Horizon Healthcare Services, Inc.

Horizon Blue Cross Blue Shield of
New Jersey

Government Programs



2021 Quality Improvement
Program Description



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1. Purpose of the Quality Improvement (QI) Program ............................................................................................................... 4

2. Program Scope ...................................................................................................................................................................... 4

3. QI Program Objectives/Goals ................................................................................................................................................ 7

3.1 Program Evaluation ................................................................................................................................................. 7

4. Structure of the QI Program ............................................................................................................................................. 8

4.1 Governing Body ....................................................................................................................................................... 8

4.2 Committees ............................................................................................................................................................. 9

4.3 Inclusion of Participating Providers in the QI Program ............................................................................................12

4.4 GP Organizational Chart ..........................................................................................................................................13

4.5 QI Program?s Resources ..........................................................................................................................................13

4.6 External Quality Review ..........................................................................................................................................18
4.6.1 Department of Medical Assistance and Health Services (DMAHS)/Island Peer Review Organization (IPRO) ........ 18
4.6.2 Centers for Medicare & Medicaid Services (CMS) ..................................................... Error! Bookmark not defined.

4.7. Behavioral Health ...................................................................................................................................................19

5. QI Program?s Function .....................................................................................................................................................20

5.1 Member Safety .......................................................................................................................................................20

5.2 Disparities in Health ................................................................................................................................................21
5.2.1 Complex Health Needs ........................................................................................................................................... 21

5.3 Quality Assurance ...................................................................................................................................................22
5.3.1 Grievances and Appeals ......................................................................................................................................... 22

5.3.1.1 Medicaid Grievances ................................................................................................................................. 22
5.3.1.2 Medicare Grievances ................................................................................................................................. 23


5.3.2 Quality of Care and Service .................................................................................................................................... 24

5.3.2.1 Quality of Care and Service ....................................................................................................................... 26
5.3.2.1.1 Mortality Data ................................................................................................................................ 26

5.3.3 Programs for the Elderly and Disabled .................................................................................................................. 26
5.3.4 Population Health .................................................................................................................................................. 27
5.3.5 Audits and Reports ................................................................................................................................................. 27
5.3.6 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) - Lead Screening .............................................. 28

5.4 Policy Management ................................................................................................................................................29

5.5 Delegation Oversight ..............................................................................................................................................30

5.6 Compliance with State and Federal Regulatory and NJ Medicaid Managed Care Contract Requirements ...............31

5.7 Accreditation ..........................................................................................................................................................33



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5.8 Credentialing and Re-credentialing .........................................................................................................................33

5.9 Clinical Practice Guidelines (CPGs) ..........................................................................................................................33

5.10 Cultural Competency and Health Literacy ...............................................................................................................34

5.11 Fraud, Waste, and Abuse ........................................................................................................................................35

5.12 Program Performance .............................................................................................................................................35
5.12.1 QI Program Work Plan ................................................................................................................................. 36
5.12.2 Performance Improvement Projects (PIPs) ................................................................................................. 36

5.12.2.1 Medicaid PIPs (State PIPs) ....................................................................................................................... 36
5.12.2.2 Medicare PIPs (CMS PIPs/CCIPs) ............................................................................................................. 37

5.12.3 Healthcare Effectiveness Data and Information Set (HEDIS) ....................................................................... 37
5.12.4 Stars ............................................................................................................................................................. 38
5.12.5 Consumer Assessment of Healthcare Providers and Systems (CAHPS) ....................................................... 38
5.12.6 Health Outcomes Survey (HOS) ................................................................................................................... 38

5.13 New Initiatives ........................................................................................................................................................39

5.14 Opportunities for Continued Improvement .............................................................................................................40




Attachments to Program Description

Attachment 1 ? 2020-2021 Medicaid Managed Long Term Services & Supports (MLTSS) Program Description

Attachment 2 ? 2021 FIDE-SNP Care Management and Quality Management Program Description

Attachment 3 ? 2021 GP Committee Organizational Chart

Attachment 4 - GP Executive Organizational Chart

Attachment 5 - Quality Management Organizational Chart







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1. Purpose of the Quality Improvement (QI) Program
The purpose of Horizon?s QI Program is to systematically monitor, assess, track, trend and

continuously improve the quality of care, service, health status and safety of its members. The QI Program is

designed to be comprehensive, with the necessary resources, infrastructure, and authority to meet the

program?s goals and objectives. The program also monitors quality assurance activities including the

development of clinical standards, medical care evaluations and member experience surveys. The QI Program

oversees quality-related activities for Medicaid, Medicare, Managed Long Term Services & Supports (MLTSS)

and FIDE-SNP.



2. Program Scope
The QI Program applies to all of Horizon?s Government Programs (GP) lines of business.1 The

membership served by the QI Program includes: Horizon NJ Health (Medicaid & MLTSS), Horizon NJ TotalCare

(HMO D-SNP), Medicare Supplement and Medicare Advantage HMO and PPO plans.

The scope of the QI Program encompasses the clinical and service aspects of the care that members

receive. The Program oversees Horizon?s efforts to monitor and improve preventive, acute, chronic,

behavioral and rehabilitative aspects of care. The Program also reviews the Plan?s initiatives and outcomes

related to member and provider satisfaction and education, access and availability of care, disparities in

health care, continuity and coordination of care, member appeals/grievances, quality-of-care concerns,

clinical and service quality metrics and the credentialing of providers. The Program effects changes to

improve Horizon?s performance on Healthcare Effectiveness Data and Information Set (HEDIS), Stars,

Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Health Outcomes Survey (HOS).


1 As a result of incongruent State and Federal requirements and timelines, Horizon BCBSNJ?s Government Programs QI Program
description acts as an overarching guide while allowing individual lines of business to meet their specific contractual and regulatory
requirements through the creation of line of business specific QI programs when necessary. These line-of-business-specific program
descriptions are reviewed and approved by the QIC. This structure allows individual lines of business (MLTSS for example) to meet their
varied filing submission dates while ensuring each line of business? QI Program information is captured within the overall Horizon
Government Programs QI Program description. See Attachment 1 for the MLTSS Program Description. See Attachment 2 for the FIDE-
SNP Care Management and Quality Management Program Description.



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Accreditation efforts and audits completed by the Quality Management Department and other departments

are also reviewed by the Program. The following Quality Assurance activities are developed and monitored on

an ongoing basis:

? Guidelines for the management of selected diagnoses and basic health maintenance, and
distribution of all standards, protocols, and guidelines to all providers and to enrollees and

potential enrollees upon request.

? Treatment protocols allowing for adjustments based on the enrollee?s medical condition, level of
functioning, and contributing family and social factors.

? Procedures for monitoring the quality and adequacy of medical and behavioral health care
including assessing the use of the distributed guidelines, assessing possible over-treatment/over-

utilization of services and assessing possible under-treatment/under-utilization of services.

? Evaluation of procedures for focused medical care evaluations that will be employed when
indicators suggest that quality may need to be studied, including procedures for conducting

problem-oriented clinical studies of individual care.

? Evaluation of timeliness of decision making and notification of Utilization Management decisions
and appeals.

? Procedures for prompt follow-up of reported problems and grievances involving quality of care
issues. Timeframes for prompt follow-up and resolution which meet the standard described in

Article 5.15B.

? Hospital Acquired Conditions and Provider-Preventable Conditions, including the implementation
of a no payment policy and a quality monitoring program consistent with guidance from the

Centers for Medicare and Medicaid Services (CMS) that addresses Hospital Acquired Conditions

and Provider-Preventable Conditions according to federal regulations.

? Data Collection Procedures for gathering and trending data, including outcome data.

? Mortality rates review of inpatient hospital mortality rates of its enrollees.



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? Corrective action procedures to inform subcontractors and providers of identified deficiencies or
areas of improvement, conducting ongoing monitoring of corrective actions, and taking

appropriate follow-up actions, such as instituting progressive sanctions and appeal processes.

? Discharge planning procedures to ensure adequate and appropriate discharge planning, including
coordination of services for enrollees with special needs.

? Ethical issues monitoring of providers for compliance with state and federal laws and regulations
concerning ethical issues, including but not limited to; advance directives, family planning

services for minors and other issues as identified. Reports are submitted annually or within thirty

(30) days to DMAHS with changes or updates to the policies.

? Emergency care methods to track emergency care utilization and to take follow-up action,
including individual counseling, to improve appropriate use of urgent and emergency care

settings.

? New medical technology policies and procedures for evidence-based criteria for the evaluation of
the appropriate use of new medical technologies or new applications of established technologies,

including medical procedures, drugs, devices, assistive technology devices and durable medical

equipment.

? Informed consent, which requires that all participating providers comply with the informed
consent forms and procedures for hysterectomy and sterilization as specified in 42 C.F.R. Part

441, Sub-part F, and shall include the annual audit for such compliance in its quality assurance

reviews of participating providers.

