Educational Material for Providers

Tikka Attach

Horizon NJ Health?s
Behavioral Health Program

October 2018




1 Government Programs

Objectives

? Overview of Beacon Health
Options and Horizon NJ
Health?s Behavioral Health
Network


? Summary of MLTSS, DDD and
FIDE-SNP Plans


? Benefit Changes - New
Effective Date October 1, 2018





? Clinical Care Management and
Authorizations


? Contracting and Credentialing

? Claims

? Beacon?s On-Line Portal

? Contact Information



2 Government Programs

Overview of Beacon Health Options
and Horizon NJ Health

1/1/14

Beacon Health Options began
managing the behavioral health
benefits for members covered
by Horizon NJ Health and
enrolled in the Division of
Developmental Disabilities
(DDD).

7/1/14

Beacon Health Options began managing the behavioral health
benefits for members covered by Horizon NJ Health and enrolled
in Managed Long Term Services and Supports (MLTSS).

Beacon Health Options began
managing the behavioral health
benefits for members covered by
Horizon NJ Health and enrolled in
the Dual Eligible Special Needs Plan
(FIDE-SNP).

1/1/17



3 Government Programs

Overview of Beacon Health Options
and Horizon NJ Health

Among the services Beacon Health Options provides include:


? Manage the Horizon Behavioral Health Networks

? Perform Credentialing and Recredentialing

? Perform Clinical Care Management and Authorizations

? Handle Complaints and Appeals, Provider and Member

? Provide Enhanced Care and Case Management programs

? Provide Provider and Member Customer Services

? Quality Improvement



4 Government Programs

MLTSS, FIDE-SNP and DDD Plans







5 Government Programs

Medicaid Managed Long Term Services & Supports (MLTSS)

Managed Long Term Services & Supports (MLTSS) refers to the
delivery of long-term services and supports through New Jersey
Medicaid?s NJ FamilyCare program. MLTSS is designed to expand
home and community-based services, promote community inclusion
and ensure quality and efficiency.

Horizon NJ Health coordinates all services for MLTSS members. The
program provides comprehensive services and supports, whether at
home, in an assisted living facility, in community residential services,
or in a nursing home. Behavioral Health is managed by Beacon.



Currently Beacon manages the Mental Health and Opioid
Treatment Services for Horizon NJ Health.





6 Government Programs

Horizon NJ TotalCare (HMO SNP)
Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

The FIDE-SNP plan is known as Horizon NJ TotalCare (HMO SNP).

FIDE-SNP is a Medicare Advantage plan that integrates all covered Medicare and Medicaid
managed care benefits into one health plan, including primary care and preventive services,
behavioral health and long-term care. Members receive quality care designed to meet all of
their needs.

*Horizon NJ Health will continue to pay both the Medicare and Medicaid components of claims
for Horizon NJ TotalCare (HMO SNP) members, eliminating the need to file Medicare claims
separately; however, any other coverage available for a Horizon NJ TotalCare (HMO SNP)
member should be filed first with that insurance program.

The most important features of the plan are:

? A team of doctors, specialists, and Horizon Care Managers working together for the FIDE-
SNP member

? A Model of Care that calls for individual care plans for each member

? No copayments, premiums or deductibles for most covered services.


Currently, Beacon manages the outpatient and inpatient mental health services for
Horizon NJ Health.

.



7 Government Programs

Division of Developmental Disabilities


The Division of Developmental Disabilities (DDD) provides
public funding for services and supports that assist New Jersey
adults with intellectual and developmental disabilities age 21
and older to live as independently as possible.

Currently, Beacon manages the outpatient and inpatient
mental health services for Horizon NJ Health.










8 Government Programs

Benefit Changes

New Effective Date

October 1, 2018













9 Government Programs

Benefit Changes for 2018
Inpatient Admissions




Effective October 1, 2018, all admissions to a general acute care or free standing psychiatric hospital,
including admissions to a psychiatric unit, shall be the responsibility of Horizon NJ Health for ALL
Horizon NJ Health enrolled members.

These changes are not limited to MLTSS, FIDE-SNP and DDD members.

Managed care organizations are responsible for all acute psychiatric admissions to a general care,
stand-alone psychiatric or specialty care hospital. This includes admissions directly from a
certified screening center.

Acute care admissions are required for individuals presenting with unstable behavior requiring
immediate professional intervention to monitor and diagnose, adjust and stabilize medications
and develop a treatment plan beyond the acute episode of care.



Guidelines on Psychiatric Continued Stays and Admissions can be found on our website:

www.horizonnjhealth.com/for-providers/resources/clinical-and-preventive-guidelines-and-policies

www.beaconhealthoptions.com/providers/beacon/network/horizon-nj-health/







10 Government Programs

Benefit Changes for 2018
Substance Use Disorder Coverage





All Substance Use Disorder (SUD) services including, but not limited to,

? Inpatient Detoxification services ? ASAM 3.7D

? Outpatient SUD services ? ASAM 1.0

? Intensive Outpatient Services (IOP) ? ASAM 2.1

? SUD partial care ? ASAM 2.5

? SUD residential services ? ASAM 3.7

? Ambulatory Withdrawal Management (AWM) services ?

ASAM 2-WM

? Medication Assisted Treatment (MAT) ? ASAM 1.0

All of the services above will be the responsibility of the managed care
organization (MCO) for all beneficiaries enrolled in MLTSS, FIDE-SNP
and DDD.







11 Government Programs

Benefit Changes for 2018
Mental Health Coverage


Effective October 1, 2018, in order to align behavioral health benefit

coverage, all managed care plans will be providing the mental health
services currently covered under MLTSS to the beneficiaries
enrolled in MLTSS, FIDE-SNP and DDD.

These services include the following mental health services:

? Outpatient

? Partial Care

? Adult Mental Health Rehabilitation (Group Homes and
Apartments)

? Inpatient

? Partial Hospitalization









12 Government Programs

Benefit Changes for 2018
Mental Health Coverage


The following services are not included in the mental health

coverage benefits for 2018, and will remain Fee-for-Service:

? Targeted Case Management (TCM) including:

? Justice Involved Services (JIS)

? Children's System of Care (CSOC) Care Management Organizations
(CMOs)

? Integrated Case Management (ICMS)

? Projects for Assistance in Transition from Homelessness (PATH)

? Behavioral Health Homes (BHH)

? Programs in Assertive Community Treatment (PACT)

? Community Support Services (CSS)







13 Government Programs

Clinical Care Management

and Authorizations







14 Government Programs

Sample NJ FamilyCare Member ID Card

ID card will have the prefix YHZ in front of the ID number.

Confirm eligibility on a monthly basis as with any other member at
NaviNet.net or call Provider Services at 1-800-682-9091.



Members will not receive new member ID cards.



15 Government Programs

Sample MLTSS Member ID Card

ID card will have the prefix YHZ in front of the ID number.

Confirm eligibility on a monthly basis as with any other member

at NaviNet.net or call MLTSS Provider Services at 1-855-777-0123.


Members will not receive new member ID cards.






16 Government Programs

Sample FIDE-SNP Member ID Card

ID card will have the prefix YHZ in front of the ID number.

Confirm eligibility on a monthly basis as with any other member at
NaviNet.net or call Provider Services at 1-800-682-9091.


Members will not receive new member ID cards.



17 Government Programs

Authorizations

Members will not need a referral from their PCP to see a behavioral health
provider.

We encourage all providers to call us in advance of providing services to
confirm the member?s eligibility, the in-network status of the facility, and to
verify benefits.

