Commercial Business Medical Cost Target

Commercial Business Medical Cost Target Measurement Period Handbook For Enhanced Personal Health Care Measurement Period beginning: April 1, 2018 CBMCT 040118 V3

Introduction Welcome to your Commercial Business Medical Cost Target Model Measurement Period Handbook. This handbook applies to those Providers who are contracted for the Enhanced Personal Health Care Medical Cost Target Program. As explained in the Program Description, the Incentive Program gives you the opportunity to share in savings achieved by your Medical Panel during a given Measurement Period. If you meet both quality and cost performance targets, your provider organization could share in the cost savings. To determine whether or how much of a shared savings payment you are eligible for, we measure your performance against quality, utilization and cost targets. In this handbook, you ll have the chance to learn more about those targets and how you can learn more about your performance. Below are definitions of some of the most important terms used in this handbook and the details of your Incentive Program: Additional terms that are used in this handbook are defined in the EPHC Attachment and Program Description. Medical Cost Baseline Report. Prior to the start of your Measurement Period, or as soon thereafter as practicable, you will be able to access your provider organization s Medical Cost Baseline (MCB) report via our secure website. The Medical Cost Baseline report shows medical costs incurred by your Attributed Patients over the course of the Baseline Period. This information is used as a starting point to establish the baseline cost that will be utilized to create the Medical Cost Targets (MCTs) for the Incentive P rogram. You are eligible to earn shared savings when the Medical Cost Performance (MCP) during the Measurement Period comes in below the MCT (with consideration to the Minimum Risk Corridor (MRC), and your measured performance on quality metrics and outcom es meets or exceeds the Program s Quality Gate. Measurement Period Start Date. The first day of the 12-month period during which we measure MCP and quality cost and utilization performance for purposes of calculating shared savings between Anthem Blue Cross and Blue Shield and the Medical Panel. Quality Gate. The minimum Performance Scorecard percentage that your provider organization must deliver in order to earn any shared savings under the Incentive. Further information about the Quality Gate is reviewed in the shared savings section, on page 1 4. Upside Shared Savings Potential. The maximum percentage of savings under the Incentive Program that you may be entitled to share, as long as your provider organization meets the Quality Gate and other Non -Cost Program Targets. Minimum Risk Corridor. (MRC) The percentage of MCB that Anthem retains before sharing any savings with the Medical Panel. Like the Gross Paid Upside Cap, the MRC is adjusted by the Paid/Allowed Ratio. 2

This percentage is determined by Anthem and is designed to limit savings payouts that are driven by random variation. Gross Paid Upside Cap (Upside Cap). The maximum limit on Gross Paid Savings that can be generated through the Incentive Program. The Upside Cap is a percentage that includes the MRC value which is calculated as a percentage of the MCB and is adjusted by the Paid/Allowed Ratio to determine the Upside Cap value expressed as a PMPM. The Upside Cap value expressed as a PMPM is compared to Gross Paid Savings and the lesse r of these two values apply to the determination of Net Aggregate Savings. Performance Scorecard Report. In addition to the MCB report, you will also be able to access your provider organization s Performance Scorecard via our secure provider portal at (www.availity.com). The Performance Scorecard shows your performance on the selected clinical, quality and utilization measures listed in this handbook. The Performance Scorecard is a tool to help you assess your quality and utilization performance on a quarterly basis. The information included in this handbook is designed to help you understand your MCB report, your Performance Scorecard and the scoring methodology 3

Contents Introduction... 2 Section 1: Medical Cost Baseline... 5 Overview... 5 Where to Find Your MCB Report and Supporting Materials... 5 Section 2: Performance Scorecard and Your Measures... 6 Overview... 6 Scorecard Report Example... 7 Quality Measures for Your Measurement Period... 8 Section 3: Calculating Your Shared Savings... 14 Overview... 14 Summary of your scoring... 31 INDEX Scorecard Measure Specifications... 38 4

Section 1: Medical Cost Baseline Overview As part of our Enhanced Personal Health Care Program, we track overall medical costs incurred by our members, and under the incentive portion of the Program, we reward participating providers who are able to provide appropriate care in a cost-effective manner while maintaining or improving performance against nationally recognized quality measures. You are eligible to earn shared savings if your performance during the Measurement Period creates Net Savings (i.e., costs in the Measurement Period come in lower than the target) and if you meet or exceed the Program s quality benchmarks. The better the quality score, the higher the potential shared savings payment The MCB Report shows medical costs incurred by a given Medical Panel s Attributed Patients over the course of the Baseline Period. This information is used to establish the Medical Cost Target (MCTs) for the Incentive Program. The MCB Report lists supporting Member Months, average risk scores and claims expenditures incurred by Attributed Patients over the course of the Baseline Period. The MCB Report is meant to give you a sense of the baseline cost from which you are starting. This level-set helps you hit the ground running at the beginning of the Measurement Period for the Incentive Program. This report is produced at the start of each annual Measurement Period. You will receive periodic reports that show your Medical Cost Performance (MCP) over the course of the Measurement Period. Where to Find Your MCB Report and Supporting Materials Your MCB report will be available prior to the start of your Measurement Period or as soon thereafter as practicable. To view your MCB report or to view a useful Quick Reference Guide for MCB, select the Provider Online Reporting link on Availity.com. 5

Section 2: Performance Scorecard and Your Measures Overview The Performance Scorecard is comprised of Clinical Quality and Utilization Measures. In addition to serving as a basis for Incentive Program savings calculations, these measures are used to establish a minimum level of performance expected of you under the Program, and to encourage improvement through sharing of information. The Performance Scorecard allows you to monitor your progress in these measures throughout the year. It will identify: Historic measure rate during the Baseline Period Rolling measure rate Rolling measure numerator and denominator Benchmarks for your Measurement Period 6