? Continuity of care system, which includes a mechanism for tracking issues over time with an
emphasis on improving health outcomes, as well as preventive services and maintenance of

function for enrollees with special needs

? Collecting data and acting on opportunities to improve collaborative care between behavioral
health and medical health care for all members receiving case management services.





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3. QI Program Objectives/Goals


The QI Program is designed to produce prospective, concurrent, and retrospective analyses of the

Plan?s activities in order to improve the quality of care and service members receive. The specific goals of the

Program are to ensure that Horizon:

? Provides health care that is medically necessary with an emphasis on the promotion of
health in a safe, effective and efficient manner

? Assesses the appropriateness and timeliness of the care and services being provided
? Promotes members? ability to maintain themselves in the least restrictive, most integrated

setting of their choice
? Optimizes care delivery for members with special and/or complex care needs
? Identifies members? needs and coordinates care to address the needs of the member
? Focuses on the quality of medical and behavioral health care and services provided to all

members
? Works to identify and reduce health care disparities within its membership
? Strives to improve member and provider satisfaction
? Maintains oversight of delegated entities
? Maintains oversight of the credentialing and re-credentialing of providers
? Meets current National Committee for Quality Assurance (NCQA) Health Plan

Accreditation requirements
? Works to improve plan performance on HEDIS, Stars, CAHPS, HOS and Performance

Improvement Projects (PIPs)
? Works to ensure compliance with State-mandated contract requirements



3.1 Program Evaluation
The QI Program is evaluated annually by the Quality Management Department with input

from all business areas represented on the Quality Improvement Committee (QIC). The format of the

QI Program Evaluation parallels the QI Program?s Work Plan and includes:

? A description of completed and ongoing QI activities that address quality of clinical care
and quality of service

? Evaluation and assessment of patient safety activities
? Tracking and trending of data to assess program performance in measures of quality of

care and quality of service
? An analysis of improvements in quality of care and service to members
? A critical assessment of barriers to achieving goals and root cause analysis
? An evaluation of the overall effectiveness of the QI Program





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The QI Program Evaluation is presented annually to the QIC for review, comments,

and approval. The (VP/CMO), or a designee, annually presents the QI Program Evaluation

to the Horizon Healthcare of New Jersey Board of Directors.



4. Structure of the QI Program

4.1 Governing Body
Horizon Healthcare Services Inc.?s (the ?Parent?) subsidiary companies report to the Parent

organization. The Parent and its subsidiary companies have administrative service agreements with

each other, wherein the subsidiaries utilize staff, policies, procedures and other items from the

Parent. The subsidiary companies that comprise the Government Programs division include Horizon

Healthcare of New Jersey, Inc. and Horizon Healthcare Services, Inc. d/b/a Horizon Blue Cross Blue

Shield of New Jersey. Horizon Healthcare Services is the contracting entity for the Medicare

Supplemental, Medicare Advantage HMO, MA PPO and Part D product lines. Horizon Healthcare of

New Jersey is the contracting entity for the FIDE-SNP HMO and Medicaid HMO product lines.

The Parent?s Board of Directors (the ?Board?) is the governing body of the Horizon BCBSNJ

enterprise, and holds the final authority and accountability for the Quality Improvement Program (the

?Program?). The Board has delegated oversight of the Program to the Quality Committee of the

Board. The Committee has further delegated the oversight of the Program to the Government

Program?s Quality Improvement Committee (QIC). The QIC reviews and approves the QI Program

Description, Work Plan and Program Evaluation Annually. The Board has assigned responsibility for

the Program to the Vice President and Chief Medical Officer (VP/CMO). The VP/CMO has the

authority over and responsibility for the development and implementation of the Program. The

director of quality improvement, who reports to the VP/CMO, has direct oversight of the

development and implementation of the Program. The VP/CMO has delegated the chairmanship of

the QIC to the medical director assigned to support the Quality Management Department. The QIC is

responsible for the day-to-day approval, monitoring and evaluation of the Program.



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4.2 Committees
The organizational structure of the committees supports the implementation of the Program.

Each committee has a charter that outlines the purpose, scope, meeting frequency, and composition.

Below are descriptions of the committees and subcommittees/workgroups that report to the QIC.

Quality Improvement Committee (QIC)

The QIC?s purpose is to oversee all QI activities. The QIC is a multidisciplinary committee that

meets at least 6 times per year. This frequency is sufficient for the committee to follow up on all

findings and required actions. The role, structure, and function of the committee are specified in its

charter. Annually, the charter is revised as needed and approved by the committee. Recorded

meeting minutes document the committee's activities, findings, recommendations and actions.

The QIC is accountable to the Board. Quarterly, QIC reports their activities, findings,

recommendations and actions to the Board?s Quality Committee. Additionally, there is active

participation on the QIC from network providers. At least one participating provider attends all QIC

meetings.


? Healthcare Disparities Workgroup


The Healthcare Disparities Workgroup meets at least 6 times per year. The purpose of
this workgroup is to reduce health care disparities within its membership. The
workgroup brings together a cross-functional team that reviews data, develops and
implements interventions, conducts barrier analysis and measures the impact of
interventions put in place to decrease health care disparities.


? Physician Advisory Committee (PAC)
The PAC meets quarterly. The purpose of this committee is to identify issues of
concern to the physician community and identify opportunities to optimize patient
care. The PAC meetings are combined with the Utilization Management/Case
Management Committee.


? Dental Committee (Special Needs and Oral Advisory)
This committee advises on and reviews issues pertinent to the delivery of oral health
care services to special needs members. This committee advises GP of changes and
advances in the treatment of oral health care issues that are unique or prevalent with
this population. The committee advises and reviews benefits and services GP provides



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to its special needs members as well as new or existing policies. This may or may not
involve quality of care issues. This committee meets quarterly.


? Delegated Vendor Oversight Committee (DVOC)
The DVOC is an interdisciplinary subcommittee that provides oversight of delegated
vendors performing services on GP?s behalf for both health care and non-health care
contracts. The committee meets at least eight times per year.


? Medicare Star Rating Subcommittee
The Medicare Star Rating Subcommittee is an interdisciplinary committee that meets
ten times per year and oversees efforts aimed to improve the quality and cost
effectiveness of the care and services provided to Medicare beneficiaries. The
committee coordinates efforts that focus on improving the plan?s Medicare Star Rating
and CAHPS scores.


? HEDIS Workgroup
The HEDIS Workgroup is an interdisciplinary team that provides oversight of efforts
aimed at improving the quality and cost effectiveness of the care and services
provided to all members. The workgroup coordinates efforts focused on improving the
plan?s Medicare and Medicaid HEDIS performance. This workgroup meets six times per
year.


? Utilization Management/Case Management Committee (UM/CM)

The purpose of the UM/CM committee is to ensure high-quality, cost-effective health
care for all members. The committee is responsible to review the management of
Medicare and Medicaid health services to support Horizon?s vision of improving
quality and enhancing the member experience. The UM/CM Committee reviews and
approves clinical criteria, monitors utilization data (including over and underutilization
of services), and reviews UM appeals data. The UM/CM Committee meets at least ten
times per year. The UM/CM Committee is inclusive of behavioral healthcare, and a
designated behavioral healthcare practitioner is actively involved in implementing and
evaluating the behavioral health aspects of the UM program.


? Managed Long Term Services & Supports Committee (MLTSS)

The purpose of the MLTSS committee is to provide oversight to the Horizon NJ Health
MLTSS Quality Program. The committee reviews the program?s progress toward its
goals to systematically monitor, assess, track, trend and improve the quality of care,
service, health status and safety of MLTSS members. The committee meets at least
quarterly.


? Fully Integrated Dual Eligible Special Needs Plan Committee (FIDE-SNP)



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The purpose of the FIDE-SNP committee is to provide oversight to the Horizon NJ
TotalCare (HMO D-SNP) Quality Program. The committee reviews the program?s
progress towards its goals to systematically monitor, assess, track, trend and improve
the quality of care, service, health status and safety of the FIDE-SNP members and
ensure compliance with stated program activities according to the Centers for
Medicare & Medicaid Services? (CMS) FIDE-SNP Model of Care (MOC). The FIDE-SNP
Committee meets at least four times per year.


? MLTSS & FIDE-SNP Community Advisory Committee (MLTSS & FIDE-SNP CAC)
The MLTSS & FIDE-SNP CAC is comprised of MLTSS and FIDE-SNP leadership as well as
providers from the communities that serve MLTSS and FIDE-SNP membership. CAC
meetings allow Horizon to share information about the operations and performance of
the MLTSS and FIDE-SNP programs with community providers, while allowing them to
share their experiences related to the programs with the Plan. The MLTSS & FIDE-SNP
CAC meets at least four times per year.


? Administrative Policy Approval (APA) Subcommittee
The APA Subcommittee meets monthly, and the purpose of the committee is to review
and approve all Administrative Policies and Procedures.