For authorization requests and other related clinical questions, please call:

Authorizations and Care Management

1-800-682-9091 (24 hours a day/7 days a week) ? NJ FamilyCare

1-800-682-9091 (24 hours a day/7 days a week) ? DDD

1-855-777-0123 (24 hours a day/7 days a week) ? MLTSS

1-855-955-5590 (24 hours a day/7 days a week) ? FIDE-SNP









18 Government Programs

Authorizations - continued

All Horizon NJ Health behavioral health authorizations requests are communicated via telephonic review only
at this time. All calls will be recorded for quality assurance. Both the provider and the member will receive
written confirmation of an authorization.

Authorization is obtained by calling the number on the back of the member?s identification card. If the
member does not have an ID card, call 1- 800 - 682- 9091.

? For all but out-patient requests, you are asked to call Beacon within 24 hours of the admission with
the reason for the admission, diagnosis, medication, treatment plan, discharge plan and any other
pertinent information we need so medical necessity review can be completed.

Medical Services: All calls are received by Horizon NJ Health. Medical needs will be addressed at the initial
point of contact. Calls will then be directed to Beacon as needed for Behavioral Health service needs





19 Government Programs

Authorizations - continued

HNJH Emergent Behavioral Health Services: Inpatient Mental Health and Inpatient Detoxification
Services:


Authorization is available 24/7


HNHJ Non-Emergent Behavioral Health Services:
Authorization is available Monday-Friday, 8 am to 5 pm


Substance Use Services for individuals who are not Non-MLTSS, DDD and FIDE-SNP Members:
IME: 1-844-276-2777 (24 hours a day/7 days a week)


For any inpatient admission that occurred prior to 10/1/18 and was discharged after 10/1/18, the

State is responsible for paying the claim under FFS.





20 Government Programs

Authorizations - continued

Out Patient Services:

In-network providers - Authorization is not required for outpatient services as detailed
on slide 21, including Medication Assisted Treatment.

Out-of-network providers - All services require authorization and a single case
agreement. Criteria for single case agreement will be discussed during the review for
authorization.





21 Government Programs

Authorization Required ? Effective 10/1/18

Requires Authorization No Authorization Required

Inpatient Psychiatric Treatment In-network Outpatient psychotherapy

Partial Hospitalization In-network outpatient psychiatric/ Medication

Management

Partial Care Medication Assisted Treatment ? not including actual

medication

Adult Mental Health Rehabilitation (AMHR) Group

Homes and Apartments

In-network Outpatient treatment for substance use

disorders

Psychological Testing In-network outpatient psychiatric/ Medication

Management for substance use disorders

ECT

Trans Magnetic Stimulation

Short Term Residential Treatment (ASAM 3.7)

Ambulatory Withdrawal Management (ASAM 2-WM)

Medically Monitored Detox (SUD ASAM 3.7D)

IOP SUD (ASAM 2.1)

Partial SUD (ASAM 2.5)

All out of network providers will require an authorization

for any level of care including outpatient levels of care.



For a complete listing of services and associated codes, please visit our website:

www.beaconhealthoptions.com/providers/beacon/network/horizon-nj-health/



22 Government Programs

Clinical Appeals Process

Members and providers that are in-network are eligible for the initial Peer Advisor review
as well as a Level 1 appeal. This is applicable whether the request for an appeal is made
while the member remains in treatment or post-service. These appeals are delegated to
Beacon Health Options.

All out-of-network provider appeals are delegated to HNJH.

To appeal a Level 1 denial rendered by Beacon, the member/facility is entitled to an
external IURO appeal via DOBI and Fair Hearing by DMAHS.



23 Government Programs

Continuity of Care Process

For the first 30-days post-go-live, we will not require authorization for any services
rendered by an out-of-network provider.

During the initial 30-day period, our Clinical team is available to work with members to
help transition them to an in-network provider.

Requests to continue with an out-of-network provider after the initial 30 days will be
evaluated on a case-by-case basis to determine the most appropriate course of action.

After the initial 30-day period, all services rendered by an out-of-network provider will
require authorization and a single case agreement.







24 Government Programs

Clinical Care Management and Follow-up Care

? HEDIS Quality Measure - Follow-up After Hospitalization

? Requires member to be seen within 7 days of discharge, by
a qualifying behavioral health provider, from the inpatient
setting

? Collaboration between the inpatient facilities and Horizon NJ
Health?s Clinical Care Management team on the discharge
planning

? Clinical Care Management team can assist with
appointment and discharge barriers.







25 Government Programs

Contracting and

Credentialing





26 Government Programs


If you are already participating - A letter with an amendment to add these new
services to your existing contract was sent to you via email, fax or mail in April.

If you are currently non-par and would like to join the Horizon NJ Health
network, please call Beacon?s Provider Services Line at 1-800-397-1630 from 8
a.m. to 8 p.m., Monday through Friday. You will be advised on how to complete
provider agreement for each line of business.


The credentialing process can take up to 90 days after we have received a
complete application and signed agreements. However, if you were previously
treating a member prior to October 1, 2018 under the state program and you
have returned your signed agreement, you will be able to treat members for six
months while your credentialing application is in process.

Effective October 1, 2018, Horizon NJ Health is aligning its standard fee schedule
with the NJ Medicaid fee schedule for non-TotalCare members. Reimbursement
for TotalCare members will not be impacted by the October 1 changes.

Contracting for New Services




27 Government Programs

Claims



28 Government Programs

Claims

Horizon NJ Health retains ownership of claims processing and claims and payment
inquiries from providers and members.

? Horizon NJ Health encourages all hospitals, physicians, and health care
professionals to submit claims electronically. We utilize the TriZetto Provider
Solutions (TTPS) as the EDI vendor.

? For more information on registering, please go to
www.trizettoprovider.com/horizon/simpleclaim. If you have any further
questions about registering with TTPS for EDI claim submission, please call TriZetto
at 1-800-556-2231 or email ttpssupport@cognizant.com.

? Submit all electronic claims to the Horizon NJ Health EDI Payer Number 22326.

? You may also choose to contract with another EDI clearinghouse or vendor who
already has access to TriZetto EDI services.

? The other electronic way to submit claims is Direct Data Entry (DDE) through the
TTPS SimpleClaim system. For more information about SimpleClaim please use the
TTPS contacts above for additional information.






29 Government Programs

Claims

? All services rendered must be submitted on the CMS 1500 (HCFA 1500) version
02/12 or UB-04 claims form, or via electronic submission in a HIPAA-compliant
837 or NCPDP format.

? NPI numbers are required for all claims submissions.

? An authorization number must be included in box #23 on a CMS 1500 (HCFA 1500)
claim form or box #63 on a UB-04 form for all services which require an
authorization.

? Although a primary insurer may have unique coding specific to their business,
providers must bill with valid ICD-10-CM, CPT-4 and HCPCS codes. Unique or
invalid codes specific to other insurers will cause claim processing delays or
denials.

? Corrected claims must be billed with a frequency 7 or the third bill type code as 7
and the PCCN number must be included on the claim.

? All claims must include taxonomy codes. More information on taxonomy codes
can be found at https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/Taxonomy.html.















30 Government Programs

Claims
Billing Outpatient Clinic Services as a Ancillary Facility



If you are contracted and credentialed to provide Outpatient Clinic services as an
ancillary facility, please include only the facility NPI number.

Ancillary facilities who bill for Outpatient Clinic services on a HCFA 1500 should
bill either the billing entity?s NPI in field J (Rendering Provider ID) or leave the field
blank.

This applies to both outpatient mental health and substance use disorder clinic
services.

If you have additional questions regarding your contracting status, please call 1-
800-397-1630 or your assigned Contract Manager.



























31 Government Programs

Claims

? Horizon NJ Health will pay claims based only on eligible charges.
Unless the provider contract states otherwise, claims will be paid on
the lesser of billed charges or the contracted rate (Horizon NJ Health
fee schedule).