Performance Scorecard Report Example The Performance Scorecard, is shown below as it appears in our web-based provider reporting system, Provider Care Management Solutions (PCMS). The report includes: 1. Earned Percentage Contribution: The proportion of the Shared Savings Potential earned for each Performance Scorecard category and for the overall Program. 2. Maximum Possible Shared Savings: The maximum percentage (out of 100%) of Shared Savings to which the provider is entitled under the Incentive Program. 3. Total Shared Savings The Performance Scorecard, shown below as it appears in PCMS, shows the Total Shared Savings Percentage. The percent Shared Savings (in this example, 26.4%) is calculated by multiplying the total earned percentage (in this example, 88%) to the Upside Shared Savings Potential (in this example, 30%). 3. 2. 1. 7

Quality Measures for Your Measurement Period Clinical Quality Measures The clinical quality measures for the Program are grouped into two categories: (1) Acute and Chronic Care Management and (2) Preventive Care. These categories are then further broken out into six subcomposites. These measures cover care for both the adult and pediatric populations. Nationally standardized specifications are used to construct the quality measures in conjunction with Plan data. Acute and Chronic Care Management Measures o Medication Adherence - Proportion of Days Covered (PDC): Oral Diabetes - Proportion of Days Covered (PDC): Hypertension (ACE or ARB) - Proportion of Days Covered (PDC): Cholesterol (Statins) o o o Diabetes Care - Diabetes: Urine Protein Screening - Diabetes: HbA1c Testing - Diabetes: Eye Exam Annual Monitoring for Persistent Medications - Annual Monitoring for Patients on Persistent Medications: ACE/ARB - Annual Monitoring for Patients on Persistent Medications: Diuretics Other Acute/Chronic/Safety - Adult - Appropriate use of Imaging for Lower Back Pain - Medication Management for People with Asthma - New Episode of Depression: Effective Acute Phase Treatment - New Episode of Depression: Effective Continuation Phase Treatment Appropriate Treatment for Adults with Acute Bronchitis Other Acute/Chronic/Safety - Pediatric - Medication Management for People with Asthma - Appropriate Testing for Children with Pharyngitis - Appropriate Treatment for Children with Upper Respiratory Infection 8

Preventive Measures o Pediatric Prevention - Childhood Immunization Status: MMR - Childhood Immunization Status: VZV - Well-Child Visits Ages 0-15 Months - Well-Child Visits Ages 3-6 Years Old - Well-Child Visits Ages 12-21 Years Old - Chlamydia Screening o Adult Prevention - Breast Cancer Screening - Cervical Cancer Screening - Chlamydia Screening 9

Utilization Measures Three different utilization measures are included in the Program Performance Scorecard. The measures focus on appropriate emergency room (ER) utilization, management of ambulatory-sensitive care conditions as measured by hospital admissions, and formulary compliance rates. As with the clinical metrics, administrative data are used to construct the utilization measures. Potentially Avoidable ER Visits This measure was developed using research that determines ER visits that were potentially avoidable by identifying visits that could have been treatable in an ambulatory care setting. Visits for treatment of conditions, such as the following, are considered potentially avoidable: Conjunctivitis Otitis media Sinusitis Bronchitis Gastritis Constipation Urinary tract infection Menstrual disorders Cellulitis Dermatitis Sun burn Osteoarthrosis Joint pain Backache Cramps Insomnia Malaise and fatigue Throat pain Cough Nausea or vomiting alone Diarrhea Sprains Abrasions Contusions First degree burns Strep throat Vaccinations Routine child Prenatal Gynecological and adult exams Change of wound dressings Radiology and laboratory exams Health screenings. Adult and Pediatric, Ambulatory Care Sensitive Condition Admissions The Agency for Healthcare Research and Quality (AHRQ) has developed Prevention Quality Indicators (PQI/PDI) of potentially avoidable hospitalizations for ambulatory care sensitive conditions that are the basis of this measure. The admission selected for this measure are : Adult 1. Diabetes (uncontrolled, short-term and long term complications) 2. Chronic obstructive pulmonary disease 3. Hypertension 4. Heart Failure 5. Dehydration 6. Bacterial pneumonia 7. Urinary tract infection 8. Asthma CBMCT 040118 V3

Pediatric: 1. Diabetes short term complications 2. Gastroenteritis 3. Urinary Tract infections 4. Asthma Brand Formulary Compliance Rate The overall percentage of carve-in pharmacy claims for brand name drugs that are on formulary. (Exclusions detailed further below and in the Index) Quality Improvement Measures In addition to assessing performance against thresholds, a subset of the clinical measures (listed below) will be scored for improvement. The selection of these measures is a subset of the current set of performance measures. These improvement measures will be assessed at your provider organization level and will be weighted equally for each measure that has a denominator greater than or equal to 30. If the denominator for each of the improvement measures is less than 30, then we will not use a score for that category. 1. Breast Cancer Screening 2. Medication Adherences: Statins 3. Diabetes: HbA1c Testing 4. Well Child Visits ages 3-6 Years Old 5. Appropriate Testing for Children with Pharyngitis Note: In some instances, pharmacy information may not be available for certain membership. Membership that is lacking pharmacy detail will be excluded from the measures that require pharmacy information. Once pharmacy information becomes available to Anthem, the data will be phased into the measures 11

