget assumes no year‐to‐year change for provider capitation rates. Membership decreases have reduced the global sub‐capitation expense and since the provider is not accepting new members, the potential increase to PHC membership will not have a material impact. Capitated medical groups, however, should have variability tied to overall plan enrollment. Variances tied to membership will be accounted for as part of the flex budget process. Similar to prior years, contract negotiations pose a risk of increased cost pressures if PHC is unable to keep rates at their current levels.

Inpatient Hospital 2020‐21: $836.7 million 2019‐20 : increase of $51.5 million or 6.6%

The Inpatient Hospital line item includes inpatient fee‐for‐service, hospital capitation, and stop loss expenses. PHC experienced an increase in average cost for high dollar cases throughout 2019‐20 fiscal year, driving a material increase to the forecasted stop loss expenses for the upcoming budget. PHC will


6

continue to evaluate the thresholds for the stop loss provision as higher inpatient trends drastically increase the number of qualifying cases. Hospital capitation has a relatively small decrease, with minimal rate increases and moderate membership decreases. The remainder of the increase is tied to inpatient fee‐for‐service. Substantial Whole Child Model (WCM or CCS) claims and increased UCSF utilization has more than offset the savings related to the updated hospital contracts that eliminated the artificially high MCE rate. Staff will continue to evaluate hospital contracts relative to revenue. If DHCS continues to reimburse at levels lower than cost, PHC will need to continue to push the reductions downstream.

Physician Services 2020‐21: $428.0 million 2019‐20 : increase of $29.2 million or 7.3%

The Physician Services line item includes prop 56, specialty capitation, primary capitation, and physician fee‐for‐service expenses. The increase is primarily driven by prop 56, as the 2019‐20 fiscal year and beyond includes a collection of new sub‐programs to be administered by the Plan. These programs are currently recorded with an MLR of 100 percent and do not have an impact to the bottom line. Future updates will reflect changes made to the programs or their base funding as a result of the final State budget.

Long Term Care 2020‐21: $378.4 million 2019‐20 : increase of $44.1 million or 13.2%

Early in each calendar year, DHCS releases rate adjustments for long term care facilities effective retroactively to the prior August. PHC Claims Department staff subsequently adjust all prior paid claims for the effective period, ensuring payment accuracy. This delayed process inherently increases the budgeting risk for this line item, as the total amount paid by date of service is unknown for a large part of the year. The LTC increase is primarily driven by the routine, annual DHCS rate increases as well as the temporary 10 percent rate bump in effect for the duration of the public health crisis. There could be additional COVID‐19 impacts on utilization and cost due to behavioral changes as members will likely be hesitant to enter congregate living settings.

Pharmacy 2020‐21: $167.7 million 2019‐20 : decrease of $155.7 million or 48.1%

The large reduction of $155.7 million is directly tied to the State’s pharmacy carve‐out from managed care plans. Effective January 1, 2021, PHC will no longer be responsible for the pharmacy benefit. For the first half of the fiscal year, Staff estimated expenses using prior period trending. The utilization trend analysis considered membership, generic vs brand, non‐drug, and specialty drugs.

Ancillary Services 2020‐21: $426.8 million 2019‐20 : decrease of $17.1 million or 3.8%

Ancillary Services is comprised of fee‐for‐service and capitated ancillary services. The budget assumes a modest decrease of $14.8 million tied to fee‐for‐service experience. The fee‐for‐service base data used for this budget cycle more accurately captures configuration changes that were made in prior years. This expense category has carried a minimal year‐to‐date variance of 1.2 percent for the 2019‐20 FY.


7

Other Medical 2020‐21: $96.3 million 2019‐20 : increase of $25.4 million or 35.8%

The Other Medical category includes transportation, quality assurance, healthcare investment fund (HCIF), nurse advice line, and Health Insurance Premium Payments (HIPP). The majority of the increase can be attributed to transportation expenses, which will continue to increase due to increasing utilization and contracting pressures. Staff also expects the quality assurance, or the medical administrative expenses, to increase from the 2019‐20 levels due to the timing of Health Services staff hiring. Over the past few years, PHC has flagged the housing SURs as a non‐budget variance due to the timing of grant accounting. This upcoming budget will continue to carry the timing caveat as there are still unspent housing funds.

Quality Improvement Programs (Incentives) 2020‐21: $75.9 million 2019‐20 : no change

PHC anticipates maintaining the same overall levels of funding for the incentive programs, subject to final revenue projections when rates from DHCS are received. There is some budgetary risk involved in estimating the exact overall payment level, which is dependent on the actual performance of participating providers. COVID‐19 introduces its own level of complexity with major disruptions to normal day‐to‐day activities for measurement year 2020. Staff will continue to use historical performance along with more recent leading indicators to predict the estimated payout of all programs. Budget funding may shift between programs as each QIP has its own set of participants, guidelines, and performance.

Administrative Expense Historically, the Plan has been able to operate at or below an administrative expense ratio of 5.0 percent. Due to the reduction in revenue related to the pharmacy carve‐out and capitation rate cuts, the administrative ratio will increase to roughly 5.3 percent in fiscal year 2020‐21.

Overall administrative spend is estimated to be $141.2 million, or an increase to the prior year’s budget of 8.9 percent. The year‐over‐year increase in total administrative expense is primarily related to the timing of filling vacant positions. This includes positions that were filled near the end of fiscal year 2019‐20, whose salaries will be recognized for a full year in fiscal year 2020‐21 along with positions that will be newly filled in 2020‐21. General operational costs increased year‐over‐year due to the depreciation expense for capital projects completed in the later part of fiscal year 2019‐20, for the anticipated capital projects in 2020‐21, and for increased computer and data costs related to technology infrastructure.

This budget includes a $12.0 million savings target, which for presentation purposes has not been assigned to any specific administrative cost category. This allows Leadership the ability to more effectively implement cost saving initiatives as new information becomes available. The largest factors being the State Budget negotiations and the looming economic impact of the pandemic.

Workforce During the fiscal year 2019‐20 budget development, staffing was maintained at prior year’s levels; however, many of the vacant positions were reassigned to departments where resources were needed due to regulatory driven program changes or the implementation of the new core system. As of today, a number of positions throughout the company remain open with a higher percentage of vacancies


8

concentrated in the Health Services Departments. For fiscal year 2020‐21, staffing changes will be focused on the effects of the pharmacy carve‐out, the State waiver, regulatory requirements, population health, and technology infrastructure needs.

Employee 2020‐21: $95.5 million 2019‐20 : increase of $14.8 million or 18.4% Prior to the onset of COVID‐19, the U.S. economy and labor market remained strong. However, in light of recent developments the economic outlook is dependent on the continued spread of COVID‐19 and timing of the resumption of normal economic activity. Despite those unknowns, the April 2020 Economic News Release from the U.S. Bureau of Labor Statistics stated that the Bay Area employment cost index (ECI) for the 12 months ending March 2020 rose from 3.2 percent at the end of December 2019 to 4.4 percent. Further research of Bay Area unemployment rates revealed the overall change in employment for those in the insurance industry is less than 2 percent. Given the ECI and industry unemployment rates, PHC will assume an average 4.0 percent merit increase which is slightly less than the current ECI number. PHC does not separately adjust salaries for COLA and merit. A 10 percent increase was applied to employee medical, dental, and vision benefits. No new benefits are projected for fiscal year 2020‐21. Travel and non‐travel related expenses are also included within this component, with a modest increase primarily due to staff vacancies being filled and additional travel not only between offices but to State meetings as well.

Occupancy 2020‐21: $20.4 million 2019‐20 : increase of $6.0 million or 42.2% The year‐over‐year increase in occupancy cost is driven by depreciation expense and building maintenance costs. A number of capital projects were not completed until mid to second‐half of fiscal year 2019‐20. Depreciation expense for these items are only for part of the year whereas in fiscal year 2020‐21 a full year of depreciation expense will be recognized. Depreciation expense will also increase based on new capital projects that are expected to be purchased and completed in fiscal year 2020‐21. The remainder of the increase is related to building occupancy costs associated with increased staff and general maintenance for all buildings.

Operating 2020‐21: $5.6 million 2019‐20 : increase of $27,666 or 0.5% Operating costs are comprised of general office supplies, printing, and postage. Overall cost is expected to remain comparable to the prior year.

Professional Services 2020‐21: $17.9 million 2019‐20 : increase of $1.2 million or 7.0% Professional Services primarily includes outside services such as consultants, contracted claims processing, and other third party processing vendors. Although pharmacy processing costs will be eliminated in the 2020‐21 budget due to the Pharmacy carve‐out, offsetting increases are expected for telehealth support fees, behavior health, and non‐capitalizable consulting costs related to the core system implementation.

Computer & Data 2020‐21: $13.7 million 2019‐20 : increase of $1.5 million or 12.0%


9

The computer and data increase is related to expected hardware and software purchases for new staff in addition to the replacement of hardware for existing staff and additional network needs.

Profit & Loss Statement


10

Fund Balance Board designated reserves are calculated according to policy: 60 days of operating expenses, $15.0 million for infrastructure, and an additional amount set aside for the Strategic use of Reserves (SUR), approved but not yet incurred. PHC, through Board approval, created the SUR initiatives and over the years was able to utilize a substantial amount of reserves in a manner that increased member access, increased provider reimbursement, and improved overall operational efficiency. PHC will continue to utilize the funds as approved. The remaining SUR balance is comprised of the Housing Program, Provider Recruitment and the Drug Medi‐Cal Program. The total fund balance, including the final SUR amount and the projected Board designated amount for the year ending June 30, 2021 is estimated at $508.6 million.


11


12

Capital Projects As part of developing the capital budget, each of the projects were evaluated based on the current economic conditions along with the strategic goals and priorities of the organization. Due to delays caused by COVID‐19 and other unforeseen circumstances, certain projects that were approved in the 2019‐20 budget were either not started or were started and not completed during the fiscal year as originally planned. These projects have been included, indicated below by dual asterisks, for 2020‐21 budget consideration. The capital budget for Facilities includes expenditures for building improvements for maintenance of the facilities, safety, and business continuity in addition to tenant improvements for vacant spaces expected to be leased in fiscal year 2021. The capital budget for Information Technology includes expenditures intended to increase system security, improve efficiency and data storage for general operations, and provide support for the core system implementation. Purchases for the core system implementation will be recorded as a capital project in progress until the year the system is fully implemented, in which case depreciation begins. Summaries of capital expenditures by department and region have been listed below:

Detail listing of capital expenditures by department and region:

Carryover Cost From FY 2019-20 ** (1,061,513)Total Facilities Purchase Cost FY 2020-21 2,105,517

(4,026,875)Total Information Technology Purchase Cost FY 2020-21 9,124,000

$ 11,229,517

Facilities

Information Technology

Total Facalities Purchase Cost

Total Information Technology Purchases Cost

Total Puchase Cost FY 2020-21

Southern 13,020,875 13,150,875

3,167,030

Northern 130,000

Northern $ 999,270 Southern 2,167,760

SUMMARY OF CAPITAL BUDGETDEPARTMENT REGION TOTAL PURCHASE COST

Carryover Cost From FY 2019-20 **

DEPARTMENT REGION Carryover BUDGET ITEM DESCRIPTION

ESTIMATED PURCHASE

DATE

TOTAL PURCHASE

COSTFacilities Northern ** Deck/Patio 7/1/2020 826,970$

Resurfacing and Striping of Airpark Facility parking lots 9/1/2020 15,000Water and Ice Machine-Avtech 7/1/2020 13,000Water/Ice Machine- Eureka 6/1/2021 12,500

** Airpark Window Gaskets - Replacement 9/1/2020 60,000Parking Lot Lighting 5/1/2021 71,800

999,270 Carryover Cost From FY 2019-20 ** (527,137) Total Northern Facilities Purchase Cost FY 2020-21 472,133$

DETAIL FACILITIES CAPITAL BUDGET

Total Purchase Cost


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Capital Projects (Continued)


ESTIMATED PURCHASE

DATE

TOTAL PURCHASE

COSTFacilities Southern ** 4820-Exterior Window Framing 7/1/2020 18,200$

** 495-Ceiling Tile Replacement 7/1/2020 52,000 Building Signage 7/15/2020 28,400 Ceiling Tile 7/1/2020 157,000 Circuit Reallocation 7/1/2020 725,000 Copy Room Cabinetry 7/1/2020 35,100

** Exterior Entry Cover 7/1/2020 68,200 ** Exterior Glass 4665 7/1/2020 42,460 ** New Roof 4820 7/1/2020 108,130

Onsite Storage 7/15/2020 13,200 Paint Exterior of 4820 Building 9/1/2020 58,700

** Restroom Flooring 7/1/2020 23,670 Touch Up Paint-Building Exterior 11/1/2020 16,400 UPS Batteries 2/15/2021 21,000 Fire Panel - Replacement 5/15/2021 234,000

** Safety Measure: Replace Deteriorated Lobby Flooring 2/1/2021 124,000 Cost Saving Measure: Landscaping Changes to Drought Tolerant Plants 7/1/2020 150,000

Cost Saving Measure: Landscaping Changes to Drought Tolerant Plants and Water Saving Irrigation System to Building 4820 7/1/2020 150,000 EV Chargers - Santa Rosa Office 3/15/2021 63,800

** 4665 Ceiling Tile Replacement 7/1/2020 78,500 2,167,760 (534,376)

1,633,384

3,167,030(1,061,513)2,105,517$

Total Purchase CostCarryover Cost From FY 2019-20 **Total Southern Faclities Purchase Cost FY 2020-21

Total Faclities Purchase CostCarryover Cost From FY 2019-20 **Total Facilities Purchase Cost FY 2020-21

DETAIL FACILITIES CAPITAL BUDGET (CONTINUED)


ESTIMATED PURCHASE

DATE

TOTAL PURCHASE

COSTNorthern Eureka Infrastructure Enhancements 8/1/2020 30,000$

Redding Infrastructure Enhancements 100,000130,000

- 130,000$

DETAIL INFORMATION TECHNOLGY CAPITAL BUDGET


Total Northern RegionCarryover Cost From FY 2019-20 **Total Northern Information Technology Purchase Cost FY 2020-21


14

Capital Projects (Continued)


ESTIMATED PURCHASE

DATE

TOTAL PURCHASE

COSTSouthern 4665 Datacenter Refurbishment 8/1/2020 60,000$

Backup System Expansion 12/1/2020 500,000Call Center Rewrite 10/1/2020 400,000

** Claims Editor 7/1/2020 2,000,000CPT Add on Codes 10/2/2020 121,000Cyber Security Tools & Expansion 8/1/2020 350,000

** Data Masking Solution/Tools 110,000Data Warehouse, PQD, and HEDIS development 7/1/2020 300,000Edifecs 8/1/2020 250,000Edifecs Support for configuration 7/1/2020 150,000Electronic Document Management System 200,000Enterprise A/V Enhancements / Upgrades 8/1/2020 175,000Enterprise IT Inventory & Asset Management System 7/1/2020 100,000Enterprise Network Upgrades & Expansion 8/1/2020 550,000Enterprise Server Infrastructure Expansion 8/1/2020 400,000Enterprise Storage Array Expansion (Primary & DR Sites) 7/1/2020 650,000Enterprise VDI Infrastructure Expansion 8/1/2020 450,000Enterprise VoIP Enhancements 7/1/2020 250,000Fairfield Infrastructure Enhancements 150,000

** HRP Project Management Resources 7/1/2020 652,000Interoperability 7/1/2020 500,000Master Data Management 250,000Misc Code Sets 10/1/2020 15,000MS Office 365 Implementation 7/1/2020 500,000ODS Development 563,000Organize and Manage Data from/to Web 1/1/2021 100,000PHOENIX Production Infrastructure Expansion 7/1/2020 350,000PR Contract Management (ECMS) 250,000Santa Rosa Infrastructure Enhancements 8/1/2020 38,000Smartcomm setup, development and support 8/1/2020 75,000UI Automation tool for Web apps 3/1/2021 75,000Web Applications Rewrite 8/1/2020 400,000Web Services Development 8/1/2020 60,000Population Health Solution 7/1/2020 90,000Grievance and Appeals Solution 9/1/2020 500,000

** Endpoint Management Solution 7/1/2020 246,000Application Performance Monitoring 8/1/2020 120,000

** EDIE Emergency Department Information Exchange Solution 12/31/2020 350,000** Member Facing Texting Technology System 7/1/2020 400,000

Core System Implementation Support 10/1/2020 100,000** Language Translation Solution for PHC Websites (Member Portal) 220,875

13,020,875 (4,026,875) 8,994,000

13,150,875(4,026,875)9,124,000$

Carryover Cost From FY 2019-20 **Total Southern Information Technology Purchase Cost FY 2020-21Total Purchase CostCarryover Cost From FY 2019-20 **Total Information Technology Purchase Cost FY 2020-21

Total Southern Region

DETAIL INFORMATION TECHNOLGY CAPITAL BUDGET (CONTINUED)



15

Version History This table was created for Committee Members to quickly review changes between the preliminary healthcare budget presented in May ‘20 and the final budget presented above.