? Horizon NJ Health is the ?payor of last resort? on all claims submitted
for members of its health plan. Hospitals, physicians and health care
professionals must verify whether the member has Medicare
coverage or any other third party resources and, if so, provide
documentation that the claim was first processed by this other
insurer as appropriate. If the amount that Medicaid (HNJH
contracted rates) would pay is less than Medicare and/or the third
party payor, then the claim will pay at $0.



32 Government Programs

Claims

? Horizon NJ Health must receive all claims within 180 calendar days
from the initial date when services were rendered. If claims are not
received within 180 calendar days from the initial date of service,
claims will be denied for untimely filing. Coordination of benefits
claims must be received within 60 days from the date on the primary
Explanation of Benefit (EOB).

? EFT and Electronic Remittance Advice (ERA-835) is available via
Navinet.



33 Government Programs

In-Patient Administrative Days - Claims Submission



? Claims will be reimbursed according to the authorization.



? In order to properly capture the encounter for the
administrative rate (Rev 199) paid in acute care hospitals,
please bill type 11x for acute care hospitalizations for
these types of encounters.





34 Government Programs

HNJH Secondary Payment

? Except Medicare for Horizon NJ TotalCare (HMO SNP) members, all coordination
of benefit (COB) claims must be submitted with a copy of the EOB from the
primary insurer. Medicaid is the ?payor of last resort.?

? Paid primary claims can be submitted via EDI. Denied primary claims must be
submitted as paper claims.

? Secondary claims must be submitted to Horizon NJ Health within 60 days of the
date of the EOB or within 180 days of the date of service, whichever is later.

? Providers must bill with valid ICD-10-CM, CPT-4 and HCPCS codes. Unique or
invalid codes specific to other insurers will cause claim processing delays or
denials.

? For more detailed information, please refer to the current Horizon NJ Health
Provider Administrative Manual.













35 Government Programs

Paper Claims

While Horizon NJ Health strongly encourages submitting claims via EDI, if a paper
claim is necessary, please submit red and white paper claims only for all medical
services to Horizon NJ Health at the following address:

Horizon NJ Health
Claims Processing Department
PO Box 24078
Newark, NJ 07101-0406

Horizon NJ Health does not accept handwritten or black and white claims.

Effective 1/1/18, Horizon NJ Health will only accept paper claims on an exception
basis. If you are unable to submit claims electronically, please contact Provider
Services at 1-800-682-9091.



36 Government Programs

Administrative Claim Appeals

All claim appeals must be submitted within 90 calendar days from the date of the
finalized claim (date of the Horizon NJ Health explanation of benefits) and initiated
on the applicable appeal application from created by the Department of Banking and
Insurance.

Claim Appeal Department
PO Box 63000
Newark, New Jersey 07101

or
Fax to: 1-973-522-4678


For more information on claim appeals and to access the appeal application form,
please visit www.horizonnjhealth.com/securecms-documents/131/Instructions-
for-Application-to-Appeal-a-Claims-Determination.pdf



37 Government Programs

Required Fields for CMS 1500 and

UB-04 Claim Forms

Information on submitting a complete CMS 1500 form can be found in
the Provider Manual on the Horizon NJ Health website under Section
9.2.1.

Information on submitting a complete UB-04 form can be found in the
Provider Manual on the Horizon NJ Health website under Section 9.2.2

www.horizonNJhealth.com/securecms-
documents/605/provider_manual.pdf






38 Government Programs

How to Check Claim Status

Online

? NaviNet.net

? Access Horizon NJ Health within the Plan Central drop-down menu

? Click Claim Management, then Claim Status Inquiry



For more information about billing and filing claims, please see
Section 9 of the Horizon NJ Health Provider Manual, available on
www.horizonNJhealth.com.









39 Government Programs

Beacon Health Options?
OnLine Portal

Provider Connect



40 Government Programs

Updating Provider Information

It is provider?s responsibility to submit updates to practice location(s), billing
information, telephone/fax numbers, hours of availability and any other
demographic changes.


Updating of provider information is available through Beacon Health Options? on-
line portal called ProviderConnect.


To learn more, call Beacon Health Options? Provider Services Line at
1-800-397-1630 (8 a.m. ? 8 p.m., EST, Monday through Friday)

or visit

Free demonstration:

www.beaconhealthoptions.com/Providers/Beacon/ProviderConnect

Click on Access the Provider Connect Demo








41 Government Programs

Contact Information



42 Government Programs

Provider Contacts

Beacon Provider Relations, Credentialing and Contracting Questions:

Provider Services Line:
1-800-397-1630 (8 a.m. - 8 p.m. ? Monday to Friday)

Email:
horizonbehavioralhealthproviderrelations@beaconhealthoptions.com



Authorizations and Care Management

1-800-682-9091 (24 hours a day/7 days a week) ? NJ FamilyCare

1-800-682-9091 (24 hours a day/7 days a week) ? DDD

1-855-777-0123 (24 hours a day/7 days a week) ? MLTSS

1-855-955-5590 (24 hours a day/7 days a week) ? FIDE-SNP







43 Government Programs

Provider Contacts

Horizon NJ Health Physician & Health Care Hotline
1-800-682-9091 (8 a.m. - 5 p.m., ET - Monday through Friday)


Navinet
www.Navinet.net or call Provider Services at 1-800-682-9091


TriZetto EDI Services and Simple Claim inquires
1-800-556-2231



Horizon NJ Health?s Website
www.horizonNJhealth.com


Horizon NJ Health?s Provider Manual
www.horizonnjhealth.com/securecms-documents/605/Provider_Manual.pdf



Horizon NJ Health?s Provider Specific Website
https://www.beaconhealthoptions.com/providers/beacon/network/horizon-nj-health/
Scroll to the section called ?NJ State Medicaid Behavioral Health Changes ? October 1, 2018? for helpful reference

information.



















44 Government Programs

Provider Contacts

Claims Submission/ Address

Reference the address on the member?s identification card, as the address may vary
based on payment location.

Member Benefits, Eligibility, and Authorizations

If you have a question about authorization or benefits, call the (800) number on the
back of the member?s identification card.

Member Customer Service

To reach Member Services, call the phone number on the back of the member?s
identification card.

If the member does not have an ID card, call 1-800-682-9091.








45 Government Programs

Questions?






Questions and answers: Contracting Initiative


Products are provided by Horizon NJ Health. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity
as administrator of programs and provider relations for all its companies. Both are independent licensees of the Blue Cross and Blue
Shield Association. The Blue Cross? and Blue Shield? names and symbols are registered marks of the Blue Cross and Blue Shield
Association. The Horizon? name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. ? 2019 Horizon
Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105. EC003660 (0619)

Below are answers to questions you may have about signing Horizon NJ Health?s provider
agreement.

Q1. Why do I need to sign this contract?

A1. All of Horizon NJ Health?s participating providers must have a dually executed contract to
protect the interest and establish the expectations of mutual agreement between parties.

Q2. What do I need to do?

A2. Sign the attached agreement and return the contract to Horizon NJ Health by June 28, 2019.

Q3. How will this impact my payments/rates?

A3. This is a seamless process that will not impact your current payments/rates. However, if the
contract is not signed and returned by June 28, 2019, it will lead to termination from the
Horizon NJ Health network.

Q4. When will the agreement become effective?

A4. The agreement will be effective the first of the month after it is received and dually executed.

Q5. Who can I contact if I have questions?

A5. Please forward any additional questions to Provider_Relations@horizonNJhealth.com with
the subject Contracting Initiative.

For Ancillary ? Lori Bembry 1-609-537-2427 or Lori_Bembry@horizonNJhealth.com

For Physician ? Tara Black-Jones 1-609-537-2636 or Tara_Black-Jones@horizonNJhealth.com

Q6. What will happen if I do not return this contract?

A6. Failure to return your contract will result in your termination as a Horizon NJ Health provider.

Q7. Can I return it by email or fax?