Composite Overview Scorecard points are divided into five categories, or composites. Several of the composites are based upon sub-composites. Then, within some of the sub-composites there are specific care measures. Performance on the clinical measures listed above will be grouped at the sub-composite level, but scored at the individual metric level. Scoring of the individual metrics occurs at the provider organization level. If a metric has a denominator less than 30, scoring will then move to a Medical Panel-level. The metric will be scored in a proportional fashion between the provider organization and the Medical Panel. For instance, if a metric denominator for a provider organization has only twenty (20) members but the panel has more than thirty (30) members, then the scoring would reflect 66.67% based on the provider organization performance (20 members in their denominator/30 members required for metric denominator) and 33.33% based on the medical panel performance. If all of the clinical metrics have a denominator less than 30, or if the Annual Monitoring for Persistent Medications is the only clinical metric with a denominator of at least 30, then scoring will occur at the Medical Panel-level. The five major composites are: 1. Acute and Chronic Care Management 2. Preventive Care 3. Utilization 4. Clinical Quality Improvement 5. Patient-Centered Medical Home (PCMH) Recognition from the National Committee for Quality Assurance (NCQA) 1 Composite Details The Acute and Chronic Care Management Composite has five sub-composites. Each of the subcomposites includes multiple care measures: 1) Medication Adherence 2) Diabetes Care 3) Annual Monitoring for Persistent Medications 4) Other Acute/Chronic/Safety Adult 5) Other Acute/Chronic/Safety - Pediatric The Preventive Care Composite has two sub-composites: 1) Adult Preventive 2) Pediatric Preventive 1 *Optional category; full shared savings can be earned without PCMH Recognition. 12

The Utilization Composite is made up of three sub-composites: 1) Potentially avoidable ER visits 2) Ambulatory Care Sensitive Condition Admissions 3) Brand Formulary Compliance Rate The Clinical Quality Improvement Composite has five measures, and was outlined previously. Patient-Centered Medical Home NCQA Recognition In addition to the opportunity to earn shared savings based on quality and cost, provider organizations that have obtained NCQA PCMH Levels 2 and 3 recognition can earn credit for that achievement. Your provider organization will not be penalized if you do not have NCQA PCMH recognition. A score of 75% is awarded if a provider organization receives Levels 2 or 3 recognition for 20% to 50% of provider organization locations. A score of 100% is awarded for Levels 2 or 3 recognition if received for 50% or more of provider organization locations. Groups that have not obtained this recognition are not penalized. The overall Shared Savings Potential percentage remains the same 13

Section 3: Calculating Your Shared Savings Overview The opportunity to share in savings that are realized for your Attributed Patients is a key characteristic of the Program. After savings are determined, the proportion of shared savings that you can earn depends on your organization s performance on a scorecard. Your Scorecard serves two functions: (1) it will let you know if you met the Quality Gate, and (2) it will show you the overall percentage of the shared savings you earn. Below, we review the four major steps to determine your shared savings: 1. Savings Pool Funded 2. Quality Gate Passed 3. Earned Contribution Calculated for each Composite 4. Overall Shared Savings Potential Calculated Savings Pool Funded Was the savings pool funded? In order to participate in shared savings, the Savings Pool must be funded. For that to happen, your Medical Panel s Attributed Member population must demonstrate savings over the course of your Measurement Period. As described more fully in the Program Description, Anthem will calculate the Savings Pool by comparing the Medical Cost Performance (MCP) for your Attributed Member population for a specified 12-month Measurement Period to the established Medical Cost Target (MCT). In the event that the MCP is less than the MCT, the Savings Pool is funded. After the pool is funded, the Minimum Risk Corridor (MRC) is calculated by multiplying the MCB by the relevant MRC percentage, and then multiplying the result with the Paid/Allowed Ratio (as outlined further in the Program Description). Ultimately, the Savings Pool is multiplied by your Shared Savings Percentage earned to calculate your shared savings payout. Quality Gate Did you pass the Quality Gate? Your provider organization must meet a minimum threshold of performance on clinical quality measures in order for you to share a portion of the savings pool. That threshold, referred to as the Quality Gate, is based on an overall clinical quality score, which is computed by aggregating your scores across the scorecard s clinical sub-composites. The Quality Gate is set at 40 points out of a total 100 possible points, so Providers with a score under forty (40) points will have no Upside Shared Savings Potential. The final, overall score is compared to the Shared Savings Potential to determine the earned Shared Savings Percentage. 14

Earned Contribution Calculated For Each Composite Weighting Composites The composite, sub-composites, and care measures do not contribute equally to the Performance Scorecard s results they are weighted more heavily toward Clinical Measures: The clinical composites (Acute and Chronic Care Management, Preventive Care and Improvement) are weighted to account for 62% or 72% of the Performance Scorecard points depending on the presence of NCQA PCMH Recognition. The weighting for recognition is explained further in a separate section below. The Acute and Chronic Care composite is weighted more heavily than preventive care. Utilization measures account for 28% of the Performance Scorecard points. The mix of adult and pediatric members in the group will vary the weight of the sub - composite categories. 15

Determination of measure weights Measure weights are determined on a provider group specific basis to account for different age mix of Attributed Members between provider groups. To determine metric weights in the Performance Scorecard the provider group s ratio of adult to pediatric membership is calculated from the member month information supplied as part of the ambulatory care sensitive admissions metric. If the ratio is greater than 70% for either the pediatric or adult membership, then the fixed sub-composite weightings are adjusted to proportionally weight the metrics specific to the membership with the most significant ratio. Examples are below. Table 1: Composite Weights Fixed Weight Example Category Allocation of Shared Savings Potential With NCQA Recognition Without NCQA Recognition Clinical: Acute and Chronic Care Management Acute and Chronic Care Management Composite 34.36% 39.86% Medication Adherence 9.02% 10.46% Diabetes Care 6.46% 7.49% Annual Monitoring for Persist Meds 1.27% 1.48% Other Acute and Chronic Care and Patient Safety Management - Adult 9.02% 10.46% Other Acute and Chronic Care and Patient Safety Management Pediatric 8.59% 9.97% Clinical: Preventive Preventive Composite 17.34% 20.14% Pediatric 11.61% 6.66% Adult 5.73% 13.48% Clinical: Improvement 10.3 12 Utilization 28.0 28.0 NCQA PCMH Recognition 10 N/A TOTAL 100% 100% 16

