1. Fallon Health and MAPAM
Moving forward. Together.
May 18, 2017

2. Agenda • Introduction • Product spotlight and new benefits
• Fallon operational updates, reminders and resources
• Your questions answered 1

3. About Fallon Health

4. About Fallon Health
Started as a provider-based organization—founded in conjunction with the Fallon Clinic (now Reliant Medical Group) in 1977—Fallon Health is a leading, not-for-profit, health care services organization
In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs.
Consistently rated as one of the nation’s top health plans for our Medicaid, Medicare and Private (Commercial) products, according to the National Committee for Quality Assurance 1

5. Fallon Health plans/products
Commercial Plans
Direct Care
Select Care
Fallon Preferred Care
Steward Community Care
Tiered Choice
Customized Employer Groups
Harrington Advantage PPO
The City of Worcester Advantage
The Advantage Plan – Hanover
Dual Eligible
NaviCare HMO SNP, and SCO
Individual health plans
Fallon Connector QHP options
Hybrid plans
Community Care
MassHealth
Medicare
Fallon Senior Plan HMO, HMO-POS, Premier HMO, Premier Preferred PPO and Medicare Supplement
Fallon Companion Care
Summit Eldercare 1

6. Product spotlight and new benefits

7. Product Spotlight- Community Care Expansion
Fallon Health has expanded its Community Care limited network in Central Massachusetts to include parts of Middlesex County.
Community Care was designed specifically to be offered as a ConnectorCare plan for the subsidized commercial individual market in Massachusetts, and is sold on the Massachusetts Health Connector. 1

8. Product Spotlight- Community Care Expansion
Provider groups
Reliant Medical Group—including Southboro Medical Group
Harrington HealthCare System PCPs and specialists
Saint Vincent Medical Group
Select PCPs and specialists affiliated with the MetroWest HealthCare Alliance
Hospitals
Saint Vincent Hospital
Additional affiliated specialists include : HealthAlliance and UMass Memorial, and tertiary hospital services to be provided by UMass Memorial hospitals
Harrington Hospital
HealthAlliance Hospitals
Clinton Hospital
Marlborough Hospital
MetroWest Medical Centers
Milford Regional Medical Center 1

9. Product Spotlight- Community Care Expansion1

10. Product Spotlight – NaviCare
Plan Highlights:
Coordinated care and coverage for low-income seniors, ages 65 and older; to improve health and support independence
NaviCare SCO (Senior Care Options Program)
NaviCare HMO SNP (Medicare Advantage Special Needs Plan)
Coverage beyond MassHealth Standard and Medicare
Patient-centered model of care
NO premiums. NO copays. NO coinsurance. NO deductibles.
Revamp 2017 benefit changes 1

11. Product Spotlight – NaviCare
2017 Benefit Changes:
The supplemental transportation benefit, which provides non-emergent transport to non-medical locations, such as fitness facilities, has been enhanced from 70 round trips to 80 round trips annually.
Under the DME benefit, NaviCare will now cover the seat lift recliner chair up to $600 per lifetime when the seat lift has been authorized.
Dental coverage has been enhanced to include additional preventive and X-ray visits, coverage of dental implants and associated services with prior authorization.
“Save Now” OTC card, which will allow members to spend up to $42 per quarter on qualified OTC items, such as oral care and pain relief items, in popular retail establishments such as Rite Aid and CVS.
Revamp 2017 benefit changes 1

12. New Benefit - Teladoc® telehealth
Effective January 1, 2017, Fallon Health began offering Teladoc, a telehealth option, to members (ASO Clients may opt in; excluding PACE products)
Teladoc is the first and largest provider of telehealth medical consultations in the United States.
Patients will need to register to use Teladoc – it is advised to do this before services may be needed.
Patients will be expected to pay their PCP copayment before the Teladoc consult.
Visits take place by phone, video within a secure member portal, or mobile application with MA board-certified physicians. 1

13. New Benefit - Teladoc® telehealth
Visits are used to diagnose, treat and prescribe short-term medications for common health issues such as sinus problems, bronchitis, cold and flu symptoms or ear infection.
Teladoc doctors will not prescribe substances controlled by the U.S. Drug Enforcement Administration, non-therapeutic or certain other drugs which may be harmful because of their potential for abuse.
Patients who access Teladoc may show the consult information to their PCP. Patients will have access to their electronic medical records and can download them or call Teladoc to have them mailed or faxed.
*** Teladoc is a member benefit separate from the Fallon Health Telemedicine payment policy which can be found at 1