A7. You can email your contract to Provider_Relations@horizonNJhealth.com with the subject
Contracting Initiative or fax your contract to 1-609-583-3004, attention Tara Black-Jones - PC&S
Contracting.

Q8. What products are covered under this contract?

A8. Horizon NJ Health products are covered, including Horizon NJ Total Care (HMO SNP) and
Medicaid.



Proprietary & Confidential

Changes to the Management of the Horizon
Behavioral Health Program

December 2019



Proprietary & Confidential 2

Overview

? Beginning on or about January 1, 2020, Horizon BCBSNJ will transition
the administration and clinical management of behavioral health services from
Beacon Health Options (formerly ValueOptions) to our internal operations for all
Horizon BCBSNJ plans that offer behavioral health benefits through the
Horizon Behavioral Health? program.

? The complete transition to Horizon BCBSNJ?s internal management will occur in
a phased approach based on line of business.

? The following are the target effective dates:
? January 1, 2020: Horizon Medicare Advantage and Horizon NJ Health Plans,

including Division of Developmental Disabilities (DDD), NJ FamilyCare and
Managed Long Term Services & Supports (MLTSS), and Horizon NJ TotalCare
(HMO D-SNP)

? April 1, 2020: Horizon BCBSNJ fully insured plans/products, self-insured
(Administrative Services Only [ASO]) employer group plans including the State
Health Benefits Program (SHBP) and the School Employees? Health Benefits
Program (SEHBP) and the Federal Employee Program? (FEP?)



Proprietary & Confidential 3

? Current Horizon Behavioral Health provider contracts will not be impacted
by the change in the management of behavioral health benefits.

? Horizon BCBSNJ remains committed to working with health care
professionals throughout the state to improve the patient experience and
lower the total cost of care

? Horizon BCBSNJ will also be looking for ways to build on the current level
of support services and programs offered through the existing
Horizon Behavioral Health Program.

Important Changes: Key Points



Proprietary & Confidential

What Will Insourcing Achieve?

Horizon BCBSNJ?s insourced behavioral health management model will:

Promote clinical integration between physical and mental health

Improve health care affordability through greater operational efficiencies
and cost trend mitigation

Increase member and provider satisfaction through a seamless experience
and expansion of access and availability of services

Promote behavioral health expertise and increased knowledge base across
all functional areas

4



Proprietary & Confidential 5

Important Changes: Key Dates

Policy/Process Change

Horizon
NJHealth &
Medicare
Advantage

Horizon
BCBSNJ fully
insured
plans/products

Recredentaling
Horizon BCBSNJ manages the recredentialing for all providers who are due to be recredentialed on and
after January 1, 2020.

7/1/19 7/1/19

Credentialing & Demographic Updates
Horizon BCBSNJ manages the initialing credentialing of non-participating Behavioral Health professionals and
ancillary providers who are seeking to join one of our network(s) and provider file changes.

10/1/19 10/1/19

Medical Necessity Criteria
Clinical care guidelines from MCG Health, LLC (MCG) will be used to make behavioral health care utilization
management determinations. The American Society of Addiction Medicine (ASAM) criteria Substance Use Disorder
determinations.

12/30/19 3/30/20

Prior Authorization
Requests and status via NaviNet, our Online Utilization Management Tool will only online option ? Beacon?s
ProviderConnect system no longer an online source.

1/1/20 4/1/20

Transition of all Network Management Functions
Horizon BCBSNJ manages all Network relationship management., i.e. education

1/1/20 1/1/20

Verifying Member Eligibility & Benefits
Online via NaviNet or phone ? Beacon?s ProviderConnect system no longer active

1/1/20 4/1/20

Doctor Hospital Finder
Enhanced behavioral health search capabilities . (Digital enhancements will continue through Q1 2020).

11/1/19 11/1/19



Horizon NJ Health and Horizon NJ
TotalCare (HMO D-SNP) Plans

6



Horizon NJ Health Behavioral Health
Overview

7

Horizon NJ Health is responsible for managing the behavioral health benefits for
members of our Developmental Disabilities (DDD), Managed Long Term Services
& Supports (MLTSS) and FIDE-SNP programs.

Horizon NJ Health is also responsible for managing the acute inpatient mental
health benefits for all of our Medicaid members, while the State manages the
non-acute behavioral health benefits through the NJ Medicaid Fee-for-Service
program.

Horizon NJ Health PCPs refer non-DDD, non-MLTSS and non-FIDE-SNP
members to a NJ Medicaid Fee-for-Service behavioral health professional.
Horizon NJ Health provides behavioral health benefits to Horizon NJ Health
members through the Horizon Behavioral Health Network.

Horizon NJ Health?s Care Management Department can coordinate the behavioral
health services for DDD, MLTSS and FIDE-SNP members with the PCP,
Horizon Behavioral Health and its professional network.



Proprietary & Confidential 8

Horizon NJ Health has adopted the following appointment scheduling standards
to ensure timely access to quality medical care. Compliance with these
standards will be audited by periodic on-site reviews and chart sampling

For Mental Health/Substance Use Disorder Appointments (Clients of the Division
of Developmental Disabilities, MLTSS and FIDE-SNP only):

? Emergency services- Immediate care
? Urgent care appointments within twenty-four (24) hours.
? Routine care appointments within ten (10) days of request.
? Waiting time in office: less than 45 minutes

Behavioral Health Appointment Scheduling
Standards



Proprietary & Confidential 9

Members will not need a referral from their PCP to see a behavioral health provider.


? Provider who use NaviNet can access the Utilization Management Request Tool to
submit authorization requests easily and securely. This tool allows providers to
communicate directly with Horizon NJ Health by checking the statuses of all requests in
real time. It also sends providers notification when requests are completed. The main
features in the tool include authorizations requests viewing status of authorization
requests. It can also be used for authorizations for home care, DME purchase /rental,
surgical procedures and inpatients admission.


? Providers can access Utilization Pre-authorization management tool through NaviNet.
Simply select Horizon NJ Health from the Plan Central page; mouse over Referrals
and Authorization on the left-hand navigation; then select Utilization Management
requests


? You may also reach out to our Utilization Management Department at 1-800-682-9094
for precertification request at least five business days before rendering services for
routine services









Procedural Standards: Prior Authorization



Proprietary & Confidential 10

Procedural Standards: Behavioral Health Prior
Authorization

List
Requires Authorization No Authorization Required

Inpatient Psychiatric Treatment In-network Outpatient psychotherapy
Residential Mental Health In-network outpatient psychiatric/ Medication Management

Partial Hospitalization Medication Assisted Treatment ? not including actual medication
Partial Care In-network Outpatient treatment for substance use disorders
Intensive Outpatient (IOP) In-network outpatient psychiatric/ Medication Management for

substance use disorders
Adult Mental Health Rehabilitation (AMHR) Group
Homes and Apartments

Psychological Testing
Repetitive Transcranial Magnetic Stimulation (RTMS)
ECT
Medically Managed Detox (ASAM 4.0)

Medically Monitored Detox (SUD ASAM 3.7D)

Inpatient SUD Rehab (ASAM 3.7)

Residential SUD (ASAM 3.5))

Partial SUD (ASAM 2.5)

IOP SUD (ASAM 2.1)

All out of network providers will require an authorization
for any level of care including outpatient levels of care.

Verify benefits prior to requesting Prior Authorization, not all products will have all levels of care. Core Medicaid only has IP Mental Health &
Detox level of care.



Proprietary & Confidential 11

Updating Your Demographic Information

? Use CAQH ProviewTM

? Or email Demographic Update requests to EnterprisePDM@horizonblue.com
? Submit requests & supporting documentation at least 30 days before the effective date of the

change.
? Always include the submitter?s name, email & telephone # with all email requests.
? EnterprisePDM@horizonblue.com is not managed by a representative who reads & responds

immediately to your emails. Emails received are converted to Service Requests which are then
addressed offline by our Provider team.