? Quality Peer Review Committee (QPRC)
The goal of the QPRC is to ensure members receive quality health care and excellent service.
QPRC meets at least six times per year and on an ad hoc basis to review potential quality of care
and service issues involving GP members. QPRC reviews both medical and behavioral health
quality of care issues, and a behavioral health practitioner is actively involved in review of
behavioral healthcare issues.

? Member Services Satisfaction Committee (MSSC)
The MSSC is a multidisciplinary committee, focusing on issues related to member satisfaction in
order to create proactive action plans that address the identified barriers to providing members
with the highest quality experience. The MSSC reviews reports focused on call center
performance, member grievances, and claims as well as appeals associated with these issues. The
MSSC reviews CAHPS results and other member satisfaction survey results so that the committee
can coordinate interventions aimed at improving member experience. The committee also
determines areas of service with the greatest effect on member satisfaction, and identifies areas
of opportunity to increase quality of care through quality initiatives. This committee meets at
least four times per year.

? Community Health Advisory Committee (CHAC)



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The purpose of the CHAC is to provide a vehicle for community review and advice on matters
related to health care education, outreach and promotion affecting members. Meetings are held
in both English and Spanish. The CHAC meets quarterly.

? Provider Service Satisfaction Committee (PSSC)
The purpose of the PSSC is to oversee and ensure provider satisfaction with the Plan. The PSSC
committee reviews grievance and appeal data and specific issues related to provider satisfaction.
The committee meets on a quarterly basis.

? Credentials Committee
The Credentials Committee reports to the QIC and was established to implement and oversee
credentialing, re-credentialing, certification, and/or re-certification of physicians, health care
professionals, facilities and ancillary providers. The Credentials Committee is empowered by
Horizon Healthcare Services, Board of Directors and the Horizon Healthcare of New Jersey Board
of Directors, the management of GP and the QIC with decision-making authority on matters
pertaining to provider credentialing and re-credentialing. This committee meets at least 10 times
per year.

? Pharmacy and Therapeutics (P&T) Committee (Medicaid)
The Medicaid P&T Committee is responsible for clinical support of the Medicaid Pharmacy
Program. The P&T Committee is comprised of primary care and specialty physicians, pharmacists
and other health care professionals. The Medicaid P&T Committee provides input on
pharmaceutical management procedures and on developing, managing, updating and
administering the Drug Formulary System. The Medicaid P&T Committee meets at least quarterly.

? Pharmacy and Therapeutics (P&T) Committee (Medicare)
The Medicare P&T Committee is responsible for clinical support of the Medicare Pharmacy
Program, including FIDE-SNP. The P&T Committee is comprised of primary care and specialty
physicians, pharmacists and other health care professionals. The Medicare P&T Committee
provides input on pharmaceutical management procedures and on developing, managing,
updating and administering the Medicare Formulary. The Medicare Formulary development and
maintenance is delegated to the Pharmacy Benefit Manager, Prime Therapeutics, and is overseen
by the Prime P&T Committee with active participation by the Horizon?s Medicare Pharmacy
Program. The Medicare P&T Committee meets at least quarterly.

4.3 Inclusion of Participating Providers in the QI Program
Horizon medical and behavioral health providers are included as voting members of the QIC.

Participating providers are also voting members of Utilization Management/Case Management



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Committee, Physician Advisory Committee, Pharmacy and Therapeutics Committees, Dental Advisory

Committee and Quality Peer Review Committee. Participating physicians and other providers are kept

informed about the written QI Program Description available in provider newsletters and on the

plan?s website at horizonNJhealth.com/for-providers. Providers can also access information in the

Provider Administrative Manual about how they can be included in the design, implementation,

review and follow up of QI activities.

4.4 GP Organizational Chart
See Attachment 3 2020 GP Committee Organization Chart, Attachment 4 for the GP Executive

Organizational Chart and Attachment 5 for the Quality Management Department?s Organizational

Chart. Due to the size of the Quality Management Department, the Quality Management Clinical

Operations Organizational Chart, the Quality Management Performance Improvement and Reporting

and the Quality Management and Administration Organizational Chart are reported separately. These

teams collaborate to share best practices and also leverage resources that will yield positive

outcomes for Horizon members.

4.5 QI Program?s Resources
Horizon?s executive leadership and all departments within the division contribute to the

success of the QI Program through their focus on quality in their daily activities and their participation

in the QIC. With the expansion and reorganization of the Quality Management Department in 2020,

and the existing health services structure, the Program has sufficient material resources and staff

with the necessary education, experience and/or training to effectively carry out the Program?s

activities. In addition, the Quality Management Department has access to consultants who provide

activities such as statistical analysis, business process improvement recommendations, quality-

related education and accreditation preparation support. To maintain and improve quality

performance, Horizon monitors all current and planned initiatives to assess current and future

staffing needs. This opportunity ensures that the appropriate staff is in place to adequately address

the needs of the quality improvement efforts. Below are descriptions of the key roles within GP that

support the QI Program.

QI Programs Staffing:

Vice President and Chief Medical Officer (VP/CMO)



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The VP & Chief Medical Officer VP/CMO of Horizon is a board-certified New Jersey licensed

physician, experienced in health insurance, health care consulting, NCQA accreditation and

pharmaceutics. The VP/CMO is responsible for the design and implementation of the QI Program.

The VP/CMO provides quarterly reports to the Quality Subcommittee of the Horizon Healthcare of

New Jersey Board of Directors, which details the quality-related activities of Horizon and the QIC. This

reporting may be delegated to the medical director of the Quality Management Department.

Executive Medical Directors

The executive medical directors provide senior level leadership and direction, and contribute

to Quality Management initiatives, including accreditation and CMS Star programs, as well as

furnishing strategic and UM oversight. The executive medical directors establish and implement

utilization standards, provide overall medical expertise to ensure continuous quality improvement,

work to ensure that cost-effective services are provided to members, maintain effective provider

relations and develop clinical innovations.

Senior Medical Directors/Medical Directors/Dental Director/Director of Behavioral Health

The Senior Medical Directors, Medical Directors, Director of Behavioral Health and Dental

Director provide support to the QI Program and the Quality Management Department. They are

involved in the evaluation of the clinical and service functions including, but not limited to, clinical

practice guidelines, grievances, and quality of care referrals, HEDIS/Stars/CAHPS/HOS initiatives and

corrective action plans (CAP).

Quality Management Coordinator

The Quality Management Coordinator is a board-certified New Jersey licensed physician who

has experience in UM, Quality Management, managed care operations, MLTSS, Medicare and Fully

Integrated Dual Eligible Special Needs Programs. The QM coordinator is responsible for the creation

and execution of the QI Program Description, work plan, and annual evaluation, as well as all the

functions carried out by the Quality Management Department. The QM Coordinator or designee

chairs the QIC and is a voting member of select QIC subcommittees. The QM Coordinator?s

representation and voting rights on QIC subcommittees may be delegated to medical directors within

Horizon or a director within the Quality Management Department.



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Director, Quality Management Performance Improvement and Reporting

The Director of the Quality Management Department reports to the VP/CMO. The Director

has experience leading HEDIS and Star Rating initiatives for large health plans as well as coordinating

quality transformation efforts within institutions and provider groups. The Director is responsible for

assisting in the planning and direction of the QI Program and Quality Management Department

functions. The Director is also responsible for the oversight and function of the business areas within

the Quality Management Department including Star Rating/HEDIS/CAHPS/HOS, pay for performance

and population health. The Director develops departmental reports and presents these reports, along

with the medical director, to the leadership team directly and through the committee reporting

structure. The Director represents the Quality Management Department on committees and may

serve as the Quality Management Medical Director?s designee when the Medical Director is not

present.

Director Quality Management Clinical Operations

The Director of Quality Management Clinical Operations reports to the Medical Director of

the Quality Management Department. The Director is a licensed professional registered nurse and

has experience in health plan management for UM, CM and appeals. The Director is responsible for

assisting in the planning and direction of the QI Program and Quality Department functions specific to

clinical operations. The Director is also responsible for the oversight and function of the business

areas within the Quality Management Department, including medical UM appeals audits, and quality

of care referrals and quality of care. The Director develops departmental reports and presents these

reports, along with the Medical Director, to the leadership team directly and through the committee

reporting structure. The Director represents the Quality Management Department on committees

and may serve as the Quality Management medical director?s designee when the medical director is

not present.

Director Quality Management Improvement Operations

The Director of the Quality Management Improvement Operations Department reports to

the VP & Chief Medical Officer. The Director has experience in Continuous Quality Improvement

(CQI) methodology, state contractual requirements, and NCQA, DMAHS and CMS quality standards.