Table 2: Shared Savings Potential per Composite in Absolute Terms with 100%/0% adult/pediatric member mix and 30% max payout. Percentage of Shared Savings Category With NCQA Recognition Without NCQA Recognition Clinical: Acute and Chronic Care Management Medication Adherence 3.60% 4.18% Diabetes Care 2.59% 3.00% Annual Monitoring for Persist Meds 0.51% 0.60% Other Acute/Chronic/Safety Adult 3.60% 4.18% Other Acute/Chronic/Safety Pediatric 0.00% 0.00% Clinical: Preventive Pediatric 0.00% 0.00% Adult 5.20% 6.04% Clinical: Improvement 3.10% 3.60% Utilization 8.40% 8.40% NCQA PCMH Recognition 3.00% NA TOTAL 30% 30% 17

Table 3: Shared Savings Potential per Composite in Absolute Terms with 0%/100% adult/pediatric member mix and 30% max payout Percentage of Shared Savings Category With NCQA Recognition Without NCQA Recognition Clinical: Acute and Chronic Care Management Medication Adherence 0.00% 0.00% Diabetes Care 0.00% 0.00% Annual Monitoring for Persist Meds 0.00% 0.00% Other Acute/Chronic/Safety Adult 0.00% 0.00% Other Acute/Chronic/Safety Pediatric 10.30% 11.96% Clinical: Preventive Pediatric 5.20% 6.04% Adult 0.00% 0.00% Clinical: Improvement 3.10% 3.60% Utilization 8.40% 8.40% NCQA PCMH Recognition 3.00% N/A Total 30% 30% 18

Table 4: Shared Savings Potential per Composite in Absolute Terms: Fixed for groups with between 70/30 and 30/70 mix and 30% max payout. Percentage of Shared Savings Category With NCQA Recognition Without NCQA Recognition Clinical: Acute and Chronic Care Management Medication Adherence 2.70% 3.14% Diabetes Care 1.94% 2.25% Annual Monitoring for Persist Meds 0.38% 0.44% Other Acute/Chronic/Safety Adult 2.71% 3.14% Other Acute/Chronic/Safety Pediatric 2.58% 2.99% Clinical: Preventive Pediatric 1.72% 2.00% Adult 3.48% 4.04% Clinical: Improvement 3.09% 3.60% Utilization 8.40% 8.40% NCQA PCMH Recognition 3.00% N/A TOTAL 30% 30% 19

Quality Performance Tiers Providers achieve a given quality score based on how they score on a range of quality measures included in their quality Performance Scorecard. The quality Performance Scorecard is based on quality measures covering areas such as preventive care and coordination of care. Compliance rates for the Provider s Member Population are displayed, along with targets and associated points. The relationship between the Provider s earned po ints relative to total possible points will determine the percentage of incentive earned. This value, expressed as a percent, is known as the quality score. The Scorecard is comprised of four composites: Acute and Chronic Care Preventive Care Improvement Utilization The total points earned is based on a maximum of 100 points (not 100%). Points are calculated for each individual measure. Each provider group s compliance rate is calculated for the measure and compared to the benchmarks to determine the percentage of the maximum points for the measure. Example 1: Illustrates 51.35% of the points met out of 100%. 20

Acute and Chronic Care The Acute and Chronic Care Management Composite has five Sub -composites: Medication Adherence Other Acute/Chronic/Safety Adult Other Acute/Chronic/Safety - Pediatric Diabetes Care Annual Monitoring for Persistent Medications The Acute and Chronic Care Management sub-composites each have related Performance Measures. Performance Measures can vary by Measurement Period. Rates are calculated for each of the Acute and Chronic Care Management Measures where the denominator size is 30 or more for both the Measurement Period and the Baseline Period. Weights for measures with a denominator less than 30 are reallocated to the remaining Acute and Chronic Care Management Measures Example 2: As seen below 21

Preventive Care The Preventive Care Composite has two sub-composites: Adult Preventive Pediatric Preventive These sub-composites each have related Performance Measures. Performance Measures can vary by Measurement Period. Rates are calculated for each of the Preventive Measures where the denominator size is 30 or more for both the Measurement Period and the Baseline Period. Weights for measures with a denominator less than 30 are reallocated to the remaining Preventive Measures Example 3: As seen below. 22

Sub-Composites Preventive Care Example 4: As seen below. Compare performance to market thresholds Market thresholds are established for each of the measures at the minimum (20 th ) and maximum (80 th ) percentiles < for the year prior to the Program Measurement Period. Performance thresholds will be provided soon after the start of the Measurement Period The thresholds are set jointly for all lines of business included in the Program using performance of all providers within the market. Note: Any measure with group performance greater than 95% will receive full credit. Assign percentage of the category earned The levels of market thresholds are used to categorize performance. After passing the minimum market threshold, the higher the performance the greater proportion of earned shared savings. The calculation is performed by taking the group score minus the minimum score and then dividing that by the range of the maximum score minus the minimum score, in this example: Group score = 62% Minimum score = 52% Maximum score = 72% (Group score-minimum score)/ (Maximum score Minimum score) or (62-52)/ (72-52) = 50% earned contribution 23