? Submit ONLY demographic Updates to this email address.
DO NOT email initial credentialing submissions, claims, questions, etc

? To help ensure that you are getting these responses (and that they are not flagged as spam),
please add EnterprisePDM@HorizonBlue.com to your list of safe or approved
senders/contacts. This will keep emails from us out of your junk/spam folder.

? Ancillary Providers should submit the following through your Ancillary Contracting Specialist:
? Provider File Change Requests
? Tax Identification Number (TIN) Changes






Proprietary & Confidential

Access our Doctor & Hospital Finder
on Horizonnjhealth.com by clicking

the Find a Doctor link

Confirming Demographic Information

12



Proprietary & Confidential

Search Options

Proprietary & Confidential

Use the search boxes to locate participating providers.

Search Options

13



Proprietary & Confidential 14

How to Update Your Information

Type of Request Documentation Required Comments
Relocation or Add New Location 1) Communication from provider

2) List of providers
3) W-9
4) ADA Survey

Specify whether you are closing an existing office and/or adding
an additional location

Add Provider to New Location/Group 1) Communication from provider
2) List of location(s)
3) W-9
4) ADA Survey for new location

Close or Open Panel 1) Communication from provider There is a 90-day waiting period, per policy. Provider must have
at least 50 members. We do not close panels for specialists.

Update Other Demographics (hours, phone, fax,
suite, languages, age limits, panel limit)

1) Communication from provider

TIN Change or Purchase of Another Entity 1) Communication from provider
2) W-9
3) List of providers

Note whether you are assuming liability of prior TIN

Billing and Remittance Change 1) Communication from provider
2) W-9

Be sure the billing address is not a P.O. box; must be a physical
location

Term from Location/Group 1) Communication from provider Advise where paneled members should be moved/transferred, if
applicable (for PCP's only)

This information can also be viewed at: horizonNJhealth.com/demographicupdates



Proprietary & Confidential 15

Credentialing

? As of October 1, 2019, Horizon BCBSNJ is managing the initial credentialing of
nonparticipating behavioral health professionals and ancillary providers who are seeking
to join one of our network(s).

? Beacon Health Options no longer performs these processes but will continue to manage
all changes and applications submitted prior to October 1, 2019

? Please visit https://www.horizonnjhealth.com/for-providers/provider-recruitment
for more information and Horizon NJ Health Applications.

- Physician Agreements are accessible via NaviNet?s Horizon BCBSNJ
plan central page. If you don?t have access to this page, email
EnterprisePDM@horizonblue.com to request a Physician Agreement.

? A complete application can take between 45 to 90 days from date of receipt at
Horizon BCBSNJ for all applicable documentation that is submitted correctly





22

? Doctor Attribute Icons

Proprietary & Confidential

Self Service Tools

? www.horizonnjhealth.com under the menu option
? Providers

?Access to our Provider Manual
?Frequently used forms and guides
?Horizon Behavioral Health dedicated landing page

? Navinet

? Online Utilization Management Request Tool (via Navinet)
? Request prior authorizations
? Check status of authorizations




Horizonnjhealth.com: Reference Material Page
options

23 Proprietary & Confidential



Dedicated Behavioral Health Landing Page

24 Proprietary & Confidential

Horizonnjhealth.com/providerbh



25

NaviNet

Proprietary & Confidential

NaviNet is a single sign on, multi-payer tool, that allows self-service options to both
in-network and out-of-network offices.

NaviNet Features:
? Claim Status
? Provider Directory
? Member Eligibility and Benefit
? Financial Reports
? Electronic Referral Submission and Inquiry
? Utilization Management Requests
? Clinical Reports
? Administrative Reports

To learn more about NaviNet, visit NaviNet.net.
? To access a NaviNet Information Demo, select Provider Reference Materials and

mouse over Resources.
? Select Training, then Education
? Select NaviNet Information Demo

All participating physicians and health care professionals are required to register for NaviNet



NaviNet Support

20



Required Information The following information is required to aid in further investigation:
? NaviNet Username
? TIN
? NPI
? Contact information
? Steps to replicate (screenshots of issue).

For error messages, please send a screenshot of error message with
date and time error occurred.

Required Information

21



22

Horizon?s participating providers are assigned to a Network
Specialist based on their county. Your Network Specialist is
available via phone or email and is your primary point of contact
for the following areas:

? General Education
? Requests for a Site/Education Visit
? Fee schedule requests
? Copies of Contracts

Please continue to contact Customer Service for all claims related
concerns.

Network Management



Behavioral Health Provider Relations:
Horizon NJ Health

23

Dottie Laisi
LaTanya
McLean Barkley Michelle McCusker Olivia Inniss

Atlantic Hunterdon Burlington Bergen

Cape May Mercer Camden Essex

Cumberland Morris Middlesex Hudson

Gloucester Somerset Salem Passaic

Monmouth Sussex

Ocean Union

Warren

856-638-3215 856-638-3228 856-638-3223 973-466-4609

Dorothy_Laisi@horizonblue.
com

LaTanya_Barkley@horizonblue.
com

Michelle_McCusker@horizonblue.
com Olivia_Inniss@horizonblue.com

BEHAVIORAL HEALTH ANCILLARY TEAM SPECIALTY ASSIGNMENT

Andrew Alleman
Andrew_Alleman@horizonblue.com
973-466-6824



24

Important Phone Numbers



How Do I Stay Informed?

? To check the status of the transition or for frequently asked questions, please
refer to:

? HorizonNJhealth.com/providernews

25



Thank you for your time today

BHNetworkrelations@horizonblue.com

Q & A

26





Appendix

27



28

There are several ways to determine a member?s eligibility for benefits:
? Check on NaviNet, our online provider center at NaviNet.net.
? Call Horizon NJ Health Provider Services at 1-800-682-9091.

Representatives are available Monday-Friday, 8 a.m. to 5 p.m.

Please note: Presentation of a member ID card is not a guarantee of member
eligibility.

Always confirm enrollment before providing services.

Member Eligibility



29

Member Eligibility: Tips!



30

Sample NJ FamilyCare Member ID Card

Confirm eligibility at NaviNet.net or call Provider Services at
1-800-682-9091.





31

Sample MLTSS Member ID Card

Confirm eligibility at NaviNet.net or call MLTSS Provider Services at
1-855-777-0123.



32

Sample FIDE-SNP Member ID Card

Confirm eligibility at NaviNet.net or call MLTSS Provider Services at
1-800-682-9091.



33

Hospitals, physicians and health care professionals submitting claims electronically should
make sure the referral number is present on the claim.

If you are a hospital, physician or health care professional interested in submitting claims
electronically to Horizon NJ Health but do not have TriZetto EDI services, contact TriZetto
at 1-800-556-2231

You may also choose to contract with another EDI clearinghouse or vendor who already
has access to TriZetto EDI services

EDI Technical Support Team is available during regular business hours, 8 a.m. through 5
p.m., Monday through Friday. It can be reached at 1-800-556-2231

Electronic Claim Submission



34

We encourage all Horizon NJ Health providers who have not yet begun to receive their payments
using Electronic Funds Transfer (EFT) to sign up.

Advantages:
? With EFT, your reimbursement cycle will be accelerated, since providers can receive EFT

payments more quickly than check payments sent through the mail.

