SMMC Managed Medical Assistance (MMA) Program Issues

1 SMMC Managed Medical Assistance (MMA) Program Issues Report Period: November, 2016 Run Date: 12/1/2016. Median Days for Median Days for # of Issues # MMA Difference per Median Days for Resolution - # of Issues # of Issues , per Resolution - Resolved Enrollees as of # of Issues 1,000 - Last Resolution - Provider Non- # of Issues Received in 1,000 enrollees, Provider Claims Incomplete /. End of Month - Received, last 3 Month Compared Beneficiary Issues , Claims Payment Pending for November, November, Payment Issues , Informational Source: Months to Last 3 Months November, 2016 Issues , Resolution 2016 2016 November, 2016 (#. HealthTrack (Mthly Avg.) (# Resolved) November, 2016. Resolved) **. (# Resolved). MMA PLANS (Standard Plans). Amerigroup Florida, Inc. 347,503 226 75 6 (46) 22 (4) 15 (5) 21 36.

2 Better Health, Inc. 101,496 48 24 7 (13) 4 (2) 4 8. Community Care Plan 45,137 25 7 7 (5) 11 (1) 3 4. Coventry Health Care of Florida, Inc. 60,609 32 12 8 (4) 100 (1) 3 12. First Coast Advantage, LLC *0 0 0 * * 0 0. Humana Medical Plan, Inc. 339,366 290 102 6 (72) 13 (4) 33 (8) 34 41. Integral Quality Care ** 0 10 4 ** ** 74 (1) 2 8. Molina Healthcare of Florida, Inc. 340,949 226 70 7 (37) 7 (3) 35 (15) 27 47. Preferred Medical Plan, Inc. ** 0 1 0 ** ** 0 0. Prestige Health Choice 321,286 206 76 6 (51) 6 (7) 52 (10) 26 34. Simply Healthcare Plans, Inc. 85,619 44 21 7 (9) 4 (1) 87 (4) 9 15. Staywell Health Plan of Florida 681,212 488 160 8 (83) 13 (31) 33 (26) 49 86. Sunshine Health Plan, Inc. 478,653 340 107 8 (59) 14 (16) 39 (23) 27 64. United Healthcare of Florida, Inc. 281,046 236 83 4 (60) 5 (4) 29 (11) 21 35.

3 MMA PLANS (Specialty). Children's Medical Services (CMS) 51,005 58 15 10 (19) 18 (4) 1 2. Clear Health Alliance HIV/AIDS Specialty Plan 9,696 23 7 9 (2) 4 (2) 29 (2) 1 6. (Simply Healthcare Plans, Inc.). Freedom Health, Inc. Cardiovascular/ CHF/ COPD/ Diabetes 130 0 0 0 0. Disease Specialty Plans Magellan Complete Care Serious Mental Illness Specialty Plan 56,390 117 46 7 (22) 8 (8) 31 (6) 11 29. (Florida MHS, Inc.). Positive Healthcare Florida HIV/AIDS Specialty Plan 2,017 4 0 0 0. (AHF MCO of Florida, Inc.). Sunshine Health Plan, Inc. Child Welfare Specialty Plan 30,914 11 3 7 (4) 41 (1) 2 0. NON-PLAN SPECIFIC. MMA System (Non-Plan Specific) Issues 3149 880 471. 1. SMMC MMA Issues Reported to the Complaint Operations Center - November, 2016. Standard Plans Specialty Plans l ta en S).

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5 M. Customer Service 7 2 4 16 12 4 1 25 14 18 1 2 1 107. GENERAL 1 1 3 6 4 4 1 9 5 7 1 1 1 44. INCORRECT INFORMATION PROVIDED 3 4 2 2 1 12. INFORMATION VERIFICATION 6 1 1 7 5 9 7 8 44. UNABLE TO OBTAIN MEMBER MATERIALS 3 3 1 7. Fraud Allegation 1 1 1 1 1 5. FRAUD ALLEGATION 1 1 1 1 1 5. General 1 2 1 1 885. GENERAL 1 2 1 1 5. SYSTEM 880 880. HIPAA 0. HIPAA 0. Marketing Violation 0. MARKETING VIOLATION 0. Network Access 8 2 1 9 5 13 1 16 10 12 7 84. APPOINTMENTS ARE NOT TIMELY 1 1 1 3. NO PROVIDERS OF A SPECIFIC TYPE 6 3 2 3 1 6 4 5 2 32. NOT ENOUGH PROVIDERS OF A SPECIFIC TYPE 2 1 1 6 2 9 7 4 4 5 41. PROVIDERS TOO FAR AWAY 1 2 2 3 8. Payment 25 5 2 6 27 4 21 23 6 50 32 21 3 4 10 239. PAYMENT 25 5 2 6 27 4 21 23 6 50 32 21 3 4 10 239. Pharmacy 5 1 8 5 4 1 7 7 2 2 42. PHARMACY 5 1 8 5 4 1 7 7 2 2 42.

6 Services 30 15 4 1 42 25 31 11 59 43 28 3 9 26 3 330. DENIED 10 4 1 11 8 9 1 17 8 8 4 8 89. GAINING PRIOR AUTHORIZATION 4 2 1 7 6 1 20 7 7 1 3 59. LIMITATIONS 4 2 2 3 1 2 14. NOT PROVIDED, MISSED, OR DELAYED 7 7 2 1 11 7 15 5 12 13 4 1 2 9 2 98. QUALITY 1 1 4 3 2 1 2 5 1 20. SCHEDULING (IN-HOME) 1 1. SCHEDULING (PROVIDER) 4 1 5 1 1 1 3 1 1 18. SCHEDULING (TRANSPORT) 4 1 2 10 5 1 5 28. NOT SPECIFIED (Complainant accepted referral to Plan) 1 2 3. Total: 75 24 7 12 0 102 4 70 0 76 21 160 107 83 7 15 0 46 0 3 880. GRAND TOTAL 1692. 2. Please note - The Agency encourages all stakeholders to surface any potential issue , concern, or complaint regarding the SMMC. Program to the SMMC Complaint Operations Center. All allegations and Issues are recorded, regardless of whether they are found to be accurate or substantiated.

7 Median Days for Resolution of Issues - Current resolution protocol direct staff to close all non- claims payment Issues within one business day of receiving the resolution from the plan. Current resolution protocol for provider claims payment Issues include days for Agency staff research and provider document collection and response. As such, median days to resolve for provider claims payment Issues cannot be exclusively attributed to plan activity. * - First Coast Advantage ceased operations effective November 30, 2014. ** - Preferred Medical Plan ceased operations effective July 31, 2015. ** - Integral ceased operations effective October 31, 2015. ** - Issues Resolved Incomplete / Informational are Issues that did not require follow-up action by the Plan. These Issues are not included in the Median Day for Resolution columns.

8 Examples include; Complainant referred to his/her Plan Member Services to answer general questions, Complainant did not provide enough information to proceed with complaint and was nonresponsive to follow-up attempts to contact. 3.