Table updated as of June 10, 2020







Topic Description: To provide greater detail on how the Plan will repurpose the 2019 PCP QIP funds that were unearned and are part of the approved FY 2019-2020 budget, as outlined on the attachment following this resolution.

Reason for Resolution: To obtain Board approval to authorize the repurposing of up to $9.7M in unearned PCP QIP funds that will be allocated to areas of need in the wake of COVID-19, in stated priority areas as listed on the following attachment. Finalization of the allocated funds will be pending the final State Budget for FY 2020-2021, and once the management team has had time to determine its overall financial impact to the HealthPlan.

Financial Impact: The impact to the HealthPlan is estimated at $9.7M, which was included in the quality improvement incentives budget to be paid during FY 2019-2020.

Requested Action of the Board: Based on the recommendation of PHC staff, the Board is asked to approve the repurposing of the unearned PCP QIP funds.






IN THE MATTER OF: APPROVING REALLOCATION OF UP TO $9.7M OF UNEARNED PCP QIP FUNDS

Recital: Whereas, A. The Board is responsible for financial oversight.B. The Board approves PHC’s funding for the PCP QIP program.

Now, Therefore, It Is Hereby Resolved As Follows: 1. To obtain approval of repurposing of the unearned PCP QIP funds from FY 2019-

2020, as described above.

PASSED, APPROVED, AND ADOPTED by the Partnership HealthPlan of California this 24th day of June, 2020 by motion of Commissioner, seconded by Commissioner, and by the following votes:

AYES: Commissioners:

NOES: Commissioners:

ABSTAINED: Commissioners:

ABSENT: Commissioners:

EXCUSED: Commissioners:

Nancy Starck, Chair

Date


ATTEST:



Partnership HealthPlan of California

Request to Repurpose 2019 PCP QIP Funds

Updated 6/9/20

Area of Focus Description Funding Amount

Status

Virtual Care

Lead: Karan Rafus/PMO

Incentive funds to convert and/or increase the number and type of PCP office visits conducted through video. Pay for threshold of switching from in-person to video visits, when compared to pre-COVID visit levels, and which are sustained for at least 90 consecutive days. Video visits should reach at least 20% of all virtual visits held. Submit basic workflows on how video visits are organized, providers and patients supported.

This grant could pay for related and retroactive expenses (retroactive to March 1st) associated with:

• Developing workflows for each PCP site that supportsvirtual care

• Providing basic medical or phone equipment to membersfor telehealth

• Pay for software that allows members to complete healthassessments electronically & remotely for well-baby,developmental, autism screens, etc.

• Can pay for telehealth hardware and software, softwarelicensing, etc.

• General operations to support this transition

$5M To be allocated by eligible PCP site patient assignment, with a simple application. Unused funds can revert to another initiative if the PCP does not choose to utilize the funds or does not meet deliverables.

Promotion of Behavioral Health

Funding for PCP sites w/ a behavioral health focus to further the integration of behavioral health and physical health care assuming a mostly virtual environment.

$1.2M A basic application has been prepared and will be released upon approval. We can repurpose these funds if the


Lead: Margaret Kisliuk, with PMO

Clinics selected: Integrated clinics (those that already have behavioral health capacity) that applied for the Proposition 56 Behavioral Health Integration grants or select PCP sites that have shown demonstrated leadership in BHI and cover PHC counties that otherwise would not be included. Eligible expenses are those that can be shown to improve integration, ranging from staff training to equipping computers with cameras so behavioral health staff can attend PCP appointments.

State does fund Prop 56 BHI grants in the near term.

Provider Workforce Development Initiatives Lead: Wendi West and Andrew Torge

Expand existing provider recruitment program by expanding provider types who can get recruitment support to include BH providers. Additional Workforce Initiatives to be reviewed and finalized, with applications made available to providers and organizations in good standing with PHC.

$3M

Mixture of short and longer-term projects.

Quality Metrics/Outside New PCP QIP Lead: QI Staff

For those measures that do NOT remain in the revised PCP QIP structure itself, such as HEDIS measures for: kids > 2 yrs, mammography, cervical cancer screens. Submit proposal to receive up to $25,000 to start a drive-through vaccine clinic, or other campaigns to provide listed preventive care measures above.

$500,000 Eligible entities are independent RHCs and smaller, private PCP sites not affiliated with health systems. By invitation. (A 47 eligible PCP sites in our 14 counties.





Recommendation by: PHC Staff

Topic Description: For the 2019 Primary Care Quality Improvement Program (QIP), we had thirteen PCP provider sites with exceptional performance; scoring at least __% of total possible points: Parent Organization Provider Site Name County 1) Petaluma Health Center Petaluma Health Center Sonoma 2) Harvest Pediatrics Harvest Pediatrics, Napa Napa 3) Harvest Pediatrics Harvest Pediatrics, St. Helena Napa 4) Cueto Salas, Martha Cueto Sonoma 5) St. Joseph Heritage Healthcare Annadel Medical Group, Ste. 303 Sonoma 6) St. Joseph Heritage Healthcare Annadel Medical Group, Petaluma Sonoma 7) Santa Rosa Community Health

Centers SRCH Elsie Allen Campus Sonoma

8) Santa Rosa Community Health Centers

SRCH Pediatric Campus Sonoma

9) NorthBay Healthcare NorthBay Center for Primary Care, Vacaville

Solano

10) NorthBay Healthcare NorthBay Center for Primary Care, Green Valley

Solano

11) Marin Community Clinics Marin Community Clinics, 3260 Kerner Blvd.

Marin

12) Marin Community Clinics Marin Community Clinics, 3110 Kerner Blvd.

Marin

13) Communicare Davis Community Clinic Yolo Reason for Resolution: Based on the recommendation from PHC staff, the Board is asked to commend the thirteen Primary Care Provider sites for achieving exceptional performance in the 2019 Primary Care Provider QIP. Financial Impact: There is no financial impact to the HealthPlan. Requested Action of the Board: Based on the recommendation from PHC staff, the Board is asked to commend the thirteen top performing Primary Care Provider sites for their excellent scores in the HealthPlan’s Quality Improvement Program for the year 2019.

REGULAR AGENDA REQUEST PHC Board Meeting Packet for 6-24-20 | of 120

for PARTNERSHIP HEALTHPLAN OF CALIFORNIA



IN THE MATTER OF: COMMENDING THE THIRTEEN PRIMARY CARE PROVIDER RECIPIENTS OF THE 2019 PRIMARY CARE PROVIDER QIP Recital: Whereas, A. The following health centers had exceptional performance in the 2019 Primary Care

QIP: Petaluma Health Center, Harvest Pediatrics (Napa & St. Helena sites), Cueto Salas, Martha, Annadel Medical Group (Ste. 303 and Petaluma sites), SRCH (Elsie Allen Campus and Pediatric Campus), Northbay Center for Primary Care (Vacaville and Green Valley sites), Marin Community Clinics (3260 Kerner Blvd. and 3110 Kerner Blvd. sites) and Davis Community Clinic

Now, Therefore, It Is Hereby Resolved As Follows: 1. To commend these thirteen Primary Care Providers for their exceptional

performance in the Primary Care Provider QIP.


Nancy Starck, Chair

Date ATTEST: BY: Colleen Valenti, Assistant Clerk


FINANCIAL HIGHLIGHTS Of The Partnership HealthPlan Of California For the Period Ending April 30, 2020

Financial Analysis for the Current Period

Total (Deficit) Surplus For the month ending April 30, 2020, PHC reported a net deficit of $25.4 million resulting in a net deficit of $19.2 million for the year-to-date. Significant variances are explained below.

Revenue Total Revenue is less than budget by $21.0 million for the month of April and greater than budget by $49.2 million for the year-to-date. The month-to-date variance is primarily driven by a $24.8 million year-to-date true-up related to the 1.5% rate decrease stemming from the May Revise. There is additional unfavorable revenue variance driven by the decision to waive the administrative fee associated with the IGT program for the 2018-19 cycle. The remainder of the fiscal year is expected to have an overall favorable revenue variance with the expanded Proposition 56 funding, the acuity adjustment to the base rates, and supplemental payments tied to Behavioral Health and American Indian Health Services, both of which have an offsetting healthcare cost component. Other revenue and interest income is lower than expected due to leasing vacancies and an overall decrease in interest rates, respectively.

Healthcare Costs Total Healthcare Costs are greater than budget by $70.0 million for the year-to-date. Total Inpatient Hospital has an unfavorable year-to-date variance of roughly $43.0 million, or 8.3%. The year-to-date unfavorable variance has been driven by higher incurred expenses than anticipated partially due to high dollar whole child model (WCM) claims, timing of assumed impacts for hospital contract changes that took place in the prior year, and a $10.0 million liability for potential COVID-19 related costs. PHC continues to closely monitor the paid claims on a weekly basis, analyzing the development against revenue and budget expectations. Long Term Care has an unfavorable year-to-date variance of $14.1 million mainly driven by an accrual for the annual long term care rate increases by DHCS effective August each year along with the 10% increase granted as part of the May Revise. Pharmacy expenses are favorable $19.3 million year-to-date primarily due to budget assumptions that were based on limited WCM information and the transition of prior year brand drugs to generics. Favorability of pharmacy may be reduced in future months as quarterly AWP increases are realized along with increased utilization of specialty drugs and new high cost treatments.

Administrative Costs Total administrative costs are over budget by $394,807 for the month, reducing the positive variance to $7.5 million for the year-to-date. The positive variances continue to be in employee costs as well as computer and data costs. As vacant positions are filled and projects in IT are completed, the positive variance should gradually decrease for these administrative cost categories.

Balance Sheet

Total Cash & Cash Equivalents increased by $7.5 million for the month. $483.1 million in State Capitation


FINANCIAL HIGHLIGHTS Of The Partnership HealthPlan Of California For the Period Ending April 30, 2020

Payments received included $130.4 million in IGT Payments which were subsequently distributed during the month. In addition to the IGT distributions, $83.5 million in directed payments and $10.7 million in administrative and capital costs were made during the month. Additionally, $249.4 million in healthcare payments were made which include $29.1 million in QIP Payments and $12.1 million in outpatient supplemental reimbursements. The remaining difference can be attributed to interest, other revenues, and transfers.

Following the latest Routine Examination by the DMHC, medical-related liabilities that were previously recorded in Accounts Payable were reclassified to the Accrued Healthcare Costs account.

General Statistics

Membership Membership had an increase of 3,300 members for the month. Medi-Cal Rate Region 1 had a membership increase of 2,217 members while Medi-Cal Rate Region 2 had a membership increase of 1,083 members.

Utilization Metrics and High Dollar Case For the fiscal year 2019/20 through April 30, 2020, 258 members reached the $250,000 threshold with an average cost of $453,639. For fiscal year 2018/19, the number of members reached 430, and the average cost per case was $459,079. For fiscal year 2017/18, 460 members reached the $250,000 threshold with an average claims cost of $421,286.

Current Ratio/Required Reserves (Excluding Capital Assets) Current Ratio Including Required Reserves 1.88 Current Ratio Excluding Required Reserves: 1.20 Required Reserves: $476,538,737 Total Fund Balance: $585,150,533

Days of Cash on Hand Including Required Reserves: 85.32 Excluding Required Reserves: 45.23


Member Months by County:

County Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20Solano 107,333 107,442 106,084 106,461 106,294 106,010 105,954 104,966 104,320 103,705 103,837 104,382 105,160 Napa 27,460 27,750 27,597 27,681 27,663 27,592 27,694 27,775 27,717 27,400 27,461 27,602 27,704 Yolo 51,672 51,798 50,905 50,909 50,690 50,117 50,432 50,217 49,882 49,385 49,291 49,486 49,829 Sonoma 104,764 105,420 104,766 104,559 104,234 103,702 103,285 102,775 102,023 101,505 101,091 101,320 101,427 Marin 37,177 37,403 37,251 37,294 37,295 37,353 37,123 36,840 36,660 36,439 37,028 37,095 37,390 Mendocino 38,232 38,007 37,228 36,820 36,899 36,172 36,032 35,496 34,983 34,735 34,659 34,710 34,658 Lake 29,917 30,082 29,772 30,040 29,994 29,985 29,939 29,681 29,387 29,242 29,276 29,423 29,411 Del Norte 11,133 11,130 11,124 11,120 11,107 11,113 11,200 11,090 11,070 11,126 11,085 11,132 11,146 Humboldt 52,460 52,762 51,856 52,179 52,016 52,035 52,103 52,086 52,009 51,646 51,353 51,707 51,648 Lassen 6,989 7,095 7,011 7,062 7,097 7,051 7,147 7,101 7,127 7,069 7,100 7,188 7,172 Modoc 3,163 3,193 3,177 3,158 3,202 3,218 3,200 3,212 3,268 3,228 3,234 3,288 3,279 Shasta 59,075 59,057 58,622 58,572 58,629 58,710 58,867 58,575 58,353 57,967 57,731 57,744 57,626 Siskiyou 17,280 17,254 16,978 17,065 16,994 17,011 17,126 16,917 16,819 16,616 16,695 16,780 16,718 Trinity 4,218 4,200 4,234 4,128 4,104 4,139 4,127 4,134 4,157 4,168 4,150 4,238 4,318 All Counties Total 550,873 552,593 546,605 547,048 546,218 544,208 544,229 540,865 537,775 534,231 533,991 536,095 537,486

Medi-Cal Region 1: Solano, Napa, Yolo & Marin; Medi-Cal Region 2: Sonoma, Mendocino & Rural 8 Counties