? Payments can be distributed more securely by virtually eliminating check payments lost in
the mail, and this can help increase cash flow. In most situations, funds are available on the
date the payment is credited to the provider's bank account

How to sign up:
? Dial 1-866-506-2830, option 1 for more information
? Email or visit the Horizon NJ Heath online to sign up:

? Email: eftenrollment@changehealthcare.com
? Link for form: http://www.horizonnjhealth.com/for-

providers/resources/forms/emdeon-electronic-funds-transfer-forms

EFT Enrollment ? Electronic Fund Transfer















35

Claim inquiries must first be directed to Provider Services at 1-800-682-9091

Provider Correspondence Unit:

For more complex problems such as inquiries on 10 or more claims, providers must
complete a spreadsheet with the following data elements:

? Member Name
? Member ID Number
? Claim Number
? Date of Service
? CPT Codes
? Specific nature of inquiry
? Total billed charges


Send these inquiries to: Provider Correspondence, PO Box 24077, Newark, NJ 07101-
0406. We can only accept inquiries for claims in dispute when all of the above elements
are included. Other inquiries will be returned.





Handling Claim Disputes



36

Claim Appeals
? When a physician, facility or health care professional is dissatisfied with a claim payment, including

determinations, prompt payment or no payment made by Horizon NJ Health, he/she may file a claim
appeal, as described herein.

? All claim appeals must be initiated on the applicable appeal application form created by the Department
of Banking and Insurance.

? The appeal must be received by Horizon NJ Health within 90 calendar days following receipt by the
physician, facility or health care professional of the payer?s claim determination.

? To file a claim appeal, a physician or health care professional must send the appeal application form,
which is available at horizonNJhealth.com/for-providers, and any supporting documentation to Horizon NJ
Health using one of the following methods: submission is considered to be correct

? Fax: 973-522-4678 /: Mail: Horizon NJ Health, Claim Appeal, P.O. Box 63000, Newark, NJ 07101-8064
? IMPORTANT ? Please do not send medical records with administrative claim appeals. Supporting

documentation, e.g., proof of timely filing, may be submitted. Please follow all appropriate procedures as
defined in this manual before submitting an appeal.

? Status of Appeal is available via Navinet (Report Functions)


*Please note: Corrected claims should be sent to Horizon NJ Health, Claims Processing Department, PO Box
24078, Newark, NJ 07101-0406. These claims should not be submitted through the appeals process, unless
the original submission is considered to be correct






Handling Claim Disputes/Appeals


Slide Number 1
Slide Number 2
Slide Number 3
What Will Insourcing Achieve?
Slide Number 5
Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) Plans
Horizon NJ Health Behavioral Health Overview
Slide Number 8
Slide Number 9
Slide Number 10
Slide Number 11
Slide Number 12
Slide Number 13
Slide Number 14
Slide Number 15
Slide Number 16
Slide Number 17
Slide Number 18
Slide Number 19
NaviNet Support
Slide Number 21
Slide Number 22
Behavioral Health Provider Relations:?Horizon NJ Health
Slide Number 24
How Do I Stay Informed?
Q & A
Appendix
Slide Number 28
Slide Number 29
Slide Number 30
Slide Number 31
Slide Number 32
Slide Number 33
Slide Number 34
Slide Number 35
Slide Number 36




This Document is Proprietary and Confidential

Do Not Print or Distribute Without Permission

Horizon NJ TotalCare (HMO D-SNP) Model of Care

Training 2021

Effective January 2021



1Proprietary and Confidential Government Programs

Objectives

? At the end of this training, the participant will be able to:

? Define the components of a Dual Special Needs Plan (DSNP)

? Understand what a Fully Integrated Dual Special Needs Plan
means

? Identify the changes to benefits for TotalCare in 2021

? Define the goals of the Horizon NJ TotalCare Model of Care (MOC)

? Identify the elements in the MOC program

? Understand the different roles of the DSNP Team members

? Understand the purpose of the Interdisciplinary Care Team

? Identify the methods by which the MOC is evaluated for
effectiveness



This Document is Proprietary and Confidential

Do Not Print or Distribute Without Permission

Horizon NJ TotalCare (HMO D-SNP)



3Proprietary and Confidential Government Programs

DSNP stands for Dual Special Needs Plan. A DSNP is a special kind of

Medicare Advantage plan that integrates all covered Medicare and Medicaid

managed care benefits into one health plan.

DSNP features:

? A Model Of Care that calls for individual care plans for members

? General Goals that are member centric

? SMART Goals (Specific, Measurable, Attainable, Relevant, Timely)

? A team of doctors, specialists and Care Managers working together for
the DSNP member

? The same member rights available to Medicare and Medicaid recipients

? Zero dollar cost sharing: no copayments, premiums or deductibles

What is DSNP?



4Proprietary and Confidential Government Programs

? FIDE SNP stands for Fully Integrated Dual Eligible Special Needs Plan.

? A FIDE SNP is a special kind of Medicare Advantage plan that integrates
all covered Medicare and Medicaid managed care benefits into one

health plan

FIDE SNPs will:

? Provide dually-eligible beneficiaries access to Medicare and Medicaid
benefits under a single managed care organization

? Have a CMS approved contract with a State Medicaid Agency that
includes coverage of specified primary, acute, and long-term care

benefits and services, consistent with State policy

What is FIDE SNP?



5Proprietary and Confidential Government Programs

2021 DSNP benefits include:

? Extra benefits for 2021:

? Over The Counter (OTC) Benefits:

? OTC Benefit Catalog - $250 per quarter for over the counter
(OTC) personal health items that can be ordered via paper / mail

or online catalog. Up to $1,000 annually.

? OTC Benefit Card - $375 per quarter for over the counter (OTC)
personal health items that can be purchased in store at

participating retailers like; Walgreens, Dollar General, Rite Aid,

Walmart, CVS. Or online at NationsOTC.com for home delivery.

This benefit can total up to $1,500 annually

? New for 2021 - Healthy Food purchases using the OTC Benefit
Card. Eligibility criteria required.

Product and Benefit Information



6Proprietary and Confidential Government Programs

2021 DSNP benefits include:

? Over The Counter (OTC) Benefits: Continued

? New for 2021 - Healthy Food purchases using the OTC Benefit
Card. For those members that qualify their OTC Benefit Card

will be enhanced to include food and produce as eligible items.

In order to qualify they must meet the following criteria:

? have been diagnosed with one or more certain chronic
conditions,

? have a higher risk to be in the hospital and

? participate in the Horizon NJ Health Care Management
Program.

? See listing of qualifying chronic conditions on next slide

Product and Benefit Information



7Proprietary and Confidential Government Programs

2021 DSNP benefits include:

? Over The Counter (OTC) Benefits: Continued

? New for 2021 - Healthy Food purchases using the OTC Benefit Card. Chronic
conditions

Product and Benefit Information

1. Chronic alcohol and other drug dependence;

2. Autoimmune disorders limited to: Polyarteritis nodosa, Polymyalgia rheumatica, Polymyositis,

Rheumatoid arthritis, and Systemic lupus erythematosus;

3. Cancer, excluding pre-cancer conditions or in-situ status;
4. Cardiovascular disorders limited to: Cardiac arrhythmias, Coronary artery disease, Peripheral vascular

disease, and Chronic venous thromboembolic disorder;

5. Chronic heart failure;

6. Dementia;
7. Diabetes mellitus;

8. End-stage liver disease;
9. End-stage renal disease (ESRD) requiring dialysis;
10. Severe hematologic disorders limited to: Aplastic anemia, Hemophilia, Immune thrombocytopenic

purpura, Myelodysplatic syndrome, Sickle-cell disease (excluding sickle-cell trait), and Chronic
venous thromboembolic disorder;

11. HIV/AIDS;
12. Chronic lung disorders limited to: Asthma, Chronic bronchitis, Emphysema, Pulmonary fibrosis, and

Pulmonary hypertension;
13. Chronic and disabling mental health conditions limited to: Bipolar disorders, Major depressive

disorders, Paranoid disorder, Schizophrenia, and Schizoaffective disorder;

14. Neurologic disorders limited to: Amyotrophic lateral sclerosis (ALS), Epilepsy, Extensive paralysis
(i.e., hemiplegia, quadriplegia, paraplegia, monoplegia), Huntington?s disease, Multiple sclerosis,
Parkinson?s disease, Polyneuropathy, Spinal stenosis, and Stroke-related neurologic deficit; and