14. New Benefit - Senior HMO - WellTrack
New program is being offered to certain Fallon Senior Plan members who have been diagnosed as having diabetes.
Members qualify for this program if they:
Are identified as having diabetes
Are enrolled in either Fallon Senior Plan Saver Enhanced Rx HMO-POS or Fallon Senior Plan Standard Enhanced Rx HMO, offered in Worcester County and parts of Franklin County
Members must get all the services listed on a scorecard within the same calendar year in order to qualify for up to a $200 copayment reimbursement
Members who qualify will automatically be sent a notice informing them that they are in the program 1

15. New Benefit - Senior HMO - WellTrack
The WellTrack scorecard looks at:
Hemoglobin A1c – blood test that measures average glucose (sugar) level over a 3-month period
Fasting lipid profile – blood test that measures cholesterol levels
Attention to nephropathy, which may include:
A urine test that measures protein
Prescription of medication for nephropathy
Diabetic eye exam – looks for problems at the back of the eye 1

16. New Benefit - Safe Transitions Program
Safe Transitions Program, a post-discharge, in-home medication review program for eligible Fallon Senior Plan and Navicare patients being discharged from acute or skilled nursing facilities
This program will be rolled out to include Summit Elder Care patients later in the year
This is a voluntary program; members will be outreached to and do have to sign up for this program. 1

17. Physician referrals are always welcome, 1-800-333-2535, ext 69689
New Benefit - Safe Transitions Program
During the in home visit the member will receive:
A comprehensive review of pre/post-discharge medication regimens
An assessment of medication-related problems
A personal medication record and action plan
A pharmacist or pharmacist technician will follow up with the member by phone seven days after the initial visit, then again at 30 days.
To determine eligibility, our predictive analytic tool identifies at-risk patients by stratifying the following parameters:
Six or more medications
Use of high risk medications
Number of ED visits within the last six months
Physician referrals are always welcome, , ext 69689
Length of stay
Acuity of admission 1

18. Operational reminders, updates and resources

19. Reminder - Nurse Practitioners and Physicians Assistants
Adding a mid level starts at the contracting level
Does your IPA/PHO or group recognize mid levels?
How are you going to bill?
Through a supervising or on their own?
See the Fallon Health Nurse Practitioner and/or Physician Assistant payment policy on our website at or contact your Provider Relations Representative

20. Update - Data Requirements & Regulations
The Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA) have enacted requirements that health plans engage providers in reviewing and maintaining provider directory information.
The regulations are designed to ensure health care consumers have current and accurate provider demographic information.
Beginning April 24, 2017, Fallon Health began an outbound call campaign whereby we are contacting providers that appear in our  Medicare (NaviCare and Senior Plan) directories to verify practice information. 1

21. Update - Data Requirements & Regulations
Providers/offices will be asked the following information including (but not limited to) :
1. Provider office details for each location
2. Phone number
3. Specialty
4. Panel status
5. Product participation
You can also verify your practice information proactively:
Calling our Provider Services Line at , prompt 4
Update your information by:
Use the provider change form which can be found on-line
Submit your change on-line(noted above)
Send it to your Provider Relations Representative in writing 1

22. Update - Provider Tools
Authorization look-up tool
Coming mid- 2017
Available to:
Hospitals, Individual providers, DME, Ambulance
Functionality allowing the ability to validate the status of a prior authorization online for your provider through the secure portal on our Fallon Health Provider site
New access forms will be required
Please look for more information in the next few months 1

23. Resources Provider Website offers you: Connection Newsletter
News and Announcements
Provider Tools
PCP Panel Reports
Claims Metrics
Eligibility
Referral Monitoring Report
Provider Manual
Policy and Procedures
Available: 1

24. Fallon Provider Relations | 1-866-275-3247
Resources
Fallon Provider Relations |
Prompt 1 | Customer Service (to determine member eligibility or benefit information)
Prompt 2 | Claims
Prompt 3 | Referrals, Prior Authorizations or Case Management
Prompt 4 | Provider Relations
Prompt 5 | Pharmacy Services
Prompt 6 | EDI Coordinators 1

25. Questions?
Thank you!