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5. QI Program’s Function

The function of the QI Program is to coordinate, oversee, guide, and assess 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 NJ 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 NJ 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.

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 2022, 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 are 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 2022 and will be included in the 2022 QI Work Plan. Current topics under review include Breast Cancer Screening (BCS), Cervical Cancer Screening (CCS), Food Insecurity in the FIDE-SNP population, 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. Food insecurity is a new project for 2022. Ongoing interventions from 2021 for BCS, CCS, Prostate Cancer Screening, Social Determinants of Health and the Maternal Health Learning Collaborative will continue through 2022.

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 Departments (product line specific) 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 Network Contracting & Servicing Department reviews geographical access reports to address the adequacy of the provider network. Reporting assesses sufficiency of PCP, obstetrics and gynecology, high volume and high impact specialties required to serve the membership. Identified deficiencies in the network are addressed to reduce barriers to care and to ensure continuity of care for members.

5.3 Quality Assurance

5.3.1 Grievances

5.3.1.1 Medicaid Grievances

Horizon is committed to improving the efficiency and quality of how the Plan manages grievances. Grievance analysts are trained to ensure grievances are handled timely and efficiently. Training includes reviewing the process for identifying quality of care issues and making outbound calls to providers to solicit information. In addition, 100 percent of all grievances receive a quality review prior to closure. During this process, an auditor reviews the grievance to ensure complete and accurate documentation, and to make sure the case is fully resolved prior to closure. This step ensures that member and provider grievances are addressed appropriately.

The Grievance Resolution Department addresses member and provider grievances within the timeframes required by the NJ Medicaid Contract, CMS Health Maintenance Organization (HMO) regulations, and in accordance with applicable NCQA standards. The staff receives grievances through incoming telephone calls to the member/provider services areas, referrals from the DMAHS, CMS referrals, internal and external direct calls, written correspondence, and the email function in the member portal on the website. 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 grievance resolution staff participate 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 handling performance 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 Member and Provider Services Satisfaction Committees by line of business. Trends for the elderly and disabled population are closely monitored for areas of opportunity. After presentation in committees, the information is presented to the QIC and the Quality Committee of the Horizon Healthcare of New Jersey Board for review and discussion. As required by the NJ Medicaid Managed Care Contract and CMS regulations, grievance reports are prepared and submitted to the state and CMS.

5.3.1.2 Medicare Grievances

CMS provides stringent guidelines related to the intake and resolution of grievances received from Medicare enrollees. In order to meet the requirements, grievances are resolved by a dedicated group in Service Operations. Their focus is to review and resolve grievances regardless of where they originate within the organization. Grievances are received via telephone calls, written correspondence, cases directed to Horizon by beneficiaries or their advocates making calls made to 1-800 Medicare line, internal referrals and referrals from legislators on behalf of their constituents.

All grievances are reviewed in detail to identify the root cause of the issue. There is continuous collaboration within various departments (including but not limited to UM, CM, Appeals, Provider Contracting and Behavioral Health) 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 members handling grievances serve as liaisons between the member/provider, delegated vendors, and regulatory bodies, and follow the grievance through resolution. Grievance inventory is monitored on a daily basis in order to ensure they are acknowledged and resolved in a timely manner. The overall outcomes are reviewed on a monthly basis in order to identify trends and indicated corrective actions are identified on a case-by-case basis. Quarterly grievance reports are presented to the Quality Board, Member Services Satisfaction Committee and the Provider Services Satisfaction Committee.

5.3.2 Quality of Care and Service

The Quality Management Department is responsible for identifying and addressing quality of care issues. Ongoing education is provided 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 condition, 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, when indicated, the issuance of an appropriate sanction to the responsible provider.

QPRC sanction determinations are forwarded to the Credentialing Department 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 Network Contracting & Servicing team through telephonic and medical record audits, as well as onsite visits. When the QPRC sanctions providers, the QPRC may require the provider to establish 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 education sessions to Horizon staff members regarding quality of care referral categories. These information sessions are conducted 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 in 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 unacceptable performance on a quality of care indicator persists, referrals are made to the Network Contracting & Servicing Department, which reports the results of its investigation to the Provider and Member Services Satisfaction Committees. These committees report to the QIC.