541,661

539,357 537,071

549,804 549,079 548,358 547,639 546,924 546,211 545,502 544,795 544,092 543,391

550,873

552,593

546,605

547,048 546,218

544,208 544,229

540,865 537,775

534,231 533,991 536,095

537,486

530,000

535,000

540,000

545,000

550,000

555,000

560,000

565,000

570,000

575,000

580,000

APR ‐19 MAY ‐19 J UN ‐19 J U L ‐19 AUG ‐19 SEP ‐19 OCT ‐19 NOV ‐19 DEC ‐19 J AN ‐20 FEB ‐20 MAR ‐20 APR ‐20

PARTNERSHIP HEALTHPLAN OF CALIFORNIAACTUAL V. PROJECTED MEDI‐CAL ENROLLMENT

APR 2019 ‐ APR 2020

Projected (Budgeted) Actual


Avg / Month43,708 As of

FINANCIAL INDICATORS Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 YTD Apr-20

Total Enrollment 543,170 542,248 540,608 540,739 537,716 533,109 529,498 529,996 529,967 533,267 5,360,318 536,032

Total Revenue 232,220,019 233,979,321 225,758,449 230,938,231 229,446,952 224,684,937 228,161,239 262,181,867 243,017,331 215,347,436 2,325,735,781 232,573,578

Total Health Care Costs 221,560,592 223,257,443 217,724,528 221,071,036 220,349,586 213,467,348 217,778,911 249,977,860 229,442,696 229,554,206 2,244,184,206 224,418,421

Total Administrative Costs 9,697,468 9,586,960 10,254,919 10,262,335 9,240,143 10,220,597 10,838,094 9,708,553 9,716,836 11,220,586 100,746,492 10,074,649

Total Current Year Surplus (Deficit) 961,959 1,134,918 (2,220,998) (395,140) (142,777) 996,992 (455,766) 2,495,454 3,857,799 (25,427,356) (19,194,917) (1,919,492)

Total Claims Payable 309,950,812 333,658,113 318,826,076 337,397,003 359,352,408 356,763,714 343,462,447 386,117,714 361,702,417 370,832,533 370,832,533 347,806,324

Total Fund Balance 605,307,407 606,442,325 604,221,326 603,826,187 603,683,410 604,680,402 604,224,636 606,720,090 610,577,890 585,150,533 585,150,533 603,483,421

Reserve Fund - Required Reserves 364,887,643 362,362,468 361,460,827 362,216,840 361,706,326 360,992,575 360,861,118 366,433,312 368,054,608 370,295,182 370,295,182 363,927,090

Reserve Fund - Capital Assets 105,166,231 108,043,421 108,574,111 107,960,113 108,326,115 107,925,149 107,752,145 106,982,789 106,790,050 106,243,555 106,243,555 107,376,368

Reserve Fund - Strategic Use of Reserves 59,756,800 59,651,513 59,380,941 57,548,808 56,942,396 91,126,990 89,751,571 89,450,038 88,442,860 87,252,581 87,252,581 73,930,450

Unrestricted Fund Balance 75,496,733 76,384,923 74,805,447 76,100,426 76,708,573 44,635,688 45,859,802 43,853,951 47,290,372 21,359,215 21,359,215 58,249,513

Fund Balance as % of Reserved Funds 114.25% 114.41% 114.13% 114.42% 114.56% 107.97% 108.21% 107.79% 108.40% 103.79% 103.79% 110.68%

Current Ratio 1.29:1 1.28:1 1.23:1 1.27:1 1.25:1 1.26:1 1.26:1 1.18:1 1.21:1 1.20:1 1.20:1 1.24:1

Medical Loss Ratio 95.41% 95.42% 96.44% 95.73% 96.04% 95.01% 95.45% 95.35% 94.41% 106.60% 96.49% 96.49%

Admin Ratio 4.18% 4.10% 4.54% 4.44% 4.03% 4.55% 4.75% 3.70% 4.00% 5.21% 4.33% 4.33%

Profit Margin Ratio 0.41% 0.49% -0.98% -0.17% -0.06% 0.44% -0.20% 0.95% 1.59% -11.81% -0.83% -0.83%

Avg / Month

As of

FINANCIAL INDICATORS Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 YTD Jun-19

Total Enrollment 558,229 555,694 554,259 553,722 554,344 551,393 550,184 549,293 548,517 547,283 547,276 544,864 6,615,058 551,255

Total Revenue 223,622,396 224,627,038 223,011,248 221,839,053 238,320,688 225,145,110 229,293,826 234,635,800 237,354,464 240,583,405 248,302,311 235,490,761 2,782,226,099 231,852,175

Total Health Care Costs 215,098,111 213,849,684 210,084,055 209,799,985 223,764,851 211,650,497 216,013,007 226,612,352 225,474,410 219,531,756 218,022,242 205,309,098 2,595,210,049 216,267,504

Total Administrative Costs 7,937,564 8,576,255 7,892,305 8,992,573 8,487,438 9,080,268 9,079,667 8,720,456 9,568,053 8,989,395 10,037,320 9,906,862 107,268,157 8,939,013

Medi-Cal Hospital & Managed Care Taxes 11,196,958 11,196,958 11,196,958 11,196,958 11,196,958 11,196,958 11,196,958 11,196,958 11,196,958 11,196,958 11,196,958 11,196,958 134,363,496 11,196,958

Total Current Year Surplus (Deficit) (10,610,237) (8,995,859) (6,162,070) (8,150,463) (5,128,559) (6,782,613) (6,995,806) (11,893,966) (8,884,957) 865,296 9,045,791 9,077,843 (54,615,603) (4,551,300)

Total Claims Payable 238,728,946 242,503,297 266,069,388 251,011,405 298,803,635 294,871,571 309,072,419 331,116,229 334,992,569 318,215,062 330,437,589 342,352,414 342,352,414 296,514,544

Total Fund Balance 648,231,184 639,235,325 633,073,254 624,922,791 619,794,231 613,011,618 606,015,812 594,121,845 585,236,888 586,102,184 595,147,976 604,225,819 604,225,819 612,426,578

Reserve Fund - Required Reserves 468,852,166 470,106,280 470,618,797 375,187,068 374,339,552 371,639,122 373,138,099 376,969,141 381,309,416 383,837,629 376,627,068 376,097,730 376,097,730 399,893,506

Reserve Fund - Capital Assets 84,135,058 85,929,106 88,073,284 89,834,151 93,533,892 97,192,597 97,351,505 96,896,491 95,866,835 95,577,773 104,951,344 105,532,414 105,532,414 94,572,871

Reserve Fund - Strategic Use of Reserves 66,188,548 63,204,100 73,804,101 72,586,265 71,540,381 68,267,962 66,495,382 66,082,314 65,094,988 63,538,939 61,259,598 60,646,102 60,646,102 66,559,057

Unrestricted Fund Balance 29,055,412 19,995,839 577,072 87,315,307 80,380,406 75,911,937 69,030,826 54,173,899 42,965,649 43,147,843 52,309,966 61,949,573 61,949,573 51,401,144

Fund Balance as % of Reserved Funds 104.69% 103.23% 100.09% 116.24% 114.90% 114.13% 112.86% 110.03% 107.92% 107.95% 109.64% 111.42% 111.42% 109.16%

Current Ratio 1.13:1 1.11:1 1.09:1 1.38:1 1.31:1 1.30:1 1.29:1 1.24:1 1.13:1 1.12:1 1.23:1 1.24:1 1.24:1 1.19:1

Medical Loss Ratio w/o Tax 101.26% 100.20% 99.18% 99.60% 98.52% 98.93% 99.04% 101.42% 99.70% 95.70% 91.95% 91.54% 98.01% 98.01%

Admin Ratio w/o Tax 3.74% 4.02% 3.73% 4.27% 3.74% 4.24% 4.16% 3.90% 4.23% 3.92% 4.23% 4.42% 4.05% 4.05%

Profit Margin Ratio w/o Tax -4.99% -4.21% -2.91% -3.87% -2.26% -3.17% -3.21% -5.32% -3.93% 0.38% 3.82% 4.05% -2.06% -2.06%

Partnership HealthPlan of CaliforniaComparative Financial Indicators Monthly ReportFiscal Year 2019 - 2020 & Fiscal Year 2018 - 2019


$105.0 $105.5 $105.2 $108.0 $108.6 $108.0 $108.3 $107.9 $107.8 $107.0 $106.8 $106.2

$376.6 $376.1 $364.9 $362.4 $361.5 $362.2 $361.7 $361.0 $360.9 $366.4 $368.1 $370.3

$61.3 $60.6 $59.8 $59.7 $59.4 $57.5 $56.9

$91.1 $89.8 $89.5 $88.4

$87.3

$52.3 $62.1 $75.5$76.4 $74.8 $76.1 $76.7 $44.6 $45.9 $43.9 $47.3

$21.4

$0.0

$100.0

$200.0

$300.0

$400.0

$500.0

$600.0

$700.0

May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Jan 2020 Feb 2020 Mar 2020 Apr 2020

Partnership HealthPlan of CaliforniaFund Balance Comparison

(in Millions of Dollars)

Required Reserves - Capital Required Reserves - Other Strategic Use of Reserves Unrestricted Funds

For the Past 12 Months Ending April 30, 2020


CURRENT MONTH

PRIORMONTH INC / DEC MEMBERSHIP SUMMARY

CURRENT YTD AVG

PRIOR YTD AVG VARIANCE

218,237 216,020 2,217 Medi-Cal Region 1 218,011 224,068 (6,058) 315,030 313,947 1,083 Medi-Cal Region 2 318,021 328,224 (10,202) 533,267 529,967 3,300 TOTAL 536,032 552,292 (16,260)

ACTUALMONTH

BUDGETMONTH

$ VARIANCE MONTH FINANCIAL SUMMARY

ACTUAL YTD

BUDGET YTD

$ VARIANCE YTD

215,347,436 236,395,736 (21,048,300) Total Revenue 2,325,735,781 2,276,558,702 49,177,079 229,554,206 219,552,948 (10,001,258) Total Healthcare Costs 2,244,184,206 2,174,145,282 (70,038,924)

11,220,586 10,825,779 (394,807) Total Administrative Costs 100,746,492 108,271,480 7,524,988 (25,427,356) 6,017,009 (31,444,365) Total Current Year Surplus (Deficit) (19,194,917) (5,858,060) (13,336,857)

106.60% 92.88%Medical Loss Ratio (HC Costs as a % of

Rev) 96.49% 95.50%

5.21% 4.58%Admin Ratio (Admin Costs as a % of

Rev) 4.33% 4.76%

PARTNERSHIP HEALTHPLAN OF CALIFORNIAMembership and Financial SummaryFor The Period Ending April 30, 2020


April 2020 March 2020

A S S E T SCurrent Assets

Cash &Cash Equivalents 417,818,994 410,288,975

ReceivablesAccrued Interest 157,700 504,200 State DHS - Cap Rec 221,311,568 339,713,234 Funds Receivable - Prov Risk 4,531,891 4,531,891 Miscellaneous Receivable 1,117,228 1,044,652

Total Receivables 227,118,387 345,793,977

Other Current AssetsPayroll Clearing (3,622) (1,196)Prepaid Expenses 5,185,976 4,049,783

Total Other Current Assets 5,182,354 4,048,587

Total Current Assets 650,119,735 760,131,539

Non-Current AssetsFixed Assets

Motor Vehicles 140,518 140,518 Furniture & Fixtures 7,518,859 7,518,859 Computer Equipment - HP 541,886 541,886 Computer Equipment 19,508,032 19,487,765 Computer Software 18,604,265 18,604,265 Leasehold Improvements 962,374 962,374 Land 6,767,292 6,767,292 Building 55,932,088 55,932,088 Building Improvements 27,454,868 27,454,868 Accum Depr - Motor Vehicles (113,419) (112,109)Accum Depr - Furniture (6,184,245) (6,139,372) Accum Depr - Comp Equip - HP (541,886) (541,886)Accum Depr - Comp Equipment (11,027,927) (10,633,049) Accum Depr - Comp Software (14,822,001) (14,612,772) Accum Depr - Leasehold Improvements (950,169) (948,098)Accum Depr - Building (6,066,774) (5,947,261) Accum Depr - Bldg Improvements (5,331,868) (5,181,074) Construction Work-In-Progress 13,851,662 13,495,757

Total Fixed Assets 106,243,555 106,790,051

Other Non-Current AssetsDeposits 38,674 47,174 Board-Designated Reserves 369,995,182 367,754,608 Knox-Keene Reserves 300,000 300,000 Net Pension Asset 1,350,224 1,350,224 Deferred Outflows Of Resources 927,581 927,581

Total Other Non-Current Assets 372,611,661 370,379,587

Total Non-Current Assets 478,855,216 477,169,638

Total Assets 1,128,974,951 1,237,301,177

PARTNERSHIP HEALTHPLAN OF CALIFORNIABalance Sheet

As Of April 30, 2020

Page 1 of 2PHC Board Meeting Packet for 6-24-20 | of 120

April 2020 March 2020

PARTNERSHIP HEALTHPLAN OF CALIFORNIABalance Sheet

As Of April 30, 2020

L I A B I L I T I E S & F U N D B A L A N C E Liabilities

Current LiabilitiesAccounts Payable 66,689,766 165,393,075 Unearned Income 164,445 151,888 Suspense Account 235,781 498,984 Capitation Payable 10,153,118 8,864,327 State DHS - Cap Payable 25,857,223 6,562,106 Accrued Healthcare Costs 9,109,765 - Claims Payable 81,919,688 39,185,129 Incurred But Not Reported-IBNR 288,912,845 322,517,288 Quality Improvement Programs 60,259,918 83,028,621

Total Current Liabilities 543,302,549 626,201,418

Non-Current LiabilitiesDeferred Inflows Of Resources 521,869 521,869

Total Non-Current Liabilities 521,869 521,869

Total Liabilities 543,824,418 626,723,287

Fund BalanceUnrestricted Fund Balance 21,359,215 47,290,372

Reserved FundsReserve Fund-Board Designated 354,995,182 352,754,608 Reserve Fund-Board Designated-Infrastructure 15,000,000 15,000,000 Reserve Fund-Board Designated-Capital Assets 106,243,555 106,790,050 Reserve Fund-Strategic Use Of Reserve 87,252,581 88,442,860 Reserve For Restricted Fund-Knox-Keene 300,000 300,000

Total Reserved Funds 563,791,318 563,287,518

Total Fund Balance 585,150,533 610,577,890

Total Liabilities And Fund Balance 1,128,974,951 1,237,301,177

Page 2 of 2PHC Board Meeting Packet for 6-24-20 | of 120

Current Month Activity Year-To-Date Activity

CASH FLOWS FROM OPERATING ACTIVITIES:Cash Received From:Capitation from California Department of Health Care Service 483,093,738 2,839,522,984 Other Revenues 3,998 157,261Cash Payments to Providers for Medi-Cal Members

Capitation Payments (34,362,641) (344,250,561) Medical Claims Payments (215,019,739) (1,836,054,220)

Cash Payments to Vendors (215,753,144) (546,087,520) Cash Payments to Employees (8,144,639) (81,066,209) Net Cash (Used) Provided by Operating Activities 9,817,573 32,221,735