Calculate shared savings earned After the percentage of the category earned is determined, that value is multiplied by the group s Upside Shared Savings Potential. This yields the earned shared savings. Table 5: How the Benchmark Relates to Earning Potential Relation to Benchmark Earning Potential Below Minimum 0% Between Minimum and Maximum Greater of actual score achieved or 30% At or Above Maximum 100% 24

Maximum Minimum Composite 3: Utilization Measures Calculated We use five steps to determine the proportion of shared savings earned for each utilization sub - composite. Table 6 uses sample data to show hypothetical calculations. Table 6: The Five Steps Used to Score Ambulatory Sensitive Admissions Current Performance Market Benchmark Shared Savings Measures Member Months Admi ts Risk Adj. Factor Risk Adj. Rate Upside Shared Savings Potential Earned Contributio n Shared Savings % Commercial Adult 441,586 170 0.83 3.82 6.16 1.49 2.65% 50.11% 1.33% Commercial < 18 41,200 10 0.72 2.09 1.26 0.00 0.25% 00.00% 0.00% Weighted Sub composite Total: 2.90% 45.79% 1.33% Step 1 Step 2 Step 3 Step 4 Step 5 Step 1 Calculate utilization rates for the Medical Panel for distinct line of business and age categories. Ambulatory Sensitive Admits and Potentially Avoidable ER measures: - To control for variation in patient mix and associated variable utilization between Medical Panels, utilization rates are calculated separately for: Commercial members at least 18 years of age Commercial members less than 18 years of age - The numerator is the count of qualifying events during the Measurement Period. - The denominator is the sum of Member Months for members attributed to the Medical Panel during the Measurement Period. - The actual raw rate is computed as (numerator/denominator)*12,000. For Ambulatory Sensitive Admits: - This rate is risk-adjusted by dividing the actual raw rate for the provider panel by the risk adjusted rate. - The Medical Panel risk score is calculated as the sum of weighted retrospective diagnostic cost grouping risk scores for members attributed to the Medical Panel, divided by number of Attributed Patients with a risk score. That rate is then divided by the average Risk Score of all members within the line of business/age group (excluding BlueCard). 25

Brand Formulary Compliance Rate - To control for variation in patient mix and associated variable utilization between Medical Panels, utilization rates are calculated separately for: Commercial members at least 18 years of age Commercial members less than 18 years of age - The denominator = a count of all brand prescriptions for the Medical Panel s Attributed Patients population. The numerator = count of formulary brand prescriptions during Measurement Period. - The rate is computed as (numerator/denominator) percentage for each line of business/age group. The metric measures the Brand Formulary Compliance Rate exclusion criteria noted in the Index. Note: The list of excluded drugs is available upon request and will be updated quarterly to incorporate new products that meet exclusion criteria. Step 2 Compare performance to market thresholds. Market thresholds are established for each of the utilization measures for three distinct line of business/age groups (commercial adult, commercial <18). The levels of market thresholds are used to categorize performance. After passing the minimum market threshold, the higher the performance the greater proportion of earned shared savings. For Brand Formulary Compliance Rate Only: Informational only baseline benchmarks will be provided at the beginning of the Measurement Period. Throughout the Measurement Period, your performance will be compared to the claims experience of the market, which represents the actual claims for all Providers within your defined market. At the close of your Measurement Period, we will compare your compliance rate during your Measurement Period to the defined market compliance rate which will be used to compute the earned percentage of shared savings. The compliance rates calculated at the end of the Measurement Period will be inclusive of pertinent formulary changes that may have occurred during the period. Step 3 Determine Shared Savings Potential for each line of business/age group. Shared Savings -Potential for the utilization measures: - Potentially avoidable emergency room visits = 4.0% - Brand Formulary Compliance Rate = 2.90% - Ambulatory sensitive care admissions = 2.90% Since these measures are assessed by line of business/age groups, the Shared Savings Potential opportunity for each of these groups must be determined. 26

Step 4 Assign the earned contribution percentage. The levels of market thresholds are used to categorize performance. After passing the minimum market threshold, the higher the performance the greater proportion of earned shared savings. The calculation is performed by taking the group score minus the minimum score and then dividing that by the range of the maximum score minus the minimum score, in this example, Group score = 3.82 Minimum score = 6.16 Maximum score = 1.49 (Group score-minimum score)/ (Maximum score Minimum score) or (3.82-6.16)/ (1.49-6.16) = 50.11% earned contribution Step 5 Calculate earned shared savings for each utilization measure and the overall category. The earned shared savings for each measure/group combination is calculated by multiplying the percentage of the category earned for each line of business/age group for each of the utilization measures by the Medical Panel s Maximum Upside Shared Savings Potential. These scores are summed to determine the overall percentage of shared savings for each of the Utilization Metrics, and then summed for an overall utilization shared savings earned. Overall Scoring Summary for Utilization Components Table 7 demonstrates how 3, 4 and 5 steps, described above, are used to calculate the overall score for the utilization subcomponents. 3. Determine Upside Shared Savings Potential for each line of business/age group. 4. Assign the earned contribution percentage. 5. Calculate earned shared savings for each utilization measure and the overall category. 27