15. Stroke.



8Proprietary and Confidential Government Programs

2021 DSNP benefits include:

? Home delivered meals after an acute inpatient
hospital stay for those members who qualify

? 14 meals for 1 week or 28 meals for 2 weeks

? Eligibility requirements must be met

? Limit 1 episode of meal delivery per year

Product and Benefit Information



9Proprietary and Confidential Government Programs

2021 DSNP benefits include:

? Medicare Part A and B services

? Medicare Part D plus Medicaid covered drugs

? Medicaid Services

? Behavioral Health and Substance Use Treatments

? Telemedicine for:

? Physical Health

? Behavioral Health

Product and Benefit Information



10Proprietary and Confidential Government Programs

2021 DSNP benefits include:

? 24/7 Nurse Line

? Silver & Fit Healthy Aging and Exercise Program

? Worldwide emergency/urgent care ($60,000 cap)

? Routine podiatry care up to 8 visits

? No referrals required

? Routine dental and vision benefits

Product and Benefit Information



11Proprietary and Confidential Government Programs

11

New or Changed Benefit/Cost

Share
2020 Benefit 2021 Benefit

OTC Benefit Card $300 per quarter $375 per quarter

OTC Benefit Card
Dollars used only to purchase

personal health items

Dollars can be also used to purchase

healthy foods from current retailors (for

eligible members)

OTC Benefit Card
OTC card used to purchase

personal care items onsite at

approved retailers

OTC card can also be used to order items

by phone or online through mail order

partner NationsOTC

Meal Benefit N/A Available following an acute inpatient stay

Fitness Benefit FitnessCoach Silver&Fit? (change in Program)

Telemedicine Medical Services only
Behavioral Health Services in addition to

Medical

Opioid Treatment Services Prior authorization required Prior authorization not required

Overall 2021 Changes to Horizon NJ TotalCare (HMO D-SNP) Benefits and Cost Share
Product and Benefit Information

DSNP benefits: 2020 vs. 2021



12Proprietary and Confidential Government Programs

12

2021 Medicaid Wrap and OTC Benefit Comparison

Features/Process Medicaid Wrap* OTC Catalog OTC Benefit Card

Total Annual

Benefit Unlimited $1,000 $1,500

$$ Limit Per

Quarter Not Applicable $250 $375

Unused amount

rolls to next
quarter?

Not Applicable No No

Prescription

Required? Yes No No

How are OTC

medications and
supplies obtained? Take prescriptionto a

participating Provider
(i.e. CVS Pharmacy)

? Member orders
online or by phone

? Order shipped to their
home in 7-10 days

? Member uses Benefit
card to purchase
OTC items directly

from designated
retailers or Nations

OTC

* Medicaid Wrap - Unlimited supplemental Wrap benefit covering many medications and supplies, including over the counter vitamins that are
not covered by Part D Medicare, that members can obtain with a prescription (in addition to drugs already covered under their prescription benefit)



13Proprietary and Confidential Government Programs

Horizon NJ TotalCare (HMO D-SNP) Service Area 2021

Service Area

1. Atlantic

2. Cumberland

3. Essex

4. Gloucester

5. Hudson

6. Hunterdon

7. Mercer

8. Monmouth

9. Morris

10. Passaic

11. Salem

12. Somerset

13. Sussex

14. Union

15. Warren

16. Bergen

17. Middlesex

18. Ocean

19. Burlington

20. Camden

21. Cape May

CMS
Contract # Individual/Group Product Type PBP Service Area

H-8298 Individual SNP 001 21Counties



14Proprietary and Confidential Government Programs

Horizon NJ TotalCare (HMO D-SNP)

Definition of deemed

? A dual-eligible enrollee of a DSNP
may become ineligible for the plan

due to the loss of his/her Medicaid

eligibility for a period of time that

may be one or more months in

duration

? Horizon NJ TotalCare (HMO SNP)
deeming period is 2 calendar

months/60 days

Deemed
/demed/

1. Period of time

in which a member

may lose Medicaid

benefits

-



15Proprietary and Confidential Government Programs

Special Enrollment Period Changes

Continued in 2021
Dual Eligible members can

enroll/dis-enroll quarterly,
instead of monthly

? Members can enroll or dis-enroll
from an MA plan once per calendar

quarter during the first 9 months of

the year.

Dual SEP
Time Periods

January ? March

April ? June

July - September

? Example; if an election is made in March and
effective in April, the 1st quarter use of the SEP

would be considered ?used?, not the 2nd

quarter. Once the SEP is used in a given

quarter the member will need to wait to the

next quarter or qualify for another type of SEP.



This Document is Proprietary and Confidential

Do Not Print or Distribute Without Permission

What is a Model of Care?



17Proprietary and Confidential Government Programs

Horizon NJ TotalCare (HMO D-SNP)

Model Of Care (MOC) overview

? CMS requires that all Special Needs Plans (SNP) have an MOC

? The projected membership is to grow to 17,000 members by the end of 2021

? The MOC goals include:

? Care coordination and care management for all DSNP members enrolled in the
plan

? An individualized care plan (ICP) based on member assessment and member
feedback

? An interdisciplinary care team (IDT) that reviews the member?s plan of care and
provides input in a collaborative way



18Proprietary and Confidential Government Programs

Goals of Horizon NJ TotalCare (HMO D-SNP)

? Efficiently coordinate the care members receive

? Improve members? experience with care

? Improve members? health outcomes

? Improve quality

? Keep members in the community

? Reduce unnecessary costs

Horizon NJ TotalCare (HMO D-SNP)

Enhancing

member experience

Improving

health outcomes

Lowering costs



This Document is Proprietary and Confidential

Do Not Print or Distribute Without Permission

Elements of the Model of Care



20Proprietary and Confidential Government Programs

Horizon NJ TotalCare (HMO D-SNP)

Medical

Director

Behavioral

Health Care

Manager

Horizon NJ TotalCare (HMO D-SNP)

Care Management Team

SNP

Director

Care

Manager

SNP

Manager

Clinical Care

Coordinator

SNP

Supervisor

SNP

Operations



This Document is Proprietary and Confidential

Do Not Print or Distribute Without Permission

Roles and Responsibilities



22Proprietary and Confidential Government Programs

Role of the Care Coordinator

? Call member to complete the Confirmation/Welcome Call

? Review the Horizon NJ TotalCare (HMO D-SNP) benefits with the
member

? Perform annual reassessment and management for Level 1 SNP
Members

? Provide education and ongoing support to the member as needed

Horizon NJ TotalCare (HMO D-SNP)



23Proprietary and Confidential Government Programs

Role of the Care Manager

? Address barriers to care

? Advocate for the member

? Arrange for homecare, therapies and evaluation

? Conduct face-to-face visits as indicated

? Contact member and PCP and/or specialist on a regular basis as needed

? Coordinate behavioral health

? Coordinate with community resources/agencies

? Guide, direct and educate member

? Assess and reassess health status, including conditions, medications and
functional status

Horizon NJ TotalCare (HMO D-SNP)



24Proprietary and Confidential Government Programs

Role of the Behavioral Health (BH) Care Manager

? Address and close care gaps relevant to BH

? Arrange and coordinate care for the member as needed

? Contribute to the development of the BH plan of care

? Participate in the IDT Meetings

? Provide education and ongoing support to the member as needed

? Facilitate coordination and linkage of formal and informal community
supports related to behavioral health to enhance member outcomes and
wellness

? Work closely with the Care Manager to coordinate care for the member

Horizon NJ TotalCare (HMO D-SNP)



25Proprietary and Confidential Government Programs

Horizon NJ TotalCare (HMO D-SNP)

Role of the PCP:

? Attend/participate in the ICT meetings

? Receive calls from the member?s Care Manager

? Review and comment on the plan of care

? Collaborate with the member?s Care Manager to address needs



26Proprietary and Confidential Government Programs

Role of the behavioral health provider:

? Attend/participate in the IDT meetings

? Collaborate and coordinate care with the member?s PCP (physical health)

? Review and comment on the Interdisciplinary Plan of Care

? Receive calls from the member?s Care Manager

? Behavioral health

? Physical health

Horizon NJ TotalCare (HMO D-SNP)



This Document is Proprietary and Confidential

Do Not Print or Distribute Without Permission

Key Member Touches



28Proprietary and Confidential Government Programs

? Confirmation/Welcome call completed by the CCC

? Once enrollment is confirmed and prior to the effective date

? Confirm the member?s plan of choice is Horizon NJ
TotalCare (HMO D-SNP)

? Review of benefits

? Review PCP selection

? Health Risk Assessment

? Within 90 days of enrollment effective date

? Review of Medications

? Complete the Health Risk Assessment

Horizon NJ TotalCare (HMO D-SNP)



29Proprietary and Confidential Government Programs

2021 HRAT Incentive

? In 2021 TotalCare Members will be eligible for an
incentive ($10 CVS Gift Card) as part of the Health

Risk Assessment process

? Initial within 90 days of enrollment

? Annually / 365 days from last assessment

HRAT Incentive Information



This Document is Proprietary and Confidential

Do Not Print or Distribute Without Permission

Levels and Time Frames



31Proprietary and Confidential Government Programs

? Level 1: Low Risk, or Unable to Reach / Member chose
to opt out

? Level 2: Moderate Risk

? Level 3: High Risk

Horizon NJ TotalCare (HMO D-SNP)



This Document is Proprietary and Confidential

Do Not Print or Distribute Without Permission

Care Plan Elements for DSNP Members



33Proprietary and Confidential Government Programs

Individual Care Plan (ICP)

? Created for each member using the HRAT and other data

? Coordinated with the member/caregiver

? Goals

? General Goals

? SMART Goals

? Interventions/actions

? Culturally appropriate

? Easy to understand

? No medical terminology/ abbreviations

? Updated when a member?s

status changes

? Share with PCP and member

Horizon NJ TotalCare (HMO D-SNP)



34Proprietary and Confidential Government Programs

Purpose of the Interdisciplinary Care Team (IDT)

? Meets five times per week to review DSNP member Care Plans

? Level 1 reviewed at least annually by consent agenda

? Level 2 reviewed at least every 180 days

? Level 3 reviewed at least every 90 days

? Comprised of internal and external attendees that impact the member?s

plan of care

? Behavioral Health Readmission Rounds once per month for members

with multiple BH hospitalizations

Horizon NJ TotalCare (HMO D-SNP)



35Proprietary and Confidential Government Programs

Interdisciplinary Care Team (IDT)

? Attendees include (but are not limited to):

? Member or designee

? Medical Director

? PCP

? SNP Care Manager

? Behavioral Health Care Manager

? Pharmacist

? MLTSS

? Quality

? PT/OT

? Dental

Horizon NJ TotalCare (HMO D-SNP)



This Document is Proprietary and Confidential

Do Not Print or Distribute Without Permission

DSNP Operations, Correspondence and Rights and

Responsibilities



37Proprietary and Confidential Government Programs

Horizon NJ TotalCare (HMO D-SNP)

Member Information Mailings

? New Members (Initially)

? Welcome Guide

? OTC Catalog

? OTC Benefit Card and Information

? Member may also access other documents via online or by calling Member Services

? Existing Members (Annually)

? Updated Welcome Guide

? Updated OTC Catalog

? Updated OTC Benefit Card Information

? Member may also access other documents via online or by calling Member Services



38Proprietary and Confidential Government Programs

Horizon NJ TotalCare (HMO D-SNP)

Ongoing Member Mailings

? Quarterly Newsletters

? Health Information (examples)

? How to Read a Medication Label

? Nutrition/ Healthy Habits

? Disease Specific

? Dental Care

? Eye Care

? Care Plan

? TotalCare Care Management Brochure



This Document is Proprietary and Confidential

Do Not Print or Distribute Without Permission

Evaluation of Effectiveness of the Model Of Care



40Proprietary and Confidential Government Programs

Purpose

? To ensure the DSNP Model of Care Monitoring and Evaluation is
an ongoing process that is reported through a committee and

monitored by the leadership team for DSNP so that any deficits

or opportunities can be addressed and remediated

? To ensure the ability to intervene or take action on program
components if undesired trends are identified

? To monitor the MOC program effectiveness on a regular basis
through multiple channels

Horizon NJ TotalCare (HMO D-SNP)



41Proprietary and Confidential Government Programs

Scope and oversight

? The DSNP Committee and the QIC will review findings of ongoing
monitoring and evaluation of the MOC and will review any open corrective

action plans to address identified deficiencies

? Annually (on a calendar year schedule), a formal program evaluation will
be completed and submitted for committee review and approval as

follows:

? DSNP Committee

? Quality Improvement Committee (DSNP Report)

? Board of Directors (QIC Report)

Horizon NJ TotalCare (HMO D-SNP)



42Proprietary and Confidential Government Programs

Elements of monitoring the MOC

? Elements of the MOC will be monitored via multiple approaches
including formal and informal ongoing monitoring and evaluation

? D-SNP Committee and QIC ? quarterly

? Care Management Dashboard (Tableau) ? ongoing

? D-SNP Key Performance Indicator Report ? monthly

? Readmissions Report ? monthly

Horizon NJ TotalCare (HMO D-SNP)



43Proprietary and Confidential Government Programs

Examples of elements for monitoring the MOC

? The elements of the MOC to be monitored via the Care Management Dashboard
include:

? Care Manager case loads

? Risk stratification levels

? Health Risk Assessment completion rate

? CNA completion rate

? Care plans developed

? Interdisciplinary Care Team meetings

? Unable to reach rate

? Behavioral health referrals

Horizon NJ TotalCare (HMO D-SNP)



44Proprietary and Confidential Government Programs

Examples of elements for monitoring the MOC

? The elements of the MOC to be evaluated quarterly via the D-SNP Committee and
QIC include:

? Care Management

? Pharmacy

? Operations

? Behavioral health

? Call center

? Appeals and grievances

? Complaints/critical incidents

? HEDIS and Star Rating

? Provider network

Horizon NJ TotalCare (HMO D-SNP)



45Proprietary and Confidential Government Programs

Horizon NJ TotalCare (HMO D-SNP)

Quality Improvement Program (QIP)

? Required by both CMS and DMAHS

? Supports the national and CMS quality strategy goals

? Promotes effective management of chronic conditions

? In 2021, the Horizon NJ TotalCare (HMO SNP) QIP continues to focus on
Management of Asthma

? NEW in 2021 will be a QIP focused on PCP Access & Diabetes Care

? CMS & State
required

? Better manages
chronic conditions



46Proprietary and Confidential Government Programs

Horizon NJ TotalCare (HMO D-SNP)

In closing

? Horizon NJ TotalCare (HMO D-SNP) will begin year five of its D-SNP Program on
January 1, 2021

? Some of the highlighted benefit changes include: Silver & Fit Health Aging and
Exercise Program, Telemedicine, increase in OTC Benefit card from $300 to $375

per quarter, ability to purchase healthy groceries (criteria applied) and the addition of

home delivered meals once per year after a hospital stay (criteria applied & 1
occurrence / year)

? Each member will receive individualized care management and a plan of care that is
developed in a collaborative manner

? The Interdisciplinary team meets several times each week to review member plans
of care and provide collaborative feedback and input

? The members? providers are an integral part of the care team

? The MOC effectiveness is monitored in several ways both formally and informally to
ensure adherence to the program timelines and identify opportunities for

improvement