CASH FLOWS FROM CAPITAL FINANCING & RELATED ACTIVITIES:Purchases of Capital Assets (696,611) (9,760,515) Net Cash Used by Capital Financial & Related Activities (696,611) (9,760,515)

CASH FLOWS FROM INVESTING ACTIVITIES:Board-Designated Reserve Transfers (2,240,574) 5,802,548Interest and Dividends on Investments 649,632 5,026,609Net Cash (Used) Provided by Investing Activities (1,590,942) 10,829,157

NET (DECREASE) INCREASE IN CASH & CASH EQUIVALENTS 7,530,020 33,290,377

CASH & CASH EQUIVALENTS, BEGINNING 410,288,975 384,528,617

CASH & CASH EQUIVALENTS, ENDING 417,818,994 417,818,994

RECONCILIATION OF OPERATING (LOSS) INCOME TO NET CASH PROVIDED (USED) BY OPERATING ACTIVITIES:

TOTAL OPERATING (LOSS) INCOME (25,730,488) (23,916,325) DEPRECIATION 922,667 9,167,765CHANGES IN ASSETS AND LIABILITIES:Other Receivables (72,576) (862,752) California Department of Health Services Receivable 118,401,666 16,687,121Other Assets (804,829) (301,317) Accounts Payable and Accrued Expenses (69,260,282) (2,458,880) Accrued Claims Payable 9,130,117 28,480,120Quality Improvement Programs (22,768,703) 5,426,003Net Cash Provided (Used) by Operating Activities 9,817,572 32,221,735

PARTNERSHIP HEALTHPLAN OF CALIFORNIAStatement of Cash Flow

For The Period Ending April 30, 2020


-

ACTUALMONTH

BUDGETMONTH

$ VARIANCE MONTH

ACTUAL MONTH PMPM

BUDGET MONTH PMPM

ACTUAL YTD

BUDGET YTD

$ VARIANCE

YTD

ACTUAL YTD

PMPM

BUDGET YTD

PMPM

533,267 533,267 - TOTAL MEMBERSHIP 5,360,318 5,360,318 -

REVENUE214,934,549 225,698,046 (10,763,497) 403.05 423.24 State Capitation Revenue 2,319,755,998 2,259,581,802 60,174,196 432.76 421.54

303,132 513,350 (210,218) 0.57 0.96 Interest Income 4,721,409 5,133,500 (412,091) 0.88 0.96 109,755 10,184,340 (10,074,585) 0.21 19.10 Other Revenue 1,258,375 11,843,400 (10,585,025) 0.23 2.21

215,347,436 236,395,736 (21,048,300) 403.83 443.30 TOTAL REVENUE 2,325,735,781 2,276,558,702 49,177,079 433.87 424.71

HEALTHCARE COSTS15,459,251 14,846,402 (612,849) 28.99 27.84 Global Subcapitation 146,240,197 147,053,570 813,373 27.28 27.43

1,902,849 2,146,910 244,061 3.57 4.03 Capitated Medical Groups 20,231,419 21,215,869 984,450 3.77 3.96

Physician Services5,139,650 5,249,871 110,221 9.64 9.84 PCP Capitation 51,790,947 52,301,833 510,886 9.66 9.76

177,620 381,239 203,619 0.33 0.71 Specialty Capitation 2,761,273 3,786,482 1,025,209 0.52 0.71 30,734,297 27,210,139 (3,524,158) 57.63 51.03 Non-Capitated Physician Services 306,632,243 272,167,734 (34,464,509) 57.20 50.77

36,051,567 32,841,249 (3,210,318) 67.60 61.58 Total Physician Services 361,184,463 328,256,049 (32,928,414) 67.38 61.24

Inpatient Hospital15,672,033 16,230,688 558,655 29.39 30.44 Hospital Capitation 157,740,944 160,767,370 3,026,426 29.43 29.99 50,095,303 47,381,842 (2,713,461) 93.94 88.85 Inpatient Hospital - FFS 511,485,888 468,975,670 (42,510,218) 95.42 87.49 1,727,040 1,727,040 - 3.24 3.24 Hospital Stoploss 20,731,847 17,231,847 (3,500,000) 3.87 3.21

67,494,376 65,339,570 (2,154,806) 126.57 122.53 Total Inpatient Hospital 689,958,679 646,974,887 (42,983,792) 128.72 120.69

33,927,537 27,929,060 (5,998,477) 63.62 52.37 Long Term Care 293,507,806 279,414,363 (14,093,443) 54.76 52.13

25,285,362 27,160,385 1,875,023 47.42 50.93 Pharmacy 245,562,306 264,890,913 19,328,607 45.81 49.42

Ancillary Services827,093 972,643 145,550 1.55 1.82 Ancillary Services - Capitated 9,007,611 9,688,108 680,497 1.68 1.81

34,213,044 36,096,040 1,882,996 64.16 67.69 Ancillary Services - Non-Capitated 350,492,723 354,787,770 4,295,047 65.39 66.19 35,040,137 37,068,683 2,028,546 65.71 69.51 Total Ancillary Services 359,500,334 364,475,878 4,975,544 67.07 68.00

Other Medical2,744,321 2,193,321 (551,000) 5.15 4.11 Quality Assurance 20,913,031 21,936,600 1,023,569 3.90 4.09 1,177,598 459,870 (717,728) 2.21 0.86 Healthcare Investment Funds 8,187,774 4,598,700 (3,589,074) 1.53 0.86

75,700 96,350 20,650 0.14 0.18 Advice Nurse 765,864 963,500 197,636 0.14 0.18 6,825 18,170 11,345 0.01 0.03 HIPP Payments 66,602 181,700 115,098 0.01 0.03

4,063,692 3,127,989 (935,703) 7.62 5.87 Transportation 34,815,822 30,933,363 (3,882,459) 6.50 5.77 8,068,136 5,895,700 (2,172,436) 15.13 11.05 Total Other Medical 64,749,092 58,613,863 (6,135,229) 12.08 10.93

6,324,991 6,324,989 (2) 11.86 11.86 Quality Improvement Programs 63,249,910 63,249,890 (20) 11.80 11.80

229,554,206 219,552,948 (10,001,258) 430.47 411.70 TOTAL HEALTHCARE COSTS 2,244,184,206 2,174,145,282 (70,038,924) 418.67 405.60

ADMINISTRATIVE COSTS6,777,607 6,659,946 (117,661) 12.71 12.49 Employee 65,147,725 66,613,090 1,465,365 12.15 12.43

23,784 89,644 65,860 0.04 0.17 Travel And Meals 484,568 896,500 411,932 0.09 0.17 1,305,947 1,192,916 (113,031) 2.45 2.24 Occupancy 12,059,269 11,929,160 (130,109) 2.25 2.23

456,551 465,739 9,188 0.86 0.87 Operational 3,118,536 4,657,390 1,538,854 0.58 0.87 1,417,410 1,396,044 (21,366) 2.66 2.62 Professional Services 13,662,748 13,960,440 297,692 2.55 2.60 1,239,287 1,021,490 (217,797) 2.32 1.92 Computer And Data 6,273,646 10,214,900 3,941,254 1.17 1.91

11,220,586 10,825,779 (394,807) 21.04 20.31 TOTAL ADMINISTRATIVE COSTS 100,746,492 108,271,480 7,524,988 18.79 20.21

(25,427,356) 6,017,009 (31,444,365) (47.68) 11.29 TOTAL CURRENT YEAR SURPLUS

(DEFICIT) (19,194,917) (5,858,060) (13,336,857) (3.59) (1.10)


For The Period Ending April 30, 2020Statement of Revenues and Expenses

**The Notes to the Financial Statement are an Integral Part of this Statement



NOTES TO FINANCIAL STATEMENTS

April 30, 2020

Page 1 of 3

1. ORGANIZATION

The Partnership HealthPlan of California (PHC) was formed as a health insurance organization,

and is legally a subdivision of the State of California, but is not part of any city, county or state

government system. PHC has quasi-independent political jurisdiction to contract with the State

for managing Medi-Cal beneficiaries who reside in various Northern California Counties. PHC is

a combined public and private effort engaged principally in providing a more cost-effective

method of health care. PHC began serving Medi-Cal eligible persons in Solano in May 1994. That

was followed by Napa in March of 1998, Yolo in March of 2001, Sonoma in October 2009, Marin

and Mendocino in July 2011, and eight Northern Counties in September 2013. Beginning July

2018 and in accordance with direction from the Department of Health Care Services (DHCS), PHC

has consolidated its reporting from these fourteen counties into two regions; these are in alignment

with the two DHCS rating regions.

As a public agency, the HealthPlan is exempt from state and federal income tax.

2. SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES

ACCOUNTING POLICIES:

The accounting and reporting policies of PHC conform to generally-accepted accounting

principles and general practices within the healthcare industry.

PROPERTY AND EQUIPMENT:

Effective July 2015, property and equipment totaling $10,000 or more are recorded at cost; this

includes assets acquired through capital leases and improvements that significantly add to the

productive capacity or extend the useful life of the asset. Costs of maintenance and repairs are

expensed as incurred. Depreciation for financial reporting purposes is provided on a straight-line

method over the estimated useful life of the asset. The costs of major remodeling and

improvements are capitalized as building or leasehold improvements. Leasehold improvements

are amortized using the straight-line method over the shorter of the remaining term of the

applicable lease or their estimated useful life. Building improvements are depreciated over their

estimated useful life. Buildings purchased are recorded at cost and are depreciated on the straight-

line basis over their estimated useful lives.

INVESTMENTS:

PHC investments can consist of U.S. Treasury Securities, Agency Notes, Repurchase Agreements,

Shares of Beneficial Interest and Commercial Paper and are carried at fair value.




April 30, 2020

Page 2 of 3

BOARD-DESIGNATED & KNOX KEENE RESERVES:

In April 2004, PHC’s Board established a policy to set aside in a reserve account a designated

amount that represents the Knox-Keene Tangible Net Equity (TNE) requirement. This policy was

subsequently revised in May 2012 and beginning July 2012, the new methodology has been

reflected on the balance sheet. Based on this policy and as of April 2020, PHC has Board-

Designated and Knox-Keene Reserves of $476.2 million and $0.3 million respectively. To account

for the Board approved Strategic Use of Reserves (SUR) initiatives, which includes funding for

the Wellness & Recovery program, $87.3 million has been set aside as a “Reserve Fund-Strategic

Use of Reserve.” The amount represents the net amount remaining of all of the SUR projects that

have been approved to date; this balance is periodically adjusted as projects are completed.

3. STATE CAPITATION REVENUE

Medi-Cal capitation revenue is based on the monthly capitation rates, as provided for in the State

contract, and the actual number of Medi-Cal eligible members. Capitation revenues are paid by

the State on a monthly basis in arrears based on estimated membership. Prior to January 2010,

enrollment was subject to retrospective adjustments by the State upon completion of the 6th and

12th months following the month of service. Effective January 2010, the retrospective adjustments

have been replaced with monthly reconciliations with the State. As such, capitation revenue

includes an estimate for amounts receivable from or refundable to State for these retrospective

adjustments. These estimates are continually monitored and adjusted, as necessary, as experience

develops or new information becomes known.

4. HEALTH CARE COST

PHC continues to develop completion factors to calculate estimated liability for claims incurred

but not reported. These factors are reviewed and adjusted as more historical data become available.

Budgeted capitation revenues and health care costs are adjusted each month to reflect changes in

enrollee counts.

5. QUALITY IMPROVEMENT PROGRAM

PHC maintains quality incentive contracts with acute care hospitals and primary care physicians.

As of April 2020, PHC has accrued a Quality Incentive Program payout for of $60.3 million.




April 30, 2020

Page 3 of 3

6. ESTIMATES

Due to the nature of the operations of the Partnership HealthPlan, it is necessary to estimate

amounts for financial statement presentation. Substantial overstatement or understatement of these

estimates would have a significant impact on the statements. The items estimated through various

methodologies are:

- Value of Claims Incurred But Not Received

- Quality Incentive Payouts

- Earned Capitation Revenues

- Total Number of Members

- Retro Capitation Expense for Certain Providers

7. COMMITMENTS AND CONTINGENCIES

In the ordinary course of business, the HealthPlan is party to claims and legal actions by enrollees,

providers, and others. After consulting with legal counsel, HealthPlan management is of the

opinion any liability that may ultimately be incurred as a result of claims or legal actions will not

have a material effect on the financial position or results of the operations of the HealthPlan.

8. UNUSUAL OR INFREQUENT ITEMS REPORTED IN CURRENT MONTH’S

FINANCIAL STATEMENTS

Budget for Other Revenue during the month includes $10 million of IGT administrative fee

revenue, which was approved by the Board during the annual budgeting process and was expected

to be received for the fiscal year; PHC, however, has made the decision to waive this administrative

fee.

State Capitation Revenue rates were revised resulting in a reduction of $22.3 million retroactive

to July 2019 through March 2020. This is offset by the recording of an additional $3.0 million

following the finalization of the MLR calculation for fiscal year 2016/17 completed by the DHCS.

Both of These amounts are reflected in the State DHS Capitation Payable account.

Following the latest Routine Examination by the DMHC, medical-related liabilities that were

previously recorded in Accounts Payable were reclassified to the Accrued Healthcare Costs

account.


Partnership HealthPlan of CaliforniaInvestment ScheduleApril 30, 2020

Name of Investment Investment Type Yield to Maturity

Trade Date Maturity Date

Call Date Face Value Market Value Credit Rating Agency

Credit Rating

FUNDS HELD FOR INVESTMENT:

Highmark Money Market Cash & Cash Equiv NA Various NA NA NA 1,532,446$ NA NRCertificate of Deposit for Knox Keene Cash & Cash Equiv 0.00015 9/12/2015 1/3/2021 NA NA 300,000$ NA NR

FUNDS HELD FOR OPERATIONS:

Merrill Lynch Institutional Cash for Operations NA NA NA NA NA 68,299,133$ Merrill Lynch MMA - Checking Cash for Operations NA NA NA NA NA 216,324$UBOC - General/MMA and Checking Cash for Operations NA NA NA NA NA 600,241,543$ Government Investment Pools (LAIF) Cash for Operations NA NA NA NA NA 74,999,805$ Government Investment Pools (County) Cash for Operations NA NA NA NA NA 40,006,989$ West America Payroll Cash for Operations NA NA NA NA NA 2,514,637$ Petty Cash Cash for Operations NA NA NA NA NA 3,300$

GRAND TOTAL: 788,114,176$

Required Reserves (Liquid)Board Designated Assets 369,995,182$ Knox Keene Reserves 300,000$Total Required Reserves (Liquid) 370,295,182$

Cash on Hand / Cash Days Available:Including Required Reserves 788,114,176$ Excluding Required Reserves 417,818,994$

Cash Days Available incl. Required Reserves 85.32

Cash Days Available excl. Required Reserves 45.23


Partnership HealthPlan of CaliforniaInvestment Yield Trends

11 10 9 8 7 6 5 4 3 2 1 1

FISCAL YEAR 19/20 JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN YTD

Interest Income 539,906 498,345 494,906 466,588 476,303 467,858 479,686 483,937 510,749 303,132 4,721,410Cash & Investments at Historical Cost (1) 340,928,511 360,668,380 450,471,374 358,134,538 382,162,687 373,861,975 357,469,528 536,443,228 410,288,975 417,818,994 398,824,819

Computed Yield (2) 1.79% 1.70% 1.46% 1.38% 1.54% 1.49% 1.57% 1.30% 1.29% 0.88%Total Rate of Return (3) 1.90% 1.78% 1.60% 1.59% 1.57% 1.56% 1.57% 1.48% 1.48% 1.42%CA Pooled Money Investment Account (PMIA) (4) 2.38% 2.34% 2.28% 2.19% 2.10% 2.04% 1.97% 1.91% 1.79% 1.65%

FISCAL YEAR 18/19 JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN YTD

Interest Income 372,994 530,984 384,540 500,869 404,948 415,805 646,883 454,679 538,970 921,112 535,643 598,435 6,305,862Cash & Investments at Historical Cost (1) 360,595,665 563,240,721 578,907,713 291,918,698 318,206,676 280,512,593 234,334,438 229,386,771 682,241,507 750,226,571 355,195,367 384,528,617

Computed Yield (2) 0.52% 0.29% 0.28% 0.51% 0.32% 0.33% 0.77% 0.49% 0.52% 0.88% 0.59% 0.68%Total Rate of Return (3) 1.24% 1.17% 1.03% 1.20% 1.25% 1.31% 1.49% 1.56% 1.44% 1.45% 1.47% 1.50%CA Pooled Money Investment Account (PMIA) (4) 1.05% 1.08% 1.11% 1.14% 1.17% 1.24% 1.35% 1.41% 1.52% 1.66% 1.76% 1.85%

NOTES:

(1) Investment balances include Restricted Cash and Board Designated ReservesYTD for Cash & Investments is average year-to-date

(2) Computed yield is calculated by annualizing the current month's interest divided by the current month's average balance.