The Director has a master?s degree in business administration, with concentrations in management



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information systems and risk management. The Director is responsible for design, development, and

implementation of on-going improvement and maintenance of quality improvement initiatives

necessary for attaining NCQA accreditation, and meeting CMS and DMAHS contractual

requirements. The Director provides leadership for implementing, monitoring and evaluating the

Quality Improvement Program. The Director also leads and directs processes and overall quality

improvement activities that produce better patient care and more efficient operations. They also

develop programs to review and evaluate patient care and outcomes. The Director represents the

Quality Management Department on GP committees and may serve as the Quality Management

Medical Director?s co-chair.

Director of Clinical Behavioral Health Services

The Director of Clinical Behavioral Health Services reports directly to the Vice President of

Behavioral Health. The Director has a doctoral degree in social work and is a licensed clinical social

worker. The Director monitors the effectiveness of behavioral health care services including

utilization management, Medicare Case Management and all Quality Management activities related

to behavioral health. Internal management of behavioral health services allows Horizon to be in a

stronger position to work directly with providers and health systems to improve integration of

physical and behavioral health care for our members.

Quality Management Department Managers

Quality Management Department managers report to the Directors within the Quality

Management Department. GP Quality managers are nurses, social workers and non-clinicians with

backgrounds in quality assurance, compliance, analytics and State Health Department operations.

Managers are responsible for routine operations within their scope of accountability. Managers have

specific business areas within the Quality Management Department that they oversee including

member and provider grievances and appeals, quality peer reviews, audits, HEDIS/Star Rating

performance, quality policy revisions, accreditation, quality assurance and quality-related

compliance.

Quality Management Department Supervisors

Supervisors within the Quality Management Department report to managers or directors.

Quality Management Department supervisors include both clinicians (RNs and LPNs) and non-



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clinicians. The supervisors are responsible for ensuring that the Quality Management Department?s

staff completes daily operations as outlined within policies and procedures.

Quality Management Department Subject Matter Experts

Accreditation Specialists

The accreditation specialists support the Quality Management Department?s goal of

improving the quality of health care for its members through ongoing monitoring of compliance with

accreditation standards and regulatory requirements. The specialists work with all business areas, as

well as with delegated vendors, to ensure that their work and reporting supports all applicable NCQA

Health Plan Accreditation Standards.

PIP Specialists

There is a dedicated team responsible for assisting in the design, implementation, execution,

analysis, and reporting of State and CMS required PIPs. They lead the Quality Management

Department, as well as other departments and external collaborators, in the work required to

successfully achieve the goals of each of QI project.

Health Data Analysts

Health data analysts perform research, analysis, programming, implementation and

coordination to ensure accurate and timely reporting for the Quality Management Department. The

responsibilities include, but are not limited to, analysis reporting, development of databases and

reports that are responsive to department needs, review and coordination of all data requests to

ensure data consistency and accuracy, and utilization of various software packages to extract and

analyze data. They provide support and education to all Health Services departments on data

requirements and needs for quality activities.

Quality Outreach Specialists

Quality Outreach Specialists are responsible for the coordination, implementation and

monitoring of all Medicaid and Medicare (Star Rating) HEDIS member and provider outreach,

engagement and intervention. This position is also responsible for assisting the manager of Outreach

& Interventions in operationalizing all initiatives to improve HEDIS performance by working with

internal and external stakeholders.



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Additionally, the QI program pursues an integrated approach to achieving ongoing

improvements in the quality of care and service delivered to members. Staff in the Quality

Department work closely with the following departments:

Provider Contracting & Strategy (PC&S) works with Quality Management to ensure that the

tools to assess the access and availability of practitioners and providers are adequate, that

practitioners/providers comply with the QI program, that clinical materials distributed to

practitioners are understandable and useful, and that practitioners understand members? rights and

responsibilities and treat enrolled members accordingly.

Clinical Services Operations includes Care, Case and Disease Management and UM. Care,

Case Disease Management staff identifies and refers potential quality issues to the Quality

Management Department for investigation, recommends benefit enhancement, approves clinical

practice guidelines and participates in the QIC.

Delegate Vendor Oversight (DVO) and Quality Management staff work collaboratively in the

review of Quality Management initiatives with delegates and ensure compliance with the NCQA

standards. In addition, DVO provides oversight of the activities and responsibilities of delegated

vendors to ensure quality health care is provided to members.

4.6 External Quality Review

4.6.1 Department of Medical Assistance and Health Services (DMAHS)
and the Island Peer Review Organization (IPRO)

On behalf of the New Jersey DMAHS, IPRO conducts oversight activities of Horizon NJ

Health and Horizon TotalCare (HMO D-SNP). Annually, IPRO conducts an assessment of

Horizon operations to determine if the Plan has implemented and operationalized State-

mandated contractual requirements. The Quality Management Department is responsible for

preparation, the submission of documentation and the coordination of the onsite

assessment. After the annual assessment is completed and Horizon BCBSNJ receives feedback

from DMAHS/IPRO, corrective action plans are created and executed to address the

opportunities for improvement that were highlighted in IPRO?s report. These corrective

actions are monitored by the QIC through their completion.



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Additionally, as a follow up to the annual assessment, the plan receives a Quality

Technical Report (QTR) each year from IPRO that aggregates and analyzes relevant data to

draw conclusions on quality, timeliness and access to Medicaid managed care services. IPRO

is required to make improvement recommendations as a part of its external quality review

activities and then discuss how the managed care organization addressed those

recommendations in the next annual QTR.

DMAHS/IPRO also has oversight of additional activities including focused studies,

audits to evaluate the quality of care received by the publicly insured enrolled in managed

care, HEDIS performance, CAHPS performance and evaluation of Horizon?s Performance

Improvement Projects (PIPS).

In addition to the external quality reviews performed by the State, Horizon

undergoes quality reviews/audits performed by CMS and NCQA. Horizon ensures required

QIPs and CIPS are approved by CMS. Horizon maintains compliance with NCQA Health Plan

Accreditation standards and the plan?s Medicaid and Medicare lines of business are assessed

by NCQA as part of the health plan accreditation process.

4.7. Behavioral Health
The Behavioral Health Program is committed to providing quality services to help members

manage all aspects of their health. Behavioral Health Case Management services are available to

Medicare and Medicaid members. The outpatient behavioral health benefits provided through

Medicaid are limited to the enrollees in the Division of Developmental Disabilities (DDD), MLTSS and

FIDE-SNP programs. Acute inpatient services are covered for the entire Medicaid membership. Case

managers assess, develop and implement individualized plans of care; and offer coordination of

medical and behavioral health care services for members and their families. The Behavioral Health

Program utilizes the Care Radius medical management system to support delivery and

documentation of the case management process.

The Director of Behavioral Health Services reports into QIC and a behavioral health

practitioner participates on the QIC, UM/CM, P&T and FIDE-SNP Committees to provide information

and guidance on mental health/substance use disorder topics and related quality initiatives and

activities. Additionally, the Provider Contracting & Strategy and Network Operations Departments



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review geographical access reports that address the adequacy of the behavioral health provider

network and member experience accessing the network. Grievances and requests for out of network

services are also analyzed. Deficiencies are addressed to reduce barriers to access and ensure

continuity of care for members.



5. QI Program?s Function
The function of the QI Program is to coordinate, oversee, guide, and assess GP efforts to ensure

continuous quality improvement throughout the organization. The following sections highlight the

functions of the QI Program. The Program also has the ability, through the QIC, to add focus areas when

indicated.

Each year the QI Program Description is reviewed and revised as necessary. Annually, a QI Work

Plan is developed and implemented to guide the execution of the QI Program. At the conclusion of each

year, a QI Program Evaluation is completed to assess the success of the QI Program and guide the

creation of the following year?s QI Program Description and Work Plan. The Program Evaluation identifies

areas where goals were not met and will continue to be monitored into the next calendar year. The work

plan is used as a tool to monitor, review and track quality improvement activities on a quarterly basis, and

new initiatives are added as needed.

5.1 Member Safety
Promoting safety for its members is a key focus for Horizon BCBSNJ and involves a wide range

of activities. The QI Program, as well as the Quality Management Department, are central

contributors and coordinators of member safety initiatives performed throughout the organization.

To promote safety for hospitalized members in accordance with CMS guidelines, state law,

and the State Medicaid Managed Care Contract, Horizon has policies to address quality of care and

service, hospital acquired conditions and serious adverse events. The Quality Management

Department reviews the State Medicaid Managed Care contract, CMS regulations, applicable state

laws, national clinical practice and other guidelines at least annually. Policies are reviewed and

approved every year, including the list of selected hospital-acquired conditions and serious adverse

events.



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Additional activities occurring within the Quality Management Department and QIC that

focus on enhancing member safety include: assisting in the reporting of quality indicators to the

provider network, monitoring and follow up on corrective action plans required from delegated

vendors and/or network providers who identified care and/or service deficiencies, conducting quality

of care reviews focused on member safety issues, designing quality improvement projects targeted to

at-risk populations, researching grievances related to member safety issues, coordinating responses

to potential urgent/immediate member safety threats when appropriate.