Table 7: As seen below Shared Savings Sub composites Measurement Level Earned Contribution Upside Shared Savings Potential Shared Savings % Ambulatory Sensitive Admits Panel 52.09% 2.90% 1.51% Potentially Avoidable ER Visits Panel 26.86% 4.00% 1.07% Brand Formulary Compliance Rate Panel 44.49% 2.90% 1.29% Utilization Composite Totals 9.80% 3.88% Composite 4: Clinical Quality Improvement Components Calculated There are five clinical improvement measures selected from the clinical quality measures as follows: 1. Breast cancer screening 2. Medication adherence: statins 3. Diabetes: HbA1c Testing 4. Well child visits for ages 3-6 Years old 5. Appropriate testing for children with pharyngitis Scoring of this Performance Scorecard component is performed only at the individual provider organization level. Performance is measured as follows: Rates are calculated for each of the five clinical improvement measures where the denominator size is 30 or more for the Baseline Period and the final Measurement Period. Weights for measures with a denominator less than 30 are reallocated to the remaining improvement measures. A target rate is set for each of the improvement measures. This target represents an improvement of 20% in closing the quality gap. (1-Group Baseline Rate)*.20)+group baseline rate If the target is achieved, you will receive full credit for that measure. Additionally, if the current rate is 90% or higher, full credit is received. Scoring for improvement measures will always take place at the group level. Each of the five improvement measures will be weighted equally at 20%. 28

If the denominator is less than 30 for any measure, that measure will not be scored but the weighting will be redistributed to the remaining measures with sufficient denominator size. If none of the five measures have a denominator of 30 or more, no points will be awarded or reallocated for the improvement component. Note: The Baseline Period for determining both the improvement and quali ty metrics benchmarks is the 12-month period of incurred service dates which precedes both a three-month paid claims run out period and a period of time needed to calculate and report benchmarks. The period needed for calculation and reporting of the benchmarks for improvement metrics is approximately one month while the quality metrics take three months. As a result, the improvement metrics are based on data which is two months more current than the data used to set the quality metrics benchmarks. 29

Composite 5: NCQA PCMH Level 2 and 3 Recognition Component Groups that have obtained NCQA PCMH Levels 2 and 3 recognition can receive credit for that achievement. Groups that do not have recognition are not penalized. The section bellow explains how PCMH recognition is calculated into the scorecard. Provider organizations with 20% or more of their locations having achieved NCQA PCMH Level 2 or 3 Recognition during the Measurement Period will receive up to 10% of the upside shared savings payout automatically as part of this scorecard component. 10% of the upside shared savings payout will be awarded to provider organizations that have Level 2 or Level 3 recognition for 50% or more of their locations. In absolute terms 10% x 3 0% maximum payout equals a guaranteed 3.0% payout. 7.5% of the upside shared savings payout will be awarded to provider organizations that have Levels 2 or Level 3 recognition for between 20% and 50% of its provider organization locations. In absolute terms 75% x 30% maximum payout equals a guaranteed 2.25% payout of shared savings. The remaining 2.5% of the possible payout for NCQA PCMH Recognition shall not be reallocated to the other clinical quality and improvement components. Instead, provider organizations receiving partial credit for the NCQA PCMH recognition shall have their clinical quality and improvement components measured using both the with and without NCQA PCMH weights and shall be awarded the result with the greatest payout amount. The maximum payout level (3.0% of the total 30% maximum shared savings payout assigned to this component) is subtracted from the total possible payout levels available in the clinical quality and improvement components. For example, a provider organization with no NCQA PCMH recognition has a max imum payout opportunity from clinical quality and improvement components of 21%, whereas this provider organization with all of its locations having achieved NCQA PCMH level 3 recognition would be guaranteed a 3.0% payout from NCQA PCMH recognition and an opportunity to earn up to 17.5% (21% - 3.0%) from performance in the clinical quality and improvement measures. Provider Organizations that have not obtained this recognition are not penalized. The overall shared savings percentage remains the same and can be earned entirely from the utilization, clinical quality and improvement components. Information about your NCQA PCMH status by location must be communicated to Anthem no later than 30 days after the close of any Measurement Period for which recognition was in effect by completing the electronic attestation form. 30

Overall Shared Savings Potential Calculated Summary of your scoring The tables below pull together all of the scoring that is described in this Measurement Period Handbook. The performance of your Medical Panel is used to calculate a score (0-100%) for each scorecard component. Your shared savings for each scorecard component is calculated by multiplying the Upside Shared Savings Potential (shown above in table 4) by the category score. The sum of your earned shared savings for each scoring components yields your overall earned shared savings examples of this calculation are shown in Tables 8 and 9 below. The tables below, which you will receive with your scorecard posted to Availity, will show whether you passed the Quality Gate and the overall percentage of shared savings that you have earned for the Measurement Period. 31

Table 8: Example Scorecard summary Without NCQA Recognition, assume 50%/50% adult/pediatric mix, 30% shared savings target In the example below the provider organization does not have NCQA PCMH recognition and would earn 20.61% of a Shared Savings Pool. Example Without NCQA PCMH Recognition Category Savings Potential Measure % Earned Savings Earned Passed Quality Gate ------> YES (1) Clinical: Acute and Chronic Care Mgmt. 11.96% Medication Adherence 3.14% PDC for Hypertension 1.05% 70% 0.73% PDC Oral Diabetes 1.05% 68% 0.71% PDC for cholesterol 1.05% 78% 0.82% Diabetes Care 2.25% Eye Exam 0.75% 40% 0.30% A1C 0.75% 100% 0.75% Proteinuria 0.75% 80% 0.60% Annual Monitoring for Persistent Medications 0.44% Diuretics 0.22% 73% 0.16% ACE/ARBs 0.22% 66% 0.15% Other Acute and Chronic Care and Patient Safety Management Adult 3.14% Use of AB in Adult Bronchitis 0.63% 25% 0.16% 32