(3) Total Rate of Return is computed based on year-to-date interest income annualized divided by an average of the fiscal year's portfolio's market value at month-end.

(4) LAIF limits the amount a single government entity can deposit into LAIF; currently that amount is set at $65 million.


0.010%0.110%0.210%0.310%0.410%0.510%0.610%0.710%0.810%0.910%1.010%1.110%1.210%1.310%1.410%1.510%1.610%1.710%1.810%1.910%2.010%2.110%2.210%2.310%2.410%2.510%

JUL AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN

Per

cen

tage

Yie

ld

Periods

Partnership HealthPlan of California Investment Yield Trends

FISCAL YEAR 19/20

PMIA 19/20

FISCAL YEAR 18/19

PMIA 18/19


Operations Report Sonja Bjork, Chief Operating Officer

June 2020

Provider Relations Provider Relations Department staff have continued their daily contacts with the providers in PHC’s network. During this COVID-19 era, provider office visits and joint operations meetings have continued via WebEx and conference calls. The team obtains updated information related to site closures, limited office hours, modified office appointments and the alternative options for patient access to care based on the state emergency pandemic declaration. We use this information to ensure that our internal resources have the most current information on the status of our providers. Additionally, we regularly complete multiple ad hoc reports for DHCS related to our members’ access to care during the COVID-19 crisis. The Provider Relations Education team has been focused on creating a large volume of Provider bulletins, webinars, newsletters and notices based on DHCS APLs (All Plan Letters) and revisions to state regulatory requirements to address the health care environment during the pandemic.

Our staff worked very closely with the Finance Analytics team to complete the DHCS Network Certification project. We submitted our reports for 14 counties, mapping time and distance to the nearest provider for “potential membership” and documenting our contracting efforts with the two nearest non-PHC contracted providers. The report includes all hospitals, PCP sites and specialty sites. This was the first year the Plan was required to submit analysis for “potential PHC members” and report the time and distance to the nearest provider by specialty. This posed quite a challenge due to the many geographically isolated areas in our rural region.

Credentialing staff have been focused on applications by providers who wish to be a part of the network for our new Wellness and Recovery substance abuse treatment benefit. We are diligently processing applications to ensure that as many providers as possible can be credentialed by July 1, 2020. To that end, an additional Credentialing Committee meeting will be held in July to facilitate additional credentialing of these provider types. Our PR Education team has worked with the Claims Department staff on multiple Wellness and Recovery provider training sessions. Topics have included: online services, member eligibility and authorizations. Meetings and training sessions will continue over the next few months to support our Wellness and Recovery providers and to educate the primary care network about the availability of the benefit for their patients.


Operational Excellence/Project Management Office

Telemedicine

Expansion of telehealth services for our pediatric membership (those under age 21) has taken a step forward with the completed contract with UC Davis to provide specialty care services via telehealth. We will begin a six-month pilot program with selected health centers in July with plan to expand in the following year if successful in meeting member needs.

Telehealth Video Metrics

• 22 Participating healthcare organizations across 33 locations • 5.4 average days to appointment from referral • Highest use: Endocrinology, Rheumatology and Nutrition • Lowest use: Nephrology, Gastroenterology and Infectious Disease • TeleMed2U continues to offer Direct-To-Member specialty care services • Contact: [email protected]

Telehealth Econsult Metrics

• 20 Participating healthcare organizations across 48 locations (up from 14 healthcare organizations and 33 locations reported in April)

• 68% patient needs addressed, 27% requiring a face-to-face visit • Highest use: Endocrinology, Rheumatology and Neurology • Lowest use: Pain Management, Urology, and Gastroenterology • 50 Neuro-Surgery Econsults completed with St. Joseph • New Sites: Dignity health – Pine Street Clinic and Mountain Valley Health Centers • Added a Palliative Care Econsult Pilot with Resolution Care effective 6/1/2020 • Contact: [email protected]

Policy and Procedure Enterprise Management System Like many organizations, PHC has hundreds of policies and procedures. Many are required by law or regulation, and many are based on NCQA standards. Others describe approaches unique to PHC. Over the years, navigating the many policies that outline our business practices has become a challenging endeavor. PHC recently conducted an RFP and selected a vendor called Power DMS to help us organize our policies. Implementation of this new software is underway and will offer features such as: ease of search and navigation; reminders for timely updates; automatic updates of NCQA standards; tracking of the review and approval process. Member Services Member Portal Email Channel

The email communication channel through the Member Portal went live on May 1st and members have begun to utilize this feature. During the month of May we received 21




emails and expect this number to grow over the coming months. Our Department has a strong quality review process for phone calls and we have mirrored this for emails. Members will receive prompt and accurate information in response to their email inquiries. Establishing email as a communication route for members adds convenience for our members and helps PHC meet NCQA requirements.

Membership Enrollment Numbers

Member Services has been closely monitoring enrollment numbers since March. We anticipated a membership increase of approximately 60,000 based on the reported number of unemployment applications in California and across the United States. We have seen an upward trend of 1.5% increase through April and May respectively. However, as reported by our Finance team, the increase is likely due to the state’s freeze on disenrollments from Medi-Cal. Additionally, many who have lost their jobs may be extending their health care coverage through COBRA or waiting out temporary unemployment from non-essential work. We will continue to track and trend enrollment and have adequate support staff should we experience a true increase in sustained membership due to COVID impact.

Claims Claims leadership has resolved the issues we had during March and April with the vendor who processes our paper claims. The company struggled with maintaining their normal operations during the onset of the COVID-19 crisis, causing a significant delay in sending PHC the scanned, electronic versions of our paper claims. The vendor has resolved their staffing and operational issues and are back on track and meeting performance standards. Despite the delays, PHC staff were able to meet regulatory guidelines for timeliness and we did not have to pay interest on any claims.

The northern region claims team will handle all claims for the new Wellness and Recovery benefit. In order to prepare our new provider partners we have been holding many events and trainings. In upcoming education sessions we will start with the basics of how to get paid for services using a claim form. Our staff printed a five foot claim form and used it for practice sessions with our providers. We will also show provider staff how to set up electronic billing. The claims submissions of these new providers will be closely monitored in order to identify what additional assistance may be needed.

On June 18 we held two separate trainings, one for outpatient services and one for residential treatment. The staff are also conducting weekly call campaigns to check in with the providers to ensure they have received the most updated information and are enrolled in available training sessions. Over the next few weeks the claims team will be testing our internal claims processing systems to ensure the bills for the new benefit will get paid quickly and accurately. Testing will be complete by June 25, 2020.


Health Services

Care Coordination

Partnership’s Care Coordination team continues to provide coordination, referrals and navigation support to PHC’s members and providers amidst the ever-changing healthcare landscape due to COVID-19. As communities begin to slowly re-open, members are both eager and anxious about reconnecting with care. Assisting members during this time often takes a highly tailored approach, as presented needs are typically varied and complex. The team has been focused on matching those individualized needs with opportunities for appropriate, safe and timely care within the network. Members still voice concerns regarding the impacts that COVID-19 has had on their ability to access services. Examples of assistance needed include:

• rescheduling of appointments and surgeries • assistance accessing follow-up care such as specialty consults, PT/OT, imaging • information/assistance re: dental care, vision care and mental health services • education re: availability of telemedicine services • referrals to local resources, such as food banks

Our staff has been providing additional support and connection to Beacon Health Options so that members can obtain needed mental health services. In speaking with members over the past months, staff have noted increases reports of symptoms associated with anxiety and/or depression and many reports of loneliness and stress. We have also been in close contact with our transportation vendor, MTM and our non-emergency medical transportation providers during this time. We are monitoring provider availability and the precautions being implemented for safe transit of our members.

The Care Coordination team has been engaged in the member call campaign to reach families who have a child eligible for the California Children’s Service program (CCS). So far we have completed 7,000 calls with 2,500 more in progress. Our staff has noted added challenges for children with special health care needs and their families. Typically, these members are appropriate, high utilizers of healthcare resources. However, given the current challenges with COVID-19 many of their care needs have had to be augmented. Their parents/caregivers have needed additional support to manage the added pressures of juggling multiple roles at home. Providers have also been connecting with the team to better understand available resources, programs and case management support options for their patients who present with unique circumstances.

Population Health

The Population Health unit has been working in close collaboration with the rest of PHC to reach out by telephone to almost 60,000 members. Our aim is to provide them with resources and information during the COVID 19 crisis to help ensure they are getting the care they need. To date, 47,000 calls have been completed with a 30% success rate in reaching members. We have also been coordinating outreach calls to families who have children under 15 months of age. We have completed 10,000 calls with a 27% success rate. During these calls, we reinforce the importance of well-baby visits and immunizations at this critical stage of life. In the coming quarter, we will focus on


adolescents who need their vaccines to maintain immunity and to prepare them for returning to school, when that is possible.

The Population Health team has continued to focus on identifying community resources to help our members find food, housing, showers, mental health support, and other needs specific to the COVID-19 outbreak. We have collaborated with findhelp.org to share our resources with this national database, and are making that database available to our members through the PHC website. In addition, our team is leading PHC’s efforts related to evaluating health disparities within our population and to propose solutions to promote equity and positive health outcomes for all members.

The Population Health team has continued to focus on identifying community resources to help our members find food, housing, showers, mental health support and other needs specific to the COVID-19 outbreak. We have collaborated with findhelp.org to share our resources with this national database, and are making that database available to our members through the PHC website. In addition, our team is leading PHC’s efforts related to evaluating health disparities within our population and to propose solutions to promote equity and positive health outcomes for all members.

Utilization Management

The UM Team continues to focus on monitoring and reporting hospitalized members, including members testing positive for COVID-19. There has been some increased challenges with alternative placements due to the pandemic. The UM workload of processing Treatment Authorization Requests (TARs) has begun to return to normal, pre-pandemic levels. In the northern region, hospital censuses are approaching normal with the re-start of elective procedures and diagnostic tests.

UM staff continue to work with Community Based Adult Services (CBAS) agencies to support Treatment Alternative Services (TAS) to ensure members are able to continue to receive virtual support with frequent check-in contacts, delivery of meals, activity packets, etc. in their home during this pandemic.

Configuration Wellness & Recovery Benefit

The Configuration team is working intently to prepare for the July 1, 2020 “go live” of PHC’s Wellness & Recovery benefit. They are conducting user acceptance testing of the new payment rates to confirm that the rates pull correctly with different billing codes and modifier combinations for various levels of care. At this point, the team has reviewed and updated rates, updated the “Configuration Guide” and created a training guide. The Configuration and IT teams will not be able to test the 834 membership file until July 1 as DHCS will not provide member information until that date. In the meantime, we are using mock members for our testing exercises. Claims for this benefit will be handled by the Northern Region Claims Department and we are working closely with them to prepare. Project Phoenix Board Update

Health Edge (“HRP”) – New Core System

The configuration team is continuing active involvement in development of Health Rulers Payor. The foundational setup and benefit configuration are nearing completion.


Configuration of PHC’s “fee-for-service” provider contracts has been completed. The team is currently focused on medical management and authorization requirement configuration and starting capitation configuration. As development is completed, our next step will be to shift resources to testing to validate the accuracy of HRP.

Santa Rosa & Eureka Regional Offices The regional offices remain open with a small number of core staff and the remaining employees working from home. The month brought a resurgence of some of our “normal” activities such as the resumption of the Joint Leadership Initiative (JLI) projects we have with some of our key providers. The JLI groups have been meeting to discuss organizational priorities and quality improvement work. All JLI partners are actively engaged in re-opening efforts. These efforts involve changes in their facilities, workflow, re-training of staff and education to patients about the various safety measures medical offices have implemented to help keep patients and staff safe. Most offices report volumes at approximately 80% of normal, with plans to continue some proportion of virtual care, such as video or phone visits on an ongoing basis. The focus on COVID-19 response remains a priority for all providers. Several counties in the southwest region are experiencing a continuing increase in positive cases. Hospitalizations have also increased, but remain within normal range of management. Of great concern in Sonoma County is the disproportionate share of COVID-19-positive cases in the Latinx population. County officials and clinic providers are outreaching to the community to provide testing and education.

Regional Medical Directors and administrative staff continue participating in local emergency preparedness calls related to COVID-19. This includes the county OES and public health meetings as well as some that are specific to health care providers. Dr. Jeff Ribordy is providing preceptor time to several residents (1st/2nd years) in the Eureka Family Medicine Residency Program with St. Joseph’s Hospital & Open Door Community Health Centers. Six students will be participating in a health systems management module and are very excited to learn about a local Medi-Cal managed care health plan.


AB 2100 (Wood) - Medi-Cal: Pharmacy benefits.

This bill includes requirements pertaining to the Medi-Cal pharmacy carve-out, including Department reporting requirements, beneficiary protections, and specialty pharmacy reimbursement.

Status: Passed Assembly – 78-0

PHC Position: Watch

AB 2164 (Rivas) – Medi-Cal: Access through telehealth

Prohibits face-to-face contact between a health care provider and a Medi-Cal eligible patient from being required for a FQHC or RHC to establish a patient at any time, including during an initial telehealth visit, or to render the bill for services by telehealth.

Status: Passed Assembly – 78-0

PHC Position: Support

AB 2276 and AB 2277 (Reyes) Medi-Cal: Blood lead screening tests

These lead bills requires DHCS to ensure that a Medi-Cal beneficiary who is a child receives blood lead screening tests at 12 and 24 months of age, and that a child 2 to 6 years of age, inclusive, receives a blood lead screening test if there is no record of a previous test for that child. Plans will be required to notify parents of the dangers of lead exposure, as well as, notify providers within 30 days if a child has missed a test. Additionally, plans may be penalized by DHCS for not meeting the requirements of notifying parents of required blood screening tests that are missed.