5.2 Disparities in Health
Disparities in health reduce the overall quality of care provided within the health care system

while adding to costs. In 2021, to address the multiplicity of the needs of the membership, the QI

Program will continue to identify and address disparities in health outcomes among different member

populations. Horizon programs to reduce disparities in health will be driven by discussions held during

Disparities Workgroup and QIC meetings, as well as recommendations made by the QIC. The

interventions selected to reduce health care disparities in clinical and service areas will be instituted

during 2021 and will be included in the 2021 QI Work Plan. Current topics under review include breast

cancer screening (BCS), cervical cancer screening (CCS), depression in the elderly FIDE-SNP population,

colorectal cancer screening (COL), prostate cancer screening, social determinants of health and the

Maternal Health Learning Collaborative. Horizon BCBSNJ?s ongoing efforts to reduce disparities will be

coordinated and monitored through the QIC.

The goal of this program is to implement interventions and community health events, which

reduce disparities between differing member populations. The Maternal Learning Collaborative was a

new project in 2020 and the interventions and strategy will be implemented in 2021. Ongoing

interventions from 2020 for depression in the elderly FIDE-SNP population, social determinants of

health, BCS, CCS, COL and prostate cancer screening will continue through 2021.



5.2.1 Complex Health Needs
The QI program is dedicated to addressing the needs of members with complex

health issues. The Complex Case Management Program resides within the Medicaid Case

Management and Medicare Advantage (MA) Care Management teams (product line specific)



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and integrates all components of case management and coordination to support access to

care for members with complex diseases including acute physical, behavioral and chronic

conditions.

Members are identified and referred for Complex Case Management using a variety

of methods, such as data provided from utilization/concurrent review, predictive modeling

tools and physician and/or member referrals. The assigned case manager coordinates care

with members, their families, and providers as appropriate to assist in assessment,

development and implementation of individualized plans of care to meet the identified needs

of the member across multiple settings. Medicaid Case Management and Medicare

Advantage Care Management utilize the Care Radius medical management system to support

both the delivery and documentation of the case management process.

Additionally, the Provider Contracting & Strategy and Network Operations

Departments review geographical access reports to address the adequacy of the provider

network. Reporting indicates sufficiency of PCP, obstetrics and gynecology, high volume and

high impact specialties required to treat the membership. Deficiencies in the network are

acted upon to reduce barriers to care and to ensure continuity of care for members.

5.3 Quality Assurance

5.3.1 Grievances and Appeals

5.3.1.1 Medicaid Grievances
Horizon is committed to improving the efficiency and quality of how the Plan

manages appeals and grievances. In 2020, all grievance analysts were provided with

additional training to ensure grievances were handled timely and efficiently, and will

continue to be monitored in 2021 to initiate additional training where needed. The

training included reviewing the process for identifying quality of care issues and

making outbound calls to providers. In addition, 100 percent of all grievances receive

a quality review prior to closure. This added step ensures that member and provider

grievances are addressed appropriately.



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The grievance resolution teams address member and provider grievances

within the mandated timeframes required by the NJ State Medicaid Contract, CMS

Health Maintenance Organization (HMO) regulations, and in accordance with

standards set forth by NCQA. The staff receives grievances through incoming

telephone calls to the member/provider services areas, State referrals, CMS referrals,

internal and external direct calls, written correspondence, the website and the

electronic internal complaint forms. The internal processes provide the opportunity

for all employees within the organization to document any grievance that was

received during an interaction with a member and/or provider. The grievance staff is

the liaison between the member/provider, Horizon, and the delegate or vendor for

grievances related to any delegate or vendor. The team participates in monthly

meetings as necessary with delegates and vendors to ensure grievances are

processed within compliance contractual agreements and service level agreements

and also discuss any issues that may arise.

Grievance data is analyzed monthly and submitted to the appropriate

committees for review and discussion. At least quarterly, member, provider and

delegated vendor grievance data is presented to the QIC by line of business. Trends

in the elderly and disabled population are closely monitored for areas of opportunity.

After presentation at the QIC, the information is presented to the Quality Committee

of the Horizon Healthcare of New Jersey Board for review and discussion. As required

by the NJ State Medicaid Managed Care Contract and CMS regulations, grievance

reports are prepared and submitted to the state and CMS.

The Horizon NJ Health appeals staff handles all member and provider

Utilization Management appeals in accordance with the NJ State Medicaid Managed

Care contract requirements, applicable CMS regulations, and accreditation standards.

Please note that grievances may also be called complaints.

5.3.1.2 Medicare Grievances
CMS provides stringent guidelines related to the intake and resolution of

grievances received by Medicare enrollees. In order to meet the requirements, a

dedicated grievances team exists within the organization to resolve grievances. The



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focus of the team is to review and resolve grievances regardless of where they

originate within the organization. The grievances staff receives referrals by telephone

calls, written correspondence, internal referrals or legislative referrals. Grievances

received by 1-800-Medicare are also handled within the grievances team.

All grievances are reviewed in detail to identify the root cause of the issue.

There is continuous collaboration within various departments of the organization to

review and resolve grievances. All grievances are handled within the CMS designated

timeframe and follow all CMS guidelines as outlined in the Managed Care Manual

Chapter 13; Medicare Managed Care Beneficiary Grievances, Organization

Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans,

and Health Care Prepayment Plans (HCPPs), collectively referred to as Medicare

Health Plans. The staff member serves as a liaison between the member/provider,

delegated vendors, and regulatory bodies, and follows the grievance until

completion. Grievance inventory is monitored on a daily basis in order to ensure

grievances are acknowledged and resolved in a timely manner. The overall outcomes

are reviewed on a monthly basis in order to identify trends and any corrective action

is identified on a case-by-case basis. Quarterly grievance reports are presented to the

appropriate committees for review. Please note that grievances may also be called

complaints.

5.3.2 Quality of Care and Service
Within the Quality Management Department is a team that focuses on quality of care

issues. This team provides ongoing education to personnel regarding potential quality of care

concerns and serious adverse events. This education includes the definitions/categories for

quality of care referrals with direction on how staff can refer potential issues to the Quality

Management Department for investigation, and to the medical director for review. All

instances where a quality of care issue and/or serious adverse event, hospital acquired, or

provider preventable event may exist are presented to the Quality Peer Review Committee

(QPRC) for discussion, determination of departure from quality standards and guidelines, and

possible practitioner sanctioning.



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QPRC sanction determinations are forwarded to the Credentialing Committee for

inclusion in the provider's credentialing file. Quality of care referrals and provider sanctions

are tracked and trended by the QPRC. Entities that receive sanctions may be monitored by

the PC&S team through telephonic and medical record audits, as well as onsite visits. When

the QPRC issues sanctions against providers, the QPRC may require the provider to create and

implement corrective action plans (CAPs). These CAPs are reviewed by the QPRC for

completeness. The QPRC reports quality of care concerns (QOC), hospital acquired conditions

(HAC) and serious adverse events (SAE) to the QIC.

The Quality Management Clinical Operations RN staff provides quarterly education

sessions regarding quality of care referral categories. These information sessions are

conducted in offices and via WebEx. In addition to structured reviews of the criteria, the

Quality Management staff provides support to all referring staff to ensure correct creation of

referrals and grievances.

Quality of Care referrals are captured by a Tableau dashboard ? a comprehensive

repository of quality of care referrals and grievances. This dashboard follows all lines of

business and is updated daily. Information obtained from Tableau is used for monthly

monitoring of total cases referred, closed, and outstanding.

Readmission monitoring for quality of care indicators is reviewed prior to proceeding

with the UM appeal process. Working with the medical directors, cases are reviewed and

quality of care indicators are validated. If no quality of care indicators are identified, the UM

appeal process will commence.

Monthly data is reviewed for trends and outliers. In the event that a quality of care

indicator persists, referrals are made to the Provider Contracting & Strategy (PC&S) team.

PC&S reports the results of its investigation to the Provider and Member Services Satisfaction

Committees, which report to the QIC.

The QI Program is designed to maintain and enhance high quality of care and service

in an era of high expectations from our members and providers.



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5.3.2.1 Quality of Care and Service
The Clinical Quality Operations team has the ability to monitor and track quality of

care grievances and quality of care referrals for all lines of business including MLTSS

and FIDE-SNP. Data regarding these lines of business is reported to the QIC. In

addition, tracking of cases for members defined as aged, blind and disabled (ABD),

Division of Developmental Disabilities (DDD) and elderly is reported to the QPRC

committee. Potential quality of service issues identified for MLTSS, FIDE-SNP, ABD,

DDD, and elderly during the investigation of a quality of care issue will be referred to

the appropriate area for review and investigation.