Imaging for Low Back Pain 0.63% 60% 0.38% Medication Management for Asthma (adult) 0.63% 75% 0.47% Depression Rx >180d 0.63% 55% 0.35% New Depression >12 wk RX 0.63% 45% 0.28% Other Acute and Chronic Care and Patient Safety Management - Pediatric 2.99% Appropriate Treatment for Children with URI 1.00% 80% 0.80% Medication Management. for Asthma (Peds) 1.00% 65% 0.65% Appropriate Testing for Children with Pharangytis 1.00% 80% 0.80% (2) Clinical: Preventive 6.04% Pediatric Preventive 2.00% Adolescent Visits Ages 12-21 0.33% 22% 0.07% Pediatric Visits Age 3-6 0.33% 65% 0.22% MMR 0.33% 100% 0.33% VZV 0.33% 100% 0.33% Pediatric Visits Ages 0-1 0.33% 80% 0.27% Chlamydia Screening (Peds) 0.33% 50% 0.17% Adult Preventive 4.04% Breast Cancer Screening 1.35% 74% 1.00% Cervical Cancer Screening 1.35% 77% 1.04% Chlamydia Screening (adult) 1.35% 55% 0.74% 33

(3) Clinical: Improvement 3.60% 75% 2.70% (4) Utilization 8.40% Ambulatory Sensitive Admit Subcomposite 2.52% 65% 1.64% Potentially Avoidable ER Visits Subcomposite 3.36% 61% 2.05% Brand Formulary Compliance Subcomposite 2.52% 77% 1.94% OVERALL SAVINGS POTENTIAL 30% EARNED SHARED SAVINGS 20.61% 34

Table 9: Example Scorecard summary With NCQA PCMH Recognition, assume 50%/50% adult/pediatric mix, 30% shared savings target In the example below the provider organization does have NCQA PCMH recognition and would earn 21.54% of a Shared Savings Pool. Example With NCQA PCMH Recognition Category Savings Potential Measure % Earned Savings Earned Passed Quality Gate ------> YES (1) Clinical: Acute and Chronic Care Management 10.30% Medication Adherence 2.70% PDC for Hypertension 0.90% 70% 0.63% PDC Oral Diabetes 0.90% 68% 0.61% PDC for cholesterol 0.90% 78% 0.70% Diabetes Care 1.94% Eye Exam 0.65% 40% 0.26% A1C 0.65% 100% 0.65% Proteinuria 0.65% 80% 0.52% Annual Monitoring for Persistent Medications 0.38% Diuretics 0.19% 73% 0.14% ACE/ARBs 0.19% 66% 0.13% Other Acute and Chronic Care and Patient Safety Management Adult 2.70% Use of AB in Adult Bronchitis 0.54% 25% 0.14% 35

Imaging for Low Back Pain 0.54% 60% 0.33% Medication Management for Asthma (adult) 0.54% 75% 0.41% Depression Rx >180d 0.54% 55% 0.30% New Depression >12 wk RX 0.54% 45% 0.24% Other Acute and Chronic Care and Patient Safety Management - Pediatric 2.58% Appropriate Treatment for children with URI 0.86% 80% 0.69% Med mgmt. for Asthma (Peds) 0.86% 65% 0.56% Appropriate Testing for Children with Pharangytis 0.86% 80% 0.69% (2) Clinical: Preventive 5.20% Pediatric Preventive 1.72% Adolescent Visits Ages 12-21 0.29% 22% 0.06% Pediatric Visits Age 3-6 0.29% 65% 0.19% MMR 0.29% 100% 0.29% VZV 0.29% 100% 0.29% Pediatric Visits Ages 0-1 0.29% 80% 0.23% Chlamydia Screening (Peds) 0.29% 50% 0.14% Adult Preventive 3.48% Breast Cancer Screening 1.16% 74% 0.86% Cervical Cancer Screening 1.16% 77% 0.89% Chlamydia Screening (adult) 1.16% 55% 0.64% 36

(3) Clinical: Improvement 3.09% 75% 2.32% (4) Utilization 8.40% Ambulatory Sensitive Admit Subcomposite 2.52% 65% 1.64% Potentially Avoidable ER Visits Subcomposite 3.36% 61% 2.05% Brand Formulary Compliance Subcomposite 2.52% 77% 1.94% (5) NCQA PCMH Recognition 3.00% 3.00% OVERALL SAVINGS POTENTIAL 30% EARNED SHARED SAVINGS 21.54% 37

INDEX Performance Scorecard Measure Specifications *Note: The term patient(s), as used throughout the Index, shall mean and refer only to Attributed Member(s). Acute and Chronic Care Management Measures Sub-composite: Medication Adherence Measure Description / Technical Specifications Measure Citation Proportion of Days Covered (PDC): Oral Diabetes This measure identifies patients with at least two prescriptions for diabetic oral agents in the measurement year who have at least 80% days covered (PDC) since the first prescription of an oral diabetic agent during the year. Patients in the denominator with at least 80% days covered for an oral diabetic Rx since the first prescription for the drug during the last 365 days. Patients who have at least two prescriptions for an oral diabetic drug during the last 365 days. >=80% days covered (PDC) for Diabetic Oral Agents (removing overlapping days for Rx) from index event to end of measurement year. >=2 Rx claims for diabetic oral agents from end of measurement year-365 to end of measurement year, saving earliest instance as index event (IE); Rx eligibility from index event to end of measurement year using HEDIS gap method, <=1 gap <=45 days max; >=18yo No Rx claims for 'Insulin' from index event to end of measurement year. CMS Part D Specifications 2014 Proportion of Days Covered (PDC): Hypertension (ACE or ARB) This measure identifies Patients with at least two prescriptions for an ACE/ARB in the measurement year who have at least 80% days covered (PDC) since the first prescription of an ACE/ARB during the year. Patients in the denominator with at least 80% days covered for an ACE/ARB since the first prescription for the drug during the last 365 days. Patients who have at least two prescriptions for an ACE/ARB during the last 365 days. >=80 days covered (PDC) for ACE/ ARB (removing overlapping days) from index event to end of measurement year. >=2 Rx claims for ACE/ ARB from end of measurement year-365 to end of measurement year, saving earliest instance as index event (IE); Rx eligibility from index event to end of measurement year, using HEDIS gap method, <=1 gap <=45 days max; >=18yo. CMS Part D Specifications 2014 Proportion of Days Covered (PDC): Cholesterol (Statins) This measure identifies patients with at least two prescriptions for a Statin in the measurement year who have at least 80% days covered (PDC) since the first prescription of a Statin during the year. Patients in the denominator with at least 80% days covered for a Statin since the first prescription for the drug during the last 365 days. Patients who have at least two prescriptions for a Statin during the last 365 days. >=80% days covered (PDC) for Statins (removing overlapping days) from index event to end of measurement year. >=2 Rx claims for Statins from end of measurement year-365 to end of measurement year, saving earliest instance as index event (IE); Rx eligibility from index event to end of measurement year using HEDIS gap method, <=1 gap <=45 days max; >=18yo. CMS Part D Specifications 2014 CBMCT 040118 V3