Status: AB 2276 – Passed Assembly 78-0

AB 2277 – Passed Assembly 77-0

PHC Position: AB 2276 and AB 2277 - Watch


http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201920200AB2100




Clearlake City Council to consider funding for Hope Center, award of animal shelter projectLake County News April 15, 2020 CLEARLAKE, Calif. – The Clearlake City Council this week will consider funding for a project to address homelessness as well as a contract to upgrade the city’s animal shelter facility.

Solano County, Vacaville get $12M in early PHC program fundingDaily Republic April 17, 2020 FAIRFIELD – Partnership Healthplan of California is distributing early #130 million in Intergovernmental Transfer program payments – including $11.0 million in Solano County –to help alleviate the financial impacts of the Covid-19 pandemic

Community food drive project successfully launchesLake County News May 6, 2020 LAKE COUNTY, Calif. –The Community Food Drive Project, a collaboration between several different organizations, successfully delivered food to more than 30 households in its first week of operation.

Supervisors back Medi-Cal substance abuse pilot, jail medical programsDaily Republic May 14, 2020 FAIRFIELD — A six-county pilot program will allow Solano County to use Medi-Cal funding for expanded substance abuse treatment services.

Planning Commission unanimously recommends approval of Paul’s Place

Davis Enterprise May 15, 2020The extent of community support for Paul’s Place was evident in the first minutes of the DavisPlanning Commission meeting Wednesday night when three commission members had to recuse themselves from considering the proposed homeless facility due to the financial support they’d previously put toward the effort.

City Council unanimously approves Paul’s Place

Daily Enterprise

June 4, 2020 A concerted multi-year effort by a group of local business and community leaders to address the city’s

homelessness issue paid off Tuesday when the Davis City Council unanimously approved Paul’s

Place.


https://www.lakeconews.com/index.php/news/65067-clearlake-city-council-to-consider-funding-for-hope-center-award-of-animal-shelter-project?__cf_chl_jschl_tk__=082c09d3de840adfa8414a2385e30a6631e98276-1586967884-0-AQwho0syMHdiwod3t36r4Gmf5ieW8T9wWkGdmGFGguj5-cvk9bDjMFlMjOLtRx_dYFYVkCcjwPABKpdMJo5KG3UfAEQj1KjR3YCtxH4efgmnzTl7lpoATG2oZPzRDmo4bxMty9Vd3Qltx8LCyuka9feQ2zVs2yqNGSWCVFEbF_E33emrir_JFKVWOH13tyYnTju-9Znv_sKdRcdEQI3utcAn5SG6Ea4kg_rTGxgBZjY4s5ze3CVT-BgZ-8ojuM8NGCPVVqb-fs5ZffPS7TiFyOhZktHKJ-cMgMlv-pjhWtsTBcncJWtLGO7Gh6rLsLNlobo7Xd7o3N0HumPlHTXE5hgWDuN-vGbjpHb1dF7ZYVDO_AtnYFg6beNPMfja_xpZqTNHc1O9P0FOdtg28gEBVK4RElyGeuu4qtLQ9Go9j2N0

https://www.dailyrepublic.com/all-dr-news/solano-news/fairfield/solano-county-vacaville-get-12m-in-early-phc-program-funding/

http://www.lakeconews.com/index.php/news/community/65280-community-food-drive-project-successfully-launches?__cf_chl_jschl_tk__=5572f26ba0401b24455c03f3bef8c96e9c428359-1588783959-0-AR87y_kLAQqEYZq0TcZxFwwJwWFkDf43TqOTvAF8QKOgwvd6ZodXP0Y7tfk-3c0J3A6GAC-lnOX1s39and2O2VDY510a95eDPNXNM3J1tik-rOeE119FnX5mO_DbrTcWoJc72VdjRES3yqMVYg_ou3KrKnV42tSKtp3qyQzm-fNSOmO_atm9yRARJ1klHPTamUiYGgbPsMvhyhzoRJ82_OIGa-wrs1uYViYndQRqxAmC9CJevEp2mzrlviDeNsaJIwhs0Qq5x7W2Anbr1HH2pQZAJc0OahgpW7CLcddHmeuBq5-OOqSNx3jnFEqUiflBta9bT9wH74QwUDGVUCef2AglmDaOBaeNT2Drzp5TR_dE4TC6B7XTfKD8JD8UrJkeMg

https://www.dailyrepublic.com/all-dr-news/solano-news/fairfield/supervisors-back-medi-cal-substance-abuse-pilot-jail-medical-programs/

https://www.davisenterprise.com/local-news/planning-commission-unanimously-recommends-approval-of-pauls-place/

https://www.davisenterprise.com/local-news/city-council-unanimously-approves-pauls-place/

Grievance & Appeals

Annual Report

2020

PARTNERSHIP HEALTHPLAN | Eureka ~ Fairfield ~ Redding ~ Santa Rosa

OUR MISSION

To help our members, and the communities we serve, be healthy


1

Company Overview

Partnership HealthPlan of California (PHC) is a non‐profit community based health care organization that

contracts with the State to administer Medi‐Cal benefits through local care providers to ensure Medi‐Cal

recipients have access to high‐quality comprehensive cost‐effective health care. Beginning in Solano

County in 1994, PHC now provides services to 14 Northern California counties ‐ Del Norte, Humboldt,

Lake, Lassen, Marin, Mendocino, Modoc, Napa, Shasta, Siskiyou, Solano, Sonoma, Trinity and Yolo. As of

June 2020, PHC provides quality health care to 551,305 lives.

The information contained in this document and corresponding attachments may be privileged, confidential, and protected under applicable law and is intended solely for the use of the individual or entity to which it is addressed. If you are not the intended recipient or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately by telephone and destroy the document.


2

Executive Summary

PHC is committed to member satisfaction. When members understand their PHC Medi‐Cal benefits, understand how to access them, and service meets expectations, we believe members are likely to seek care and maintain their health. We invite all members to tell us about any concerns or challenges they encounter so that we can help remove any barriers. Members can feel confident that PHC’s Grievance & Appeals process is compliant with All Plan Letter (APL) 17‐006 by the Department of Healthcare Services (DHCS). PHC successfully passed the 2020 DHCS audit without any findings. There is proper oversight of G&A activities through sharing of case trends, drivers of member dissatisfaction, and proposed solutions in various internal and external committees, fulfilling the requirements of the Brown Act. This wide exposure across multiple committees provides comprehensive oversight and collaborative solutions to ensure member experience is optimal. The purpose of this executive report is to summarize observations and overall dissatisfaction trends, as reported by members. Members express their dissatisfaction by filing Grievance, Appeal, Exempt and State Hearing cases. There were 5,449 investigated and closed cases in 2019. This represents less than one (1) case filed per 1,000 members. 50% of all cases were filed from members residing in Solano, Sonoma, and Shasta County. 99.9% of all cases were closed within timeframes set by DHCS. Overall trending concerns fell into the following DHCS categories: Quality of Service, Benefits/Coverage, and Accessibility. Important steps have been taken to strengthen the reporting capability of G&A trends over the past year. Reporting Interest (RI) categories allow us to isolate specific areas of dissatisfaction beyond generic DHCS categories and make meaningful member improvements. These functionalities identified the top drivers of member dissatisfaction in 2019: Services by providers did not meet expectations Dissatisfactory execution of the non‐medical transportation benefit Denied medications through the Treatment Authorization Request (TAR) process.

This report highlights improvements made in 2019 to improve these areas, including those as a result of our pursuit for full accreditation by National Committee for Quality of Assurance (NCQA). Progress has produced meaningful improvements to the investigation process improving communication with members and noted problem areas. This report excludes cases for members assigned to Kaiser Permanente as their primary care provider. It also excludes cases for services administered through Beacon Health Options. Kaiser Permanente and Beacon Health Options are delegates for managing Exempt, Grievance, Appeal and State Hearing cases on behalf of PHC for members that they serve. All case statistics herein are reported with a 95% confidence level.

La Rae Banks Director of Grievance & Appeals


3

TABLE OF CONTENTS

INTRODUCTION TO GRIEVANCE & APPEALS ............................................................................................... 4

The Role of Grievance & Appeals .............................................................................................................. 4

The Definition of Case Types ..................................................................................................................... 4

The Member Filing & Investigation Process .............................................................................................. 6

STATISTICS .................................................................................................................................................... 7

Total # Closed Cases .................................................................................................................................. 7

Rate per 1,000 Members ........................................................................................................................... 9

DHCS Timeframes ...................................................................................................................................... 9

DRIVERS OF MEMBER DISSATISFACTION .................................................................................................. 10

Member Demographics........................................................................................................................... 10

Cases by Geography ................................................................................................................................ 12

Key Drivers of Dissatisfaction .................................................................................................................. 13

DHCS/NCQA Categories .......................................................................................................................... 15

IMPROVEMENTS ......................................................................................................................................... 17

Member Improvements .......................................................................................................................... 17

Operational Improvements ..................................................................................................................... 18

CASE REVIEWS ............................................................................................................................................ 20

Exempt Case ............................................................................................................................................ 20

Appeal Case ............................................................................................................................................. 21

Grievance Case ........................................................................................................................................ 22

Second Level Grievance Case .................................................................................................................. 23

State Hearing Case .................................................................................................................................. 24

CONTACT US ............................................................................................................................................... 25


4

INTRODUCTION TO GRIEVANCE & APPEALS

The Role of Grievance & Appeals The healthcare system is a complex infrastructure and can be difficult for many members to navigate and obtain services. Beginning July 1, 2017, APL 17‐006 provided all members with the right to report any dissatisfaction to their Managed Care Plan (MCP). Partnership HealthPlan of California (PHC), a MCP, welcomes the member grievance and appeals process. It allows our members to inform us of any concerns or challenges with their health care experience and give us the opportunity to resolve them. Outcomes can strengthen our members’ understanding of their benefits, improve service delivery, refine benefit administration, resolve disputes between parties and reveal training opportunities. The process promotes constructive communication and peaceful accountability across all stakeholders. PHC is governed by the guidelines set forth by DHCS. It is also in the process of acquiring an accreditation by NCQA, inspiring many operational improvements. The Grievance & Appeals (G&A) Department is responsible for end‐to‐end investigation of all Grievance, Appeal, State Hearing and Exempt cases. It resides under the External and Regulatory Affairs Department, outside of all medical and operational departments to minimize internal conflicts of interest and ensure members have objective investigations. G&A has two divisions: the Investigation Team and the Compliance Team. The Investigation Team is responsible for case investigations. It is staffed with clinical and non‐clinical team members who manage all cases within this report. The Compliance Team is responsible for DHCS‐mandated G&A reporting, oversight of G&A casework by delegates and implementation of DHCS and NCQA as it relates to G&A standards, internal and external audit.

The Definition of Case Types Member dissatisfaction is reported under four (4) different types of cases, in compliance with DHCS definitions. The following provides a definition of each case type, typical examples, and DHCS investigating turnaround times, as applicable.

Exempt Definition: A Grievance resolved by Member Services by next business day, but member does not want to file Grievance

Dissatisfaction documented, tracked and assessed for any violation to professional standards of care, discrimination, HIPAA violations, fraud, waste and/or abuse

All cases reviewed by Medical Director and/or Grievance Clinical Nurses for potential Quality of Care concerns

No formal response to member Appeal Definition: Request to reconsider an Adverse Benefit Determination


5

Member disputing a denied Medi‐Cal benefit or service A Notice of Action (NOA) must have been issued and Appeal request filed within 60 days

of issuance Must be investigated and closed within 30 calendar days, 44 calendar days with an

extension or 72 hours if expedited

Grievance Definition: Request to consider anything other than an Adverse Benefit Determination

Member dissatisfied with their experience, including allegations of discrimination, HIPAA violations, fraud, waste and/or abuse

Can be filed at any time regardless of the date of incident Must be investigated and closed within 30 calendar days, 44 calendar days with an

extension or 72 hours if expedited Second Level Grievance Definition: Request to reconsider the outcome of a Grievance (effective May 1, 2019)

This is a new case type inspired by NCQA accreditation Member dissatisfied with their experience, including allegations of discrimination,

HIPAA violations, fraud, waste and/or abuse Can be filed at any time regardless of the date of incident Must be investigated and closed within 30 calendar days, 44 calendar days with an

extension or 72 hours if expedited State Hearing Definition: A formal court hearing by the CA Department of Social Services (CDSS) to reconsider PHC’s decision

Member files a hearing with a judge when dissatisfied with Appeal decision Request for State Hearing must be filed within 120 days from Notice of Resolution

Letter (NAR) date Cases are heard by an Administrative Law Judge (ALJ) who considers evidence,

testimony, laws, PHC policy, etc. and issues a court order reflecting the new ruling

When a case is filed by a person who was not authorized by the member, the case type defaults to Invalid AR (Invalid Authorized Representative). PHC attempts to contact the member and obtain their permission to proceed with the investigation. If obtained, the case is converted to a Grievance. If not, it remains classified as an Invalid AR. PHC records the dissatisfaction for tracking purposes but the case cannot be investigated without the member’s consent.


6

The Member Filing & Investigation Process

How are cases filed? The process starts when a member is dissatisfied and reports this to PHC. PHC encourages communication between the member and PHC by allowing filing of cases by phone, online, mail, in person at a PHC office or through a contracting provider. The investigation process ‐ Upon PHC’s receipt of case, G&A contacts the member to confirm receipt and gain any other pertinent facts. A Medical Director or a Registered Nurse completes a clinical assessment of the reported dissatisfaction. The case is assessed for any quality of care concerns, immediate clinical needs and then provides clinical guidance to the G&A Coordinator. The G&A Coordinator thoroughly analyzes the case, obtains needed medical records, seeks evidence from interested parties and develops a plan to address all of the member’s concerns. Once the resolution is complete, the G&A Coordinator calls the member to discuss the outcome and documents the resolution in a formal letter called a Notice of Resolution Letter (NAR), which is mailed to all parties of interest. A word about discrimination ‐ PHC does not tolerate discrimination. PHC follows State civil rights laws and Section 1557 of the Affordable Care Act (ACA), which adds additional protection beyond Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975. PHC investigates all allegations of discrimination by any member. A 1557 Civil Rights Coordinator, who is specially trained in all Federal and State civil rights laws, oversees these cases. When allegations fall under a Section 1557 protected class, the investigation process includes an assessment and decision by PHC’s Cultural and Linguistics team. PHC reports all Section 1557 allegations to DHCS on members’ behalf, regardless of our findings. Members are also provided contact information to the Office for Civil Rights with the U.S. Department of Health and Human Services so they can pursue further action. How long does the process take? All Grievance and Appeal cases are investigated and closed within 30‐days of receipt. If it is in the member’s best interest, some cases are extended an additional 14‐days to allow for evidence collection or to conduct a thorough investigation. However, if a PHC Medical Director determines a member’s life or health is in immediate jeopardy, the case will be investigated and closed within 72‐hours.


7

STATISTICS

Total # Closed Cases

A Multi‐Year View ‐ Since the introduction of the Final Rule APL 17‐006 in July 2017, case volumes have

increased year over year. The number of Closed Cases per Month (CCPM) was 297 in July 2017. It

reached a high of 651 in August 2018 one (1) year later. By August 2019, case volumes dropped

considerably to 460 CCPM, closing the year with 419 CCPM in December.