5.3.2.1.1 Mortality Data

Another function of the Quality Management Department is the

tracking of mortality data for Medicaid, FIDE-SNP and MLTSS members. The

mortality data is also stratified by special populations as defined by the New

Jersey Medicaid HMO contract. These categories include aged, blind, disabled

(ABD), Division of Developmental Disabilities (DDD) and elderly members. On

an annual basis, the analysis is presented to the QPRC committee for review

and approval.

5.3.3 Programs for the Elderly and Disabled
Horizon continues to focus on the care of all members. In doing so, Horizon has

segmented the population to address the needs of the most critical members, which include

a focus on elderly members aged 65 years and older and members with disabilities. The

elderly and disabled population is managed by various programs including Care, Case and

Disease Management and Quality Management Programs. They are designed to outreach,

engage and educate both members and providers on the importance of preventive visits and

communication to providers on outcomes of care.

Horizon monitors, evaluates and reports on member outcomes for elderly and

disabled enrollees at least annually. Horizon tracks and reports on each population

separately. The program is comprised of functional standards to evaluate outcomes of care,

as well as measurement and distribution of outcome reports to providers. The program also

includes a process for communicating measurement standards to providers.



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The results are incorporated into the QI Program Evaluation. Horizon includes quality

indicators of potential adverse outcomes and provides appropriate education, outreach, case

management and other activities as outlined in the Medicaid Contract.

5.3.4 Population Health
Horizon manages Medicaid and Medicare members through multiple programs to

increase member satisfaction, improve health outcomes and reduce cost, known as the Triple

Aim. The Plan utilizes a data-driven approach to population health management of its

member population. This approach includes stratifying the population into four quadrants

(Healthy, Rising Risk, Complex Care and Safety and Outcomes). In addition, the population is

also segmented by location (zip code, city or county), age and gender.

The objective of the Population Health Management Program is to improve the

overall health and wellness of the population through programs that encourage preventive

health services, health and disease maintenance programs and appropriate utilization of

practitioner and other provider services. Through population analysis, interventions are

designed to understand the target population?s needs and barriers so that their needs are

met. The Population Health Program is available to all active enrolled members, who may opt

out via a telephone call to be placed on a do not contact list.

Annually, Horizon reviews and assesses the characteristics of the Medicaid and

Medicare populations and selects subpopulations to ensure that adequate programs and staff

are available to meet the health care needs of our members. Those subpopulations are

children and adolescents, members with disabilities, pregnant women, and members with

severe and persistent mental illness. Findings are presented, reviewed, and approved

annually by the Quality Improvement Committee (QIC).

5.3.5 Audits and Reports
The Program has oversight of audits and reports completed by multiple business

areas. There are several reasons that audits and reports are performed. Audits and reports

are required by the State, necessary to meet accreditation requirements, and they provide

Horizon with insights as to how processes, providers and systems are performing. Here is a

selection of the audits and reports that are performed and then reviewed by the QIC:



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? MLTSS Quarterly Audit
? FIDE-SNP Audits
? Geo Access Reports
? 24-hour Access Audit (Medical and Behavioral Health)
? Medical Record Review Audit (Medical and Behavioral Health)
? Appointment Availability Audit (Medical and Behavioral Health)
? Office Manager Satisfaction Survey (Medical and Behavioral Health)
? Behavioral Health Clinical and Quality Performance Measures
? EPSDT Audit
? Lead Report
? Vendor Oversight Audit


These audits are incorporated into the QI Program Work Plan. The QIC uses the work

plan to track the completion of these audits. The QIC reviews the results of these

audits/reports and provides each business area with recommendations about modifications

to improve usefulness.

5.3.6 Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
- Lead Screening

Lead screening using blood lead level determination must be done for every Medicaid-

eligible and NJ FamilyCare child between nine (9) months and eighteen (18) months of age,

preferably at twelve (12) months of age and a second time between 18-26 months, preferably

at twenty-four (24) months of age. Testing should be done on any children between twenty-

seven (27) to seventy-two (72) months of age who have not been previously tested. Horizon

provides a screening program for the lead toxicity in children, consisting of two components: a

verbal risk assessment and blood lead testing. The verbal risk assessment is given to providers

to perform at every periodic visit between the ages of six (6) months and seventy-two (72)

months. Monthly data reports are reviewed for the 9-18 month and 18-26 month age groups.

Those between 27-72 months that have not previously been tested are also included on this

report. Those members that have been tested and have an abnormal rate above 5 ug/dl are

handled by the Case Management Department for management and follow up. Additionally,

there are various lead monitoring methods and interventions in place to increase screening

rates plan-wide. Primary and secondary prevention methodologies have been adopted to

ensure lead screening takes place earlier, rather than later, in the applicable age groups. These



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interventions include, but are not limited to, member mailings, provider mailings, call

campaigns, provider onsite education, provider webinars, member gap-detail analysis and

community events.

In 2021, Horizon will continue to monitor initiatives to increase lead screening

awareness and lead testing. In addition to our interventions targeted towards all of our

members and providers, we have interventions specific to our hard-to-reach members who

appear on the annual member work plan. There are also specific interventions in place and

developed each year specific to providers falling under 80% lead testing compliance for two-

consecutive, six month periods. Those providers who are on this ?under compliance? list are

monitored throughout the year and reported to the Quality Peer Review Committee in the

case that they are unable to increase their rate to 80% or higher. Providers that are placed on

a CAP are notified in April following the measurement year (i.e. letters are sent out in April

2021 for providers under 80% for two consecutive, six month periods in 2020) via letter and

fax. They are advised that they have been placed on a CAP and their lead screening

performance will be monitored throughout the year (i.e. 2021 for 2020 non-compliance). In

August of the following year (August 2021 for 2020 non-compliance), providers who are still

under 80% compliance are notified via fax as a reminder that they have until year-end to

increase their lead screening rates. If their lead screening compliance is still below 80% by

year-end, they are referred to QPRC to determine further corrective action.

While provider compliance is key and monitored closely, there are a number of

interventions underway that support providers to increase their lead testing rates. These

efforts are proactive and ongoing throughout the year to maintain compliant rates and also to

improve low rates.

5.4 Policy Management
Annual policy review is conducted and presented by the responsible department to the QIC or

the applicable subcommittee or workgroup of the QIC. All policies are reviewed to comply with the

Corporate Policy and Procedure Development Policy and include the original effective date, current

effective date, most recent revision, most recent review dates, recertification date and revision

history. In addition, policies are reviewed for applicable regulatory and accreditation content.



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All policies are maintained on a policy repository portal. This allows all Horizon staff read-only

access to all current and archived policies. Monitoring of state compliance requirements is coordinated

with the Regulatory Affairs Department. Any policies requiring state (DMAHS or MFD) approval are

submitted to the GP Regulatory Affairs Department for submission to the state. Such policies which

require state/DMAHS review and approval require a DMAHS acceptance stamp on the policy and are

required to be submitted for State review 90 days prior to their recertification date or the change

effective date.

5.5 Delegation Oversight
Delegated managed care entities that administer health care services and/or provide covered

services under GP?s benefit plans are subject to review and oversight under the QI Program. These

services include, but are not limited to, activities/functions relating to utilization review/management,

case management, quality improvement, credentialing/re-credentialing, utilization management

appeals, HEDIS gap closures, radiology services, pharmaceutical services, laboratory services, vision

services, dental services, telemedicine, post-acute skilled nursing facility (SNF) and rehab care services,

durable medical equipment, grievances, customer service and claims processing.

Contracted delegates/vendors are obligated to provide and administer services in accordance

with contractual terms and conditions and applicable state and federal laws and statutes, including but

not limited to regulations set forth by the New Jersey Department of Banking and Insurance (DOBI),

New Jersey DMAHS Managed Care Contract provisions, the Health Claims Authorization, Processing

and Payment (HCAPP) Act, CMS regulations, Horizon policies and procedures, and current-year NCQA

standards and guidelines. Horizon remains accountable for the quality, integrity and appropriateness

of delegated functions and services provided by subcontractors for the Plan?s MLTSS, FIDE-SNP and

Medicare Advantage members.

It is Horizon?s responsibility to ensure monitoring and oversight activities are performed to

ensure delegate/vendor compliance and promote delivery of and access to quality and cost-effective

health care and services to members. The Delegate Vendor Oversight Committee is responsible for the

following: assessing ongoing monitoring and evaluation activities performed collaboratively and

independently by business units; evaluation of delegate/vendor performance results to ensure

business goals and outcomes are achieved to further the delivery of quality health goals and outcomes



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for our members and; ensuring subcontractor compliance with contractual provisions, regulatory

requirements and applicable accreditation guidelines.

A quarterly subcommittee report summarizing items and issues reviewed and discussed at

DVOC meetings must be submitted and presented to the QIC and the Horizon Quality Committee

Board (HQCB). A summarized overview on delegate/vendor oversight activities must also be submitted

to the Compliance and Ethics (C&E) Committee. Committee reports must include, but not be limited

to, delegate/vendor performance statistics, the status of delegate/vendor CAP (when applicable),

oversight monitoring reports and must highlight matters of importance and/or those that require the

attention of the QIC, HQCB or C&E Committee.