Sub-composite: Diabetes Care Measure Description / Technical Specifications Measure Citation Diabetes: Urine Protein Screening This measure identifies diabetic patients with a nephropathy screening test or evidence of nephropathy during the measurement year. Patients in the denominator with claims for urine protein tests, nephropathy treatment, ESRD, stage 4 CKD, kidney transplant, ACE inhibitors, ARBs, or an outpatient visit with a nephrologist. Patients between the ages of 18 and 75 years old who have diabetes. Any one of the following during the measurement year: At least 1 procedure in any position for urine protein tests OR at least 1 lab LOINC claim for urine protein tests OR at least 1 procedure or diagnosis in any position for treatment for nephropathy OR at least 1 procedure or diagnosis in any position for ESRD OR at least 1 diagnosis in any position for CKD stage 4 OR at least 1 procedure or diagnosis in any position for kidney transplant OR at least 1 prescription claim for ACE inhibitors or ARBs OR at least 1 outpatient visit defined by outpatient with a nephrologist specialist National Committee for Quality Assurance. HEDIS 2018. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2017. Age 18-75 years old AND service eligibility during the measurement year with no more than 1 gap of no more than 45 days AND member eligibility with no gaps on analysis date AND identified by the following criteria: o Any one of the following At least 2 claims at least one day apart with a diagnosis of diabetes in any position from an outpatient, observation, acute inpatient ED, or nonacute inpatient setting in the 2 years before the analysis date At least 1 prescription claim for insulin or oral hypoglycemic medication dispensed in the 2 years before the analysis date o Exclude patients with claims for diabetes exclusions Deviation from HEDIS specs: Added requirement to look for at least 2 diabetes diagnoses from an inpatient setting. 39

Measures Description / Technical Specifications Measure Citation Diabetes: HbA1c Testing This measure identifies patients with diabetes who have had a HbA1c test over the past year. Patients in the denominator who had an HbA1c test during the measurement year. Patients between the ages of 18 and 75 who have diabetes. Either one of the following: At least 1 procedure claim for an HbA1c test during the measurement year OR at least 1 lab result for a HbA1c test during the measurement year. Age between 18 and 75 years as of analysis date Patients identified by the following criteria: o Any one of the following - At least 2 claims at least one day apart with a diagnosis of diabetes in any position from an outpatient, observation, acute inpatient ED, or nonacute inpatient setting in the 2 years before the analysis date - At least 1 prescription claim for insulin or oral hypoglycemic medication dispensed in the 2 years before the analysis date o Exclude patients with claims for diabetes exclusions. o Deviation from HEDIS specifications: Added requirement to look for at least 2 diabetes diagnoses from an inpatient setting. Continuous member eligibility during the measurement year with maximum 1 gap of no more than 45 days. Member eligibility with no gaps on analysis date. National Committee for Quality Assurance. HEDIS 2018. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2017.. 40

Measure Description / Technical Specifications Measure Citation Diabetes: Eye Exam This measure identifies patients between 18 and 75 years old who have diabetes and who had a retinal eye exam from an eye care professional in the last 2 years. Patients in the denominator who had a retinal eye exam from an eye care professional in the last 2 years. Patients between the ages of 18 and 75 who have diabetes. At least 1 claim for an eye exam as specified by HEDIS in the last 730 days Exe exams are defined either as o non-specific office visits with an ophthalmologist or optometrist. o specific eye care code sets for a diabetic retinal screening OR At least 1 claim for an eye exam as specified by HEDIS in the last 365 days. National Committee for Quality Assurance. HEDIS 2018. Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 2017 Note that HEDIS specifications only count retinal eye exams from the previous year if the results were negative, but due to data limitations this measure was loosened to accept all eye exams from the previous year regardless of result. Age between 18 and 75 years as of analysis date Patients identified by the following criteria: o Any one of the following - At least 2 claims at least one day apart with a diagnosis of diabetes in any position from an outpatient, observation, acute inpatient ED, or nonacute inpatient setting in the 2 years before the analysis date - At least 1 prescription claim for insulin or oral hypoglycemic medication dispensed in the 2 years before the analysis date o Exclude patients with claims for diabetes exclusions o Deviation from HEDIS specs: Added requirement to look for at least 2 diabetes diagnoses from an inpatient setting. Continuous member eligibility during the measurement year with maximum 1 gap of no more than 45 days. Member eligibility with no gaps on analysis date. 41