How many cases were investigated

in 2019? In 2019, PHC investigated

and closed 5,449 cases. Ultimately,

the total volume of 2019 cases was

7% lower than 2018, closing 5,449

and 5,884 respectively. This

reduction in the number of cases was

the result of many internal

improvements to enhance

operational efficiencies and member

experience. Progress to meet NCQA

standards also produced a more

thorough investigative progress.

2,993

1,185

1,075

144

25

27

5,449

0 1,000 2,000 3,000 4,000 5,000 6,000

GRIEVANCES

EXEMPTS

APPEALS

STATE HEARINGS

SECOND LEVEL GRIEVANCE

INVALID‐AR

GRAND TOTAL

2019 Total # Closed Cases


8

Volume by case type ‐ All cases were not received in equal volume. Historically, Grievances have been

the number one type of case filed. Sequentially, Exempts, Appeals and State Hearings follow closely in

its path. Following suit, Grievances (54.93%) were the most commonly filed case, followed by Exempts

(21.75%), Appeals (19.73%), State Hearings (2.64%), Second Level Grievances (0.46%), respectfully.

There were 27 cases (0.50%) reported by a party not authorized by the member and therefore not

investigated, referred to as Invalid AR.

Why are Exempts declining? Closing at 22%, there was a notable decline in Exempt cases throughout

2019. Unlike 2019, Exempt cases represented 30% of all cases in 2018. Consequently, Grievances

represented 55% of all cases by the end of 2019, compared to 49% in 2018. These trends suggest

members were more comfortable filing official Grievances to address their dissatisfaction and seek

assistance for a resolution.

No overturned State Hearings ‐ When

members are dissatisfied with Appeal

decisions, they have the right to go to court.

Members filed 145 State Hearings. 82% were

never heard by an Administrative Law Judge

because the case was withdrawn, dismissed,

misrouted to PHC or the member did not

show for court. Of the remaining 17% that

went to court, the Administrative Law Judge

agreed with PHC’s findings.


9

Rate per 1,000 Members Is the volume high? PHC served an average of 545,558

members per month in 2019. Excluding members assigned to

Kaiser Permanente, PHC’s other contracting providers served an

average of 481,518 members per month. PHC investigated and

closed 5,449 cases out of 481,518 members. There were only

0.87 cases filed per 1,000 members.

These statistics suggest that most PHC members experience

benefits that are comprehensive, meet most of their healthcare

needs, and result in a positive experience.

DHCS Timeframes

Case Processing Times ‐ Through APL 17‐006, DHCS mandates the length of time that PHC has to

investigate and close cases. Grievance and Appeal cases must be completed within 30‐days of

receipt. If additional time is needed to investigate, collect evidence, obtain medical records or involve

any other attributes that could result in an outcome that is in member’s best interest, PHC is allowed to

extend the case an additional 14 days. To the contrary, if a member requests an urgent review and a

PHC Medical Director

determines that their life or

health is in imminent jeopardy,

PHC must investigate the case

and close the case within 72

hours. NCQA shares these

same standards.

PHC received 4,068 Grievances and Appeals by members. PHC investigated and closed 99.90% of them

within these DHCS and NCQA Turnaround Times (TAT) times. There were only four (4) cases closed

outside of the mandatory timeframes.

Acknowledgement Letters ‐ Within five (5) calendar days of receiving a case, DHCS mandates that PHC

notify members in written format that their case has been received. This acknowledgement letter

identifies the date PHC received their request, the subject of dissatisfaction, an overview of the process

and contact information for questions. However, there are exceptions to this rule. Acknowledgement

letters do not apply when members formally withdraw their Grievance or Appeal within the first (5)

days. Also, Exempt and State Hearing cases are excluded from this rule.

Beginning in 2020, PHC will start measuring and reporting this performing metric.

Case Types Rate per 1,000

State Hearings 0.02

Appeals 0.17

Exempts 0.19

Second Level Grievance 0.00

Grievance 0.48

TOTAL RATE P/1,000 0.87

CASE TURNAROUND TIMES

Timeframe Standard# Closed

Cases# Late PERFORMANCE

Standard ≤ 30 days 3,872 2 99.95%

Expedited ≤ 72 hrs 46 2 95.65%

Extension ≤ 44 days 150 0 100.00%

Overall Performance 4,068 4 99.90%

Note: Total rate per 1,000 was rounded up


10

DRIVERS OF MEMBER DISSATISFACTION

Member Demographics PHC served an average of 545,558 members per month in 2019. There were 3,871 unique members

who filed the 5,449 investigated cases during the reporting period. This represents less than 1% of

PHC’s total population. Some members filed more than

one case during the year. Research identified that 50

unique members filed six (6) more cases during the year.

Filing members spanned the spectrum of age, ranging from

birth to over 65 years old. However, the most likely to file

was a member 50‐59 years old.

Although males filed cases, the most common filing

member is a female. She filed 62% of all cases compared

to 38% of males.

Thirteen (13) different languages were represented across all cases. Most filing members spoke English,

but Spanish and Russian were

also popular languages. PHC

uses translation services to

ensure verbal and written

communications are conducted

in the language that our

members are most comfortable

with. Some members prefer to

speak in English, but prefer their

written communication in

another preferred language.

PHC can easily accommodate

such requests.

Age # of Cases % of Cases

0‐18 756 13.9%

19‐29 408 7.5%

30‐39 661 12.1%

40‐49 752 13.8%

50‐59 1399 25.7%

60‐64 871 16.0%

65+ 602 11.0%

Total Cases 5,449

AGE OF FILING MEMBERS

Gender% of

PHC Mship

# of

Cases

% of

Cases

Female 52.8% 3358 62%

Male 47.2% 2047 38%

unknown 0% 44 1%

100.1% 5449

GENDER OF FILING MEMBERS

5012

312 82 14 6 6 5 3 2 2 2 1 1 1

# Filed Cases by Language

The profile of the most commonly filing

member is a white female between 50‐59

years old, speaks English, resides in

Solano, and PHC is her only coverage


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Medi‐Cal membership

fluctuates monthly as

qualification varies.

Throughout 2019, PHC’s

membership represented

19 different ethnicities,

including two unknown

ethnic groups.

Interestingly, PHC received

a case from 18 of the 19

different ethnic categories.

Some ethnic groups filed

more cases than predicted.

Although Whites

represented 41.9% of the total membership, they filed 60.0% of all cases. Blacks represented 5.64% of

the membership, but filed 7.8% cases. 7.40% of our membership is unknown, but they filed 8.4% cases.

Medi‐Cal is typically the payer of last resort when a member has other coverage. While PHC is prime for

75.70% of the filing members, 24.30% of our members are insured with another carrier and experienced

some problem with the coordination of benefits.

Ethnicity % of Cases # of Cases

White 60.0% 3267

Hispanic 12.5% 683

Unknown 8.4% 457

Black 7.8% 425

Other 7.2% 390

Native American 1.5% 83

Other Asian 0.9% 50

Filipino 0.7% 37

Asian/Pacific 0.3% 17

Vietnamese 0.1% 7

Japanese 0.1% 7

Chinese 0.1% 7

Hawaiian 0.1% 6

Guamanian 0.1% 5

Korean 0.1% 4

Laotian 0.0% 2

Samoan 0.0% 1

Cambodian 0.0% 1

Total Cases 5,449

ETHNICITIES OF FILING MEMBERS


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Cases by Geography PHC’s 545,558 members were stratified across its service area of 14 different counties. In descending

order by percentage of members per county, the 14 counties are Solano, Sonoma, Shasta, Humboldt,

Yolo, Marin, Mendocino, Lake, Napa, Siskiyou, Del Norte, Lassen, Trinity and Modoc.

Of the 5,449 cases

investigated in 2019,

50% were filed by a

member who resided in

Solano, Sonoma or

Shasta County.

Relative to its

membership size,

Sonoma, Mendocino,

and Yolo had the least

number of cases,

suggesting member

satisfaction is higher in

these areas.

Outliers were Shasta and Siskiyou, where the percentage of total filed cases exceeded the percentage of

members in the noted county. For example, Shasta represented approximately 10.8% of PHC’s total

membership. However, 18% of the 5,449 cases were filed

by members who resided in Shasta County. Likewise,

Siskiyou represented 3.8% of all PHC members, but 5% of

the 5,449 cases were filed by members who resided in

Siskiyou. For all other

counties, the correlation

between membership size

and filed counties were

within an expected range.

While county residency is

a key indicator, it is

noteworthy to

acknowledge that

members in the city of

Redding filed the highest

number of cases.

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

% Cases by County

Mship by County % Cases by County

CountyMship by

County

# Cases by

County

Solano 19.4% 1058

Sonoma 18.9% 724

Shasta 10.8% 970

Humboldt 9.7% 546

Yolo 9.2% 437

Marin 6.9% 367

Mendocino 6.5% 220

Lake 5.5% 291

Napa 5.1% 221

Siskiyou 3.1% 274

Del Norte 2.1% 110

Lassen 1.3% 111

Trinity 0.8% 58

Modoc 0.6% 62

TOTALS 100% 5,449

# CASES BY COUNTY

City# Cases by

City

Redding 514

Vallejo 328

Santa Rosa 322

Fairfield 261

Vacaville 213

W Sacramento 197

Anderson 188

Eureka 185

Napa 151

San Rafael 118

# CASES BY TOP 10 CITIES


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Key Drivers of Dissatisfaction

Member dissatisfaction is disruptive when seeking healthcare services. To understand it is the first step

towards solving it. Using PHC’s internal dynamic reporting system, member dissatisfaction is bucketed

in core categories: Eligibility, Authorizations, Claims, Service, Discrimination and Transportation. The

purpose of the section is to highlight the most frequently observed disruptions that caused members to

be dissatisfied using their PHC Medi‐Cal plan.

What drove members to be dissatisfied? Representing 87% of all reported issues, the three driving

reasons that triggered dissatisfaction:

34.29% of members did not receive the service they expected

31.57% of members experienced a problem using their Non‐Medical Transportation (NMT) benefit

administered through Medical Transportation Management (MTM)

21.67% of members contested a denied benefit through the Treatment Authorization Process (TAR)

or had trouble with the process

Service ‐ The main reported issue with regard to service was a disagreement with the provider’s plan to

treat their health, also known as treatment plan disputes. This issue is frequently coupled with reports

of poor communication or general rudeness from the provider.

When providers communicate to members about how to treat their health, members loose the message

if they do not understand, feel dismissed, feel judged or buy into the benefits of given advice. It results

in members attempting to prescribe their own course of treatment or a request to change providers. It

can also lead into allegations of rudeness, discrimination, malpractice, bad service or poor quality of

care.

34.29%

31.57%

21.67%

4.61%2.06% 0.30%0.02%

Overall Reasons of Dissatisfaction

Service

Transportation

Prior Authorization

Referral Authorizations

Discrimination

Claims

Eligibility


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Transportation – The problems with transportation are isolated to the NMT benefit, which provides

travel to Medi‐Cal covered services by public transportation, taxi, ride share program or reimburses

drivers arranged by the member. There are three trending issues: missed/failed rides, poor service and

denied benefits.

Missed/failed rides ‐ Members reported problems with approved and scheduled rides. Some were not

executed because a taxi or ride share driver was not available at the travel time, leaving the member

without transportation to their appointment. Other times, the driver missed the trip because they came

too late, too early or never showed. Consequently, a few members reported adverse reactions to their

health because they are unable to obtain needed medical treatment. This is especially true for

members undergoing dialysis treatment or surgical procedures.

Accompanying reports of missed/failed rides, members frequently reported that MTM did not call them

before a trip was canceled. Although this is MTM’s best practice, to call every member upon an

interruption to a scheduled trip, research identified that MTM does not identify its company name on

caller ID for any outbound calls. Consequently, trip interruptions occurred because many members did

not answer their phone calls. Members reported that they do not answer phone calls from unknown

numbers or those perceived as spam. Because MTM was unable to follow safety guidelines when

making alternative travel arrangements, which include advising members of a new driver’s identity, taxi

company or vehicle information, trips were canceled. Other research identified taxi drivers

communicated directly with members instead of going through MTM. As travel changes occurred, MTM

was uninformed and unable to intervene. Lastly, research identified several cities with an insufficient

number of taxi companies to meet travel demands. Members who resided in Redding, Santa Rosa,

Petaluma, Cloverdale or Clearlake frequently reported approved, scheduled, but missed trips.

Poor service ‐ Members reported poor service with their driver, siting conditions of the vehicle, rude

behavior and unsafe or poor driving skills. Multiple incidents with this experience resulted in multiple

Grievances for the same member. When members have a poor experience with a taxi company, they

demand an alternative taxi company with better service. In areas where taxi company options are

limited, this limits members’ travel options. Members also reported they could not reach MTM

Customer Service in January and February 2019. They experienced long hold times. MTM reported

only 49.49% of PHC calls were answered within 30 seconds with a 9.95% abandonment rate, while

performance standards require 80% of all calls answered within 30 seconds with a 5 % abandonment

rate.

Denied benefits ‐ Lastly, members experienced problems obtaining gas mileage reimbursement (GMR)

when they chose their own driver or requested travel by taxi instead of public transportation. Problems

seeking reimbursement are related to inefficient notification with members. Members reported they

were unaware of the 60‐day filing limit to file a GMR claim. They were unware that a GMR claim must

be accompanied by documentation that their driver was legally able to drive on the day of travel; MTM

requires a copy of the driver’s driving license, vehicle registration and proof of car insurance. Other

times, members failed to obtain the provider’s signature on the GMR form, as proof that they attended

their doctor’s appointment. Consequently, their claim was denied, often without written notice to the

member.


15

Prior Authorization – Members reported the most dissatisfaction with denied medication than any

other benefit approved through the TAR process. Members expressed their desire to a denied

medication because of its perceived health benefits or prior use, regardless of its formulary status,

quantity supply limits, step therapy requirements or medical criteria. Approximately 17% of all

reported concerns about denied TARs, included dissatisfaction about the TAR process. Members alleged

requested TARs were delayed or refused by the provider, pharmacy or PHC. Many concerns about

medications were regarding opioids.

DHCS/NCQA Categories

DHCS has a uniform reporting methodology that requires all MCPs to classify member‐reported

concerns into five (5) core categories.

Accessibility – barriers to prevent entry to a provider or service

Benefits/Coverage – contested provisions or availability of a Medi‐Cal benefit or service

Referrals – unable to obtain services outside of assigned medical group or county

Quality of Care/Service – dissatisfaction with the quality of medical care or service received

Other – not included in the above

PHC evaluated all member‐reported concerns and classified them accordingly. Because a case can have

more than one concern, totals exceed the actual 5,449 cases investigated and closed. From DHCS

perspective, the driver of member satisfaction in 2019 was related to Quality of Care/Service or possibly

unknown as reported through the Other category. A deep dive analysis using PHC’s internal reporting

system confirmed the majority of issues are related to Service, as highlighted in the Key Drivers of

Dissatisfaction report. Of the 3,492 Quality of Care/Service concerns, approximately 104 Quality of Care

cases where identified and referred to the Quality Improvement Department for further investigation.