5.6 Compliance with State and Federal Regulatory and NJ Medicaid
Managed Care Contract Requirements
Government Programs places the utmost importance on compliance with regulatory and

contract requirements. This is particularly important as it relates to member safety, the handling of

private health information and the integrity with which the Plan cares for its members.

? Confidentiality
GP processes ensure confidentiality of protected health information about members and

physicians. Documents that are created and reviewed as part of the process are confidential and

privileged. Information is maintained in compliance with appropriate federal and state regulations,

the Health Insurance Portability and Accountability Act (HIPAA) and all applicable accreditation

standards. All employees, participating physicians, vendors and consultants must maintain the

Horizon standards of ethics and confidentiality regarding both member information and proprietary

information. All employees and non-employees are required to sign a confidentiality statement, as

well as any consultant or business associate that may need to access confidential member

information. In addition, certain business associates perform certain business functions on behalf of

Horizon involving the use, disclosure or receipt of private health information. These third parties are

business associates of Horizon and sign a Business Associate Agreement to protect the privacy and

safeguard the security of such private information when assisting with administrative functions or

providing services for or on behalf of the Plan.



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? Member Rights, Responsibilities and Patient Engagement
Horizon is committed to maintaining a mutually respectful relationship with its members that

promotes effective health care. Horizon makes clear its expectation for the rights and responsibilities

of members and sets a structure for cooperation among members, practitioners and the health plan.

Horizon recognizes that members must establish a dynamic partnership in the management of their

care, which includes the members' family and their health care practitioner.

Horizon complies with all applicable Federal civil rights laws and does not discriminate against

nor does it exclude people or treat them differently on the basis of race, color, gender, national

origin, age disability, pregnancy, gender identity, sex, sexual orientation or health status in the

administration of the plan, including enrollment and benefit determinations.

When care does not meet the member's expectations, Horizon assures members of their

right to voice grievances (complaints) and to appeal any decisions with which they do not agree.

? Regulatory Compliance
The QI Program through the QIC:

o Monitors regulatory requirements for quality management and compliance;

o Ensures that the appropriate actions are taken when areas of quality management non-
compliance are identified; and

o Ensures that the quality management reporting system provides adequate information for
meeting the regulatory external review and accreditation requirements of mandatory and
voluntary review bodies.

? Ethics
The program functions as a key component in the promotion of integrity and values in the

care and services provided to members. As outlined in the Horizon Corporate Code of Business

Conduct and Ethics, Horizon is committed to maintaining the highest legal and ethical standards in

the conduct of its businesses. In maintaining these standards, Horizon places heavy reliance on

individual good judgment, honesty and character. This commitment applies without exception to all

activities.



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5.7 Accreditation
Medicare and Medicaid lines of business are accredited by the NCQA. The Quality

Management Department, through the QI program, continuously monitors all applicable business

areas to ensure their compliance with the most current NCQA Health Plan Accreditation standards

and guidelines. The Accreditation Team provides education, assessment and feedback to business

areas for continual readiness in between reaccreditation cycles. The Accreditation Team monitors

compliance with standards on an ongoing basis and reports the status of accreditation activities at

least quarterly to the QIC. Horizon will notify DMAHS of any change to its accrediting body.

5.8 Credentialing and Re-credentialing
Horizon?s credentialing and re-credentialing activities are managed by the Credentialing

Department in a process that determines whether physicians, other health care professionals, and

organizational providers of services meet all applicable state licensing standards, participation and

credentialing criteria, and are qualified to provide the care or services for which they have been

contracted. Horizon maintains oversight of the credentialing and re-credentialing activities through

the QIC. In addition, the QPRC provides reports to the Credentialing Committee on quality of care and

service sanctions that are issued by the QPRC. This information is taken into account when providers

are evaluated for re-credentialing.

5.9 Clinical Practice Guidelines (CPGs)
CPGs are evidenced-based practice standards promoted by Horizon. They are used to assist

staff in making appropriate recommendations and to inform members and providers about making

educated health care decisions. Topics addressed by CPGs include, but are not limited to, preventive

health, asthma, diabetes, maternity, EPSDT, behavioral health and geriatric care. The CPGs are based

on nationally recognized medical association standards and medical references. The guidelines are

reviewed and updated at a minimum of every two years, or as needed, and they are presented to the

UM/CM Committee for approval. Information about Horizon?s CPGs is made available to providers

through the Provider Administrative Manual, provider newsletters and the Horizon website.

Guidelines are available to members through the website, member newsletters and can be requested

by calling the Member Services Department.



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5.10 Cultural Competency and Health Literacy
Horizon BCBSNJ recognizes the cultural diversity and health literacy needs of its health plan

members. The Plan is committed to promoting cultural competency, increasing health literacy, and

decreasing health care disparities, regardless of gender, age, race, ethnicity, disability, gender identity

or sexual orientation. Horizon utilizes data from multiple sources to develop and implement policies

and programs that increase cultural competency and health literacy. Staff and participating providers

receive education to enhance the provision of culturally competent and linguistically appropriate

care. Language assistance services, including bilingual staff and interpreter services, are offered and

provided to members at no cost. Horizon produces easily understood member-related materials in

languages that meet member needs.

The objective of cultural competency and health literacy efforts is to improve member
experience and communications by:

? Increasing the cultural competency of employees and providers
? Gaining a better understanding of the needs of our members through solicitation of

member feedback
? Optimizing members? experience with the health plan
? Enhancing the provision of quality care to members with diverse values, beliefs and

behaviors
? Encouraging the development of more effective strategies for communication with

members
? Identifying and overcoming barriers to the advancement of health care for diverse

groups


In evaluating cultural and linguistic needs, Horizon:

? Identifies linguistic needs and cultural backgrounds of members by using U.S. Census
data, enrollment data, language line utilization, analysis of grievances and member
feedback from surveys

? Identifies languages of practitioners in provider networks to assess whether they meet
members' linguistic needs and preferences


The data from these reports is analyzed and used by Horizon to adjust the practitioner

network if the current network does not meet members' language needs and preferences. Where

there is a deficiency, efforts are made to recruit providers and practitioners to meet the needs of the

underserved groups.



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Additionally, case managers identify member cultural, physical, auditory, vision and

linguistic barriers to care as a part of the Complex Needs Assessment process. Member needs are

assessed and barriers are addressed throughout the continuum of care.

5.11 Fraud, Waste, and Abuse
The Fraud, Waste and Abuse Prevention Plan documents the organization's comprehensive

approach to prevent, detect, investigate, recover and report cases of fraud, waste and abuse in the

Medicare Advantage, Medicare Advantage Part D, Medicaid, NJ FamilyCare, Horizon NJ Total Care,

Managed Long Term Services and Supports, Supplemental Social Security Income, Division of Child

Protection & Permanency and clients of the Division of Developmental Disabilities. The plan

supplements all Horizon policies and workflows on fraud, waste and abuse prevention, and provides a

framework for monitoring compliance with the following fraud waste and abuse-related

requirements including:

? NJ Medicaid Managed Care Contract
? Federal Program Fraud Civil Remedies Act, New Jersey False Claims Act
? New Jersey Anti-Fraud Prevention and Detection Plan Protocol, (N.J.A.C.

11:16-6.7)

Horizon routinely discovers issues that require intervention and analysis. The various

methods employed to aid in monitoring and identifying fraud, waste and abuse include daily queries,

the SAS analytical software package, referrals from internal departments, external referrals (i.e. State

Medicaid Fraud Unit, pharmacy audit vendors and fraud hotline) and media publications. Horizon?s

Medicaid and Medicare Special Investigations Unit (SIU) coordinates fraud waste and abuse activities

with all state and federal agencies. If a potential issue is identified, the information is reported to

Horizon?s Medicaid and Medicare SIU for evaluation and further action.

5.12 Program Performance
Horizon dedicates resources across the organization and within the Quality Management

Department to focus on quality performance. This work is guided by the QI program and included in

the QI program Work Plan. The QIC oversees this work, including the planning, monitoring and

evaluation of the outcomes of these efforts.



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5.12.1 QI Program Work Plan
Annually, the Quality Management Department creates the QI program Work Plan.

The work plan is presented to the QIC in the first quarter of the year. The QIC provides

recommendations for revisions and the committee approves the work plan. The QI program

Work Plan is designed to be inclusive of all aspects of the QI program?s responsibilities. The

work plan is updated as needed during the year to incorporate recommendations identified

through the completion of the QI Program Evaluation and/or by recommendations made by

the QIC. The QIC reviews the work plan at least quarterly to ensure that the activities outlined

are being addressed by the appropriate business owners, and to ensure progress is being

made toward the stated goals. If the QIC determines that progress is not being made toward

goals, the committee is tasked with providing recommendations to assist the business area in

identifying barriers and developing interventions to overcome the barriers. The 2021 QI Work

Plan will identify items applicable to Medicaid, Medicare, MLTSS and FIDE SNP.

5.12.2 Performance Improvement Projects (PIPs)
A performance improvement project (PIP) is a concentrated effort on a specific

problem within the health plan. Information is systematically collected for the clarification of

issues or problems, which are then the focus of improvement. Improvements are made via

the development of interventions. The Plan develops and conducts PIPs to examine and

improve care or services in areas that have been determined to contain deficiencies via the

analysis of data against a specific standard.

The Quality Improvement Operations team is responsible for assisting in the design,

implementation, execution, analysis and reporting of state- and CMS-required PIPs and

Chronic Care Improvement Projects (CCIPs). Plan Do Study/Check Act cycle in addition to Lean

Six Sigma methodologies are used to develop and ensure continuous quality improvement

throughout the entirety of each PIP.

5.12.2.1 Medicaid PIPs (State PIPs)
Horizon conducts four performance improvement projects (PIPs) specific to

its State/Medicaid membership. The topics for these PIPs are determined by DMAHS.

The current topics include: (1) MLTSS reducing admissions, readmissions and gaps in



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service for members with congestive heart failure in the Horizon MLTSS Medicaid

population; (2) Increasing Developmental Screening and Early Intervention; (3) FIDE-

SNP reducing admissions, readmissions and Emergency Room (ER) visits in members

with asthma; (4) MCO Adolescent Risk Behavior and Depression Collaborative. Twice

per year, Horizon submits reports to the State detailing its efforts and outcomes

related to each PIP. This takes place in April and August. In addition to semi-annual

submissions, Horizon monitors intervention implementation timeliness and

effectiveness along with all other PIP-related activities to ensure positive results.

5.12.2.2 Medicare PIPs (CMS PIPs/CCIPs)
Horizon participates in ongoing quality improvement programs for each

contract. The purpose of the QI program is to ensure that Horizon has the necessary

framework and infrastructure to coordinate care, promote quality, performance, and

efficiency on an ongoing basis. The guidelines followed and incorporated into the QI

programs are based on the 42 CFR? 422.152 regulation. Each Chronic Care

Improvement Project (CCIP) applies to the three MA contracts in place. Currently,

there are three CCIPs in place for each contract with a focus on promoting effective

management of chronic disease. The CCIPs in place have a three-year project cycle.

Horizon is no longer required to submit updates for its Medicare CCIPs to CMS, but

rather monitors CCIPs internally and submits an attestation that confirms the projects

are in place.

5.12.3 Healthcare Effectiveness Data and Information Set (HEDIS)
Medicare, FIDE-SNP and Medicaid HEDIS measures are evaluated and analyzed

monthly. Initiatives are developed, changed, and/or enhanced based on measure

performance. Initiatives and outreach activities are discussed with stakeholders in the HEDIS

workgroup meetings. HEDIS performance results are reported annually to the State, QIC,

NCQA and at the Quality Committee board meeting through review of the QI Program

Evaluation.

Annually, Horizon creates a new work plan to address State HEDIS measures that fall

below 50th percentile with the exception to the Lead Screening Measure, which is added if it

falls below the 75th percentile. This work plan is provided to DMAHS on or before August 15.



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Existing initiatives and outreach areas are evaluated for their impact and, if needed, are

enhanced to improve measure performance. The results and outcomes of initiatives and

outreach are monitored monthly and shared in HEDIS workgroup meetings held four times

per year.

5.12.4 Star Ratings
Medicare Star Rating measures are monitored monthly. Star Rating measures are

assigned to business owners who develop strategies, initiatives and outreach activities to

maintain and/or improve performance. Star Rating progress is reported to the QIC on a

quarterly basis and to executive leadership on a monthly basis. Star Rating measure

performance results are reported annually to the State (FIDE-SNP product only), to the QIC,

NCQA and at the Quality Committee board meeting through review of the QI Program

Evaluation.

5.12.5 Consumer Assessment of Healthcare Providers and Systems
(CAHPS)

The CAHPS survey captures accurate and complete information about member-

reported experiences and how well the Plan and providers are meeting members?

expectations and goals. The Quality Management Department coordinates Government

Programs? efforts to improve CAHPS scores for Medicare, Medicaid and FIDE-SNP for adults

and children. The planning, work and results of these efforts are reported to QIC directly.

Specific CAHPS work plans are created to manage each line of business. Horizon has

determined that in 2021, opportunity exists to continue efforts to improve on several key

measures. These measures focus on member experience and satisfaction, and they impact

the Plan?s overall ratings. The QI Program Work Plan will incorporate the QIC?s oversight of

CAHPS improvement efforts. All CAHPS scores are reported to DMAHS. If Horizon conducts an

additional non-CAHPS member satisfaction survey, it will send the results of the survey to

DMAHS.

5.12.6 Health Outcomes Survey (HOS)
The Health Outcomes Survey (HOS) provides an assessment of how Horizon members

describe changes in their health status over time. Horizon?s Customer Experience team



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analyzes the results of the HOS survey and this analysis is presented to the QIC for discussion

and recommendations for interventions that can be put in place to improve survey results.

Review of the HOS survey results is included in QI Program Work Plan.

5.13 New Initiatives
In 2021, Horizon will be embarking on multiple new initiatives. While all of Horizon?s new

initiatives have the potential to impact the quality of care and service provided to members, the

following specific initiatives require direct monitoring by the QI program because of their scope and

impact on members and providers.

? In an effort to improve member experience, Medicaid members are no longer required to
obtain a referral from their PCP to visit an in-network specialist. This change occurred in

2020, however additional efforts will be taken in 2021 to ensure that members are aware of

this change.

? Horizon has engaged providers on clinical best practice including coordination of care. In
parallel, Horizon has performed member outreach to provide reminders and education for

gaps in care. The Quality Performance Improvement team developed a new intervention

aimed at partnering Horizon?s outreach coordinators with a selected (piloted) subset of

provider groups to improve coordination of care and throughput among their member panel.

Selected providers with volumes will be confirmed in the 4th quarter of 2020. The outreach

coordinators will work with provider representatives to confirm gaps in care, identify open

orders and scripts and facilitate appointments. By working together, outreach coordinators

will be better informed before initializing the call with the member. This will improve the

member?s experience and perspective on their healthcare. The partnership will also support

members in addressing open healthcare concerns by connecting them to the targeted care

they need.

? The Horizon Quality Improvement Operations team developed two new Performance
Improvement Projects that will be initiated in 2021:

o Increasing PCP Access and Availability for members with low-acuity ED visits ?
Horizon NJ Total Care (FIDE-SNP) Membership



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? Aim: By the end of each measurement year, Horizon NJ Total Care aims to
improve access and availability to primary care for continuously enrolled FIDE

SNP members greater than 6 years of age within designated practices with

high emergency department (ED) utilization for low acuity, non-emergent

(LANE) only diagnoses. Detailed performance increases will be specified and

included once participating practice groups have been confirmed and

baseline data for the practice groups has been finalized.

o Increasing PCP Access and Availability for members with low acuity, non-emergent ED
visits ? Core Medicaid Membership

? By the end of each measurement year, Horizon NJ Health aims to improve
access and availability to primary care for continuously enrolled core

Medicaid members greater than 6 years of age within designated practices

with high emergency department (ED) utilization for low acuity, non-

emergent (LANE) only diagnoses. Detailed performance increases will be

specified and included once participating practice groups have been

confirmed and baseline data for the practice groups has been finalized.

5.14 Opportunities for Continued Improvement
Opportunities for improvement that are identified in the QI Program Evaluation are

incorporated into the following year?s QI Program activities for implementation and monitoring by

the QIC including but not limited to:

? Improving collaboration with the Grievance Dept. to ensure timeliness of referrals to
Quality of Care team

? Star Rating?focused implementation of improvement initiatives
? Improving lead screening rates across all counties
? Reducing the volume of providers whose lead testing rates are under 80% for YE 2020.
? Improving the rates of preventive vaccines in the DDD population
? Reducing admissions, readmissions and gaps in services for members with congestive

heart failure in the Horizon NJ Health MLTSS Medicaid population
? Eliminating dental provider network deficiencies in Atlantic County
? Eliminating MLTSS provider network deficiencies in Gloucester and Salem counties
? Improving timeliness of grievance processing
? Continuing focus on CAHPS - to ensure that member satisfaction is achieved.





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? Improving Medicaid HEDIS performance to reduce the number of items on the State
work plan and achieve 3.5 stars in NCQA accreditation

? Addressing gaps and opportunities for improvement with underperforming delegates.
? Improving CAHPS performance for both the Medicaid Adult and Child Population


Horizon will pursue these opportunities for improvement in 2021 and include updates to

activities in the QI Work Plan to monitor, track and trend progress toward goals.