DHCS Category Exempt Grievance AppealState

Hearings

2nd Level

GrievancesTOTALS

Accessibility 317 401 2 2 6 728

Benefits\Coverage 57 184 78 21 1 341

Referral 59 117 64 9 0 249

Quality of Care\Service 847 2,216 379 32 18 3,492

OTHER 434 2,073 1,007 125 24 3,663

TOTALS 1,714 4,991 1,530 189 49 8,473

MEMBER CONCERNS BY DHCS CATEGORIES


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Like DHCS, NCQA has five (5) core categories. However, categories vary in classifications and definitions.

NCQA categories highlight the same drivers for member dissatisfaction as PHC’s internal reporting and

DHCS Categories, Attitude/Service.

NCQA Category Exempt Grievance AppealState

Hearings

2nd Level

GrievancesTOTALS

Quality of Care 90 0 14 0 0 104

Quality of Practitioner's Site 7 0 0 0 0 7

Attitude/Service 3,402 889 970 26 121 5,408

Billing/Financial 217 187 14 9 5 432

Access 104 53 135 0 8 300

TOTALS 3,820 1,129 1,133 35 134 6,251

MEMBER CONCERNS BY NCQA CATEGORIES


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IMPROVEMENTS

Member Improvements Case classifications reveal that the majority of issues were related to members’ experience and/or

service. Represented by the number of Exempt, Grievance and Second Level Grievance cases, they

capture 77.27% of all reported issues. All other issues were related to a benefit denied by PHC, which

represented 27.73% of all reported issues via Appeal and State Hearing cases. The improvement

opportunity lies with better communication and execution of the benefits as members use their Medi‐

Cal plan. Recall that the three key drivers of member dissatisfaction are related to service, the NMT

benefit and prior authorization of medications. The following improvement efforts were pursued in

2019 to reduce member abrasion.

Service Improvements – Treatment plan disputes can be minimized with improved communication

between the member and their provider. However, PHC does not interfere with this relationship. Our

goal is to bridge the communication gap by empowering members with knowledge and resources about

their health condition and treatment options. Improved understanding leads to better communication

with their healthcare providers and personal investment in their health.

Traditionally, the investigation process for treatment plan disputes included a quality of care assessment

and outreach to the provider to obtain their perspective of the incident. New in 2019, the investigation

process provides resources to help members achieve long‐term success beyond the incident reported.

PHC frequently refers members to PHC’s 24‐hour nurse line through Carenet Health, who is able to

answer questions and explain providers’ recommendations patiently and in simple language. Members

are also connected to a Health Care Guide in Care Coordination where similar conversations occur, along

with navigation assistance connecting them to additional providers and services, as needed.

Transportation Improvements – A trigger of dissatisfaction for missed/failed rides was no

communication with members upon a trip interruption or denied benefit. Goals were to improve

communication between parties and better promote all available NMT benefits.

Missed/Failed Rides ‐ Several exploratory discussions between PHC and MTM revealed that MTM is

unable to change their caller ID such that “MTM’ displays on outbound calls. They were also unable to

communicate with members via text or email upon a trip interruption. However, MTM improved their

customer service scripting with members. When trips were scheduled, MTM Customer Service

Representatives proactively advise members that MTM would call them if any interruptions occurred.

They encouraged members to answer all phone calls, as an unreturned phone call could lead to a trip

cancellation. Additionally, MTM contracted with additional transportation providers to reduce

missed/failed rides. Special concentration was given to Redding, Santa Rosa, Petaluma, Cloverdale and

Clearlake, improving travel partners where travel demands were high.

Traditionally, the investigation process, for missed/failed rides included a recount of events and

informed members accordingly. New in 2019, the process also educates members about the GMR

benefit and includes a GMR form for members who frequently encounter missed rides or have limited

drivers in their service area.


18

Poor service – PHC expects all members to receive optimal service as they navigate the healthcare

system. This includes service by a taxi or ride share provider, as well as Customer Service when they call

MTM.

Exploratory discussions identified that MTM on boarded a large new client on January 1, 2019 causing

call center performance to decline and prevent PHC members from reaching MTM Customer Service.

To mitigate poor service levels, MTM placed a Florida‐based client on a dedicated 800 phone number.

They also hired and trained 240 new Customer Service Representatives between January and March

2019. MTM Customer Service call statistics resolved to satisfactory levels in March 2019. Related to

unsatisfactory service levels by taxi or Lyft drivers, MTM coaches the specific driver about expected

service stands upon each investigation. Results are shared with members accordingly in Grievance

resolutions.

Denied Benefits ‐ Related to denied GMR benefits, the claim form was revised highlighting the process

and requirements for approval. Proactive education helped members to understand the parameters for

benefit approval. In the first quarter of 2020, a new Notice of Action (NOA) letter was implemented

identifying missing information on GMR claims, when applicable. The letter specifies missed

information such as a driver’s car registration, proof of insurance, driver’s license or signed GMR so that

members can resolve their claim. Related to other denied NMT benefits, it was discovered that NOA

letters were not consistently generated. This was resolved in the first quarter of 2020. Additionally,

some NOA letters issued reasons suggesting denied rides due to reasons of medical necessity, which was

incorrect. All NOA denial reasons were reviewed and improved, however further enhancements are

underway.

Prior Authorization Improvements – Members have a right to contest disputed benefits. The

opportunity for PHC is to improve communication with members so that denial reasons are clear.

As PHC prepared for NCQA accreditation, PHC thoroughly revised member notification letters. New in

2019, NOA and NAR letters now highlight the approval criteria to cover denied benefits and specify

which criteria was unmet. The letter also includes member‐specific rationale for the decision, along

with references on which the denial was based. Letter revisions were inspired by NQCA standards and

greatly improve communication with members.

Operational Improvements PHC’s commitment to operational excellence resulted in many improvements to the investigation

process. The following highlights 2019 improvements made that had a direct influence on improving

member satisfaction.

Investigation Process Improvements ‐ The investigation process was much improved by standardizing

Grievance and Appeal cases. Enhancements now identify a series of milestones for the Investigation

Team to achieve within their case to successfully investigate it. Investigations now include a thorough

review of historical barriers, root cause analysis and events contributing to the reported issue.

Resolutions are no longer transactional, but work to resolve members’ issues, while helping them to

understand how to navigate the healthcare system. These improvements, along with new formal


19

training, resulted in more thorough and timely investigations with consistent outcomes. When possible,

the resolution includes tips and resources for the member to minimize future disruptions and/or

maximize their PHC Medi‐Cal benefits. This has reduced the number of members returning for the same

issue.

Delegation Oversight Improvements ‐ Improved oversight of delegated entities, such as MTM and

Beacon Health, identified opportunities for improvement and training. Much of the operational work

with MTM is highlighted herein. However, there was also an improvement in contract terms between

PHC and MTM. New contractual terms effective February 1, 2019 required MTM to investigate

transportation providers as directed by PHC’s Grievance and Appeal process. New terms also specify

timeframes for submitting their investigative results to PHC, ultimately supporting DHCS‐mandated

timelines. MTM is also required to provide support for State Hearings, both in the investigation process

and in court attendance, as needed.

For Beacon Health, increased oversight revealed their Customer Service representatives were incorrectly

trained on the Medi‐Cal G&A process. Many members who express dissatisfaction where not offered

the option of filing a Grievance to resolve their issue. Beacon Health revisited DHCS requirements,

developed a new training program, designated a discrimination Grievance Coordinator and retrained

their teams widely by October 2019.

Technical Improvements ‐ Numerous system and reporting enhancements were implemented.

Multiple system enhancements improved the staff’s ability to track casework milestones, monitor

casework deliverables, specify providers, record key reporting indicators and improve recording of case

decisions. PHC also improved reporting functionalities through the development of RI’s. As depicted

throughout this report, PHC can conduct a deep analysis identifying specific areas of member

dissatisfaction and develop custom solutions. Further enhancements, implemented in January 2020 will

allow PHC to report provider‐specific trends as reported by members.

In conclusion, PHC made significant improvements to identify the real drivers of member dissatisfaction

in 2019. Creative solutions worked to minimize member abrasion while seeking treatment, improve

execution of the NMT benefit and increase communication with members in the prior authorization

process. PHC is committed to continuous improvement. Our members’ point of view matters at PHC.

We look forward to reporting future enhancements in the next annual report.


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CASE REVIEWS This is a reference section. It provides case examples from the 2019 G&A Case Detail Report reflecting trending issues discussed in this report. These are actual 2019 actual cases with Personal Health Information (PHI), Personal Identifiable Information (PII), and providers’ identity removed.

Exempt Case The following case reflects an Exempt about a treatment plan dispute. There was no contact with the member since they declined to file an official Grievance. However, the case is tracked and reviewed for any potential quality of care concerns with the provider.

Case # 28580 Date Received 9/04/2019 Beneficiary Name Confidential Time Received 13:32:14 Case Filed by PHC Member Services Date Closed 09/04/2019 G&A Investigator Grievance Clinical Nurse Time Closed 14:19 Reporting Category Quality of Service Summary of Member's Concerns

Member reported the following information:

- Office keeps prescribing medication that is not working

- Member does not want to deal with them because they do not listen and constantly change drugs

- Member just wants oxygen

- All the bills make him sick and he feels better without them

- Member is trying to be natural and eat better instead of just taking tons of pills

Steps Taken to Resolve

Initial clinical risks assessed by Grievance Registered Nurse Case reviewed for quality of care issues by PHC Medical Director

PHC Resolution

Here are the results of our research:

- Grievance options offered by Member Services, which member declined

- Member Services informed member of other PCP offices in the area

- This is a quality of service and treatment plan dispute against XXX Medical group

- No quality of care issues identified


21

Appeal Case The following case reflects an Appeal about a denied reimbursement for gas mileage.

Case # 27808 Date Received 07/15/2019 Beneficiary Name Confidential Time Received 12:11:17 Case Filed by Member Date Closed 08/14/2020 G&A Investigator Grievance Coordinator Time Closed 14:36 Reporting Category Benefits/Coverage Summary of Member's Concerns

Member wants to file an appeal regarding denied GMR for travel on 5/14/2019 and 5/15/2019. Member reported the following information:

- Reimbursement was denied because Member originally had appointments scheduled on 4/30/2019 and 5/1/2019. Member called to get the trip log for reimbursement. Those appointments were cancelled and rescheduled for 5/14/2019 and 5/15/2019.

- She was not informed that she needed new trip logs so she used the ones she had since all the information was the same expect for the dates.

- Now Member told that she should have called to get a new trip #.

- Member was not explained the process and this was the first time she has used the reimbursement service.


Approved

- Grievance Coordinator contacted member

- Investigation request to MTM

- Appeal overturned by Grievance Supervisor

PHC Resolution

MTM reviewed phone calls. They found Member not told to contact MTM with any changes or cancellations to the original trip. Appeal decision overturned. Member reimbursed and educated on the GMR benefit and claim submission process.


22

Grievance Case The following case reflects a Grievance about a treatment plan dispute.

Case # 29702 Date Received 11/18/2019 Beneficiary Name Confidential Time Received 10:04:36 Case Filed by Member Date Closed 12/18/2019 G&A Investigator Grievance Coordinator Time Closed 09:10 Reporting Category Quality of Service Summary of Member's Concerns

Member states he had an appointment with family nurse practitioner, XXXXXX. This was the third appointment he has had with her. Member reported the following information:

- The FNP did not make any eye contact with you during appointment on October 4, 2019

- She avoided having a conversation with you. She only stared at her computer screen or at your chart folder

- FNP has not taken the time to get to know you or your medical history

- FNP treated you like an alcoholic after you told her you took your medication, promethazine, after having a glass of wine

- FNP lowered the dose of your medication, lorazepam 2 mg tablets, without telling you.


Concerns Addressed


- Consulted provider

- Obtained Medical Records

PHC Resolution

PHC attempted to call the member to discuss our findings. A Notice of Resolution (NAR) Letter was mailed to the member with the following resolution. Here are the results of our research: ‐ FNP feels she was not judgmental. She was trying to help member understand the dangers of mixing medication with alcohol ‐ FNP is trying to do her best to provide member with the medical care needed ‐ Lorazepam 2 mg tablets has been prescribed since 2014. There is no change to the dosage or amount ‐ Member’s medical group has other providers to see for future appointments if not satisfied


23

Second Level Grievance Case The following Second Level Grievance case is regarding a member’s dissatisfaction with a driver who do not arrive for a scheduled transportation trip. Dissatisfied with the original Grievance resolution, they requested a second investigation.

Case # 29168 Date Received 10/162019 Beneficiary Name Confidential Time Received 11:58:50 Case Filed by Member Date Closed 11/15/2019 G&A Investigator Grievance Coordinator Time Closed 13:07 Reporting Category Accessibility Summary of Member's Concerns

Member disagrees with resolution on previous Grievance # 28932 and request another investigation. Member reported the following information:

- Member disagrees with resolution on previous Grievance # 28932.

- Member was scheduled to be picked up on September 25, 2019 at 9:00 pm for a 9:45pm appointment

- Member waited inside of her home for her ride for one hour but the driver never showed

- You requested the driver to call you when they arrived. The driver never called

- The Member and her son reviewed the security camera footage and confirmed the driver never showed up


Concerns Addressed


- Investigated MTM

PHC Resolution

PHC attempted to call the member to discuss our findings. A Notice of Resolution (NAR) Letter was mailed to the member with the following resolution. Here are the results of our research:

- MTM confirmed the driver did not show up

- MTM advised that drivers must attempt to call and knock on residence door prior to cancelling a trip. The driver did not try all communication options

- MTM confirmed that the transportation provider has been educated to accommodate all trips as scheduled. If a trip cannot be completed, the provider must advice MTM immediately.


24

State Hearing Case The following State Hearing is regarding a members’ denied TAR request for an opioid medication,

which was upheld through the Appeal process.

Case # 27110 Date Received 5/29/2019 Beneficiary Name Confidential Time Received 09:48:51 Case Filed by Member Date Closed 08/23/2019 G&A Investigator State Hearing Representative

Time Closed 08:42 Reporting Category Benefits/Coverage Summary of Member's Concerns

Member reported the following information: Member requesting State Hearing for TAR denial of HYDROCODONE‐ACETAMIN 10‐325 with no reason why. Member wants for the notice of action to come in the mail. Member does not agree with the county action and would like to have a review of the case by an Administrative Law Judge.


PHC Research:

- Member diagnosed with fibromyalgia, central pain syndrome, knee pain, osteoarthritis and cervical spine. Currently receiving Hydrocodone‐Acetaminophen, quantity 120. Wants quantity increased to 180. Member requesting $97 reimbursement for purchased medication.

PHC Position: - TARs for Hydrocodone‐Acetaminophen was denied appropriately. Evidence reviewed by PHC’s medical

director reviewed the case and determined the medical records do not show medical justification for increase dose.

PHC Resolution

Decision by Administrative Law Judge: PHC correctly denied the TAR for Hydrocodone‐acetaminophen 10‐325mg, quantity 180, based on an insufficient showing of medical necessity for the dose increase of the medication at the requested daily dosage level. Order: The claim is denied.


25

CONTACT US Partnership HealthPlan of California

4665 Business Center Drive

Fairfield, CA 94534

2525 Airpark DriveRedding, CA 96001

www.partnershiphp.org