The QI Program is designed to maintain and enhance quality of care and service commensurate with the expectations of our members, network providers and other constituents.

5.3.2.1 Quality of Care and Service

The Quality Management Department monitors and tracks quality of care grievances and quality of care referrals for Medicaid, Medicare, MLTSS and FIDE-SNP. Data related to quality of care concerns 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 are 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 vulnerable members, which includes a focus on members aged 65 years and older and members with disabilities. The elderly and disabled population is addressed 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 routine preventive care.

Horizon monitors, evaluates and reports on health 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.

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 required by the NJ Medicaid Contract.

5.3.4 Population Health

Horizon establishes multiple programs to increase member satisfaction, improve health outcomes and reduce cost, (collectively often called “the Triple Aim”) for Medicaid and Medicare Advantage plan members. The Plan utilizes a data-driven approach to population health management. This approach includes stratifying the population into four quadrants (Healthy, Rising Risk, Complex Care and Safety, and Outcomes).

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, chronic disease management programs and appropriate utilization of services. Through population analysis, interventions are designed to serve the target population's needs and to remove barriers so that their health care needs are met. The Population Health Program is available to all active enrolled members, who may opt out via a telephone call, in which case they are placed on a do not contact list.

Annually, Horizon reviews and assesses the characteristics of the Medicaid and Medicare populations and select subpopulations to ensure that adequate programs and staff are available to meet the health care needs of our membership. Those subpopulations are children and adolescents, members with disabilities, pregnant women, and members with severe and persistent mental illness. Findings are presented, reviewed, and accepted annually by the Quality Improvement Committee (QIC).

5.3.5 Audits and Reports

The Quality Management Program has oversight of audits and analyses completed by multiple business areas. These audits and analyses are performed to satisfy requirements established by NJ and to meet accreditation standards. Reports from these audits provide Horizon with insights as to how processes, information systems and components of the health care delivery system are performing. The following audits and analyses are performed with comprehensive reports then reviewed by the QIC:

  • 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 Audits

This body of work is incorporated into the QI Program Work Plan. The QIC uses the work plan to track the completion of these activities. The QIC reviews the results of these audits and analyses, and may issue recommendations to each business area for modifications to improve the usefulness of the output.

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 performed 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 lead toxicity in children, consisting of two components: a verbal risk assessment and blood lead testing. The verbal risk assessment is delivered to network primary care providers to perform at every periodic visit between the ages of six (6) months and seventy-two (72) months. Monthly reports of the rate of screening 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 directed to the Case Management Department for attention 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 promote lead screening earlier, rather than later, in the applicable age ranges. These interventions include, but are not limited to, member mailings, provider mailings, outbound call campaigns, provider onsite education, provider webinars, directed outreach to members identified as deficient in lead screening on health plan analyses and community health promotion events.

In 2022, Horizon will continue to monitor initiatives to increase lead screening awareness and lead testing. In addition to our interventions directed to all of our members and providers, we pursue interventions specific to hard-to-reach members and providers that are on a corrective action plan (CAP). Providers are place on a CAP when they are noncompliant (< 80%) for two or more consecutive six-month periods. All providers on the CAP work plan are placed on a CAP and notified in June following the measurement year (i.e. letters will be sent out in June 2022 for providers under 80% for two or more consecutive, six month periods in 2021) 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. 2022 for 2021 non-compliance). In August of the following year (August 2022 for 2021 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 Quality Peer Review Committee (QPRC) to determine further corrective action.

While the standard processes primary care practices serving the pediatric community put in place to include lead screening as part of routine preventive care and developmental assessment serve as the foundation, Horizon NJ Health pursues a number of interventions to support providers to increase their lead testing rates. These efforts are proactive and ongoing throughout the year to optimize this important public health effort.

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. Policies affecting the delivery of health care and customer service 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.

All policies are maintained on a policy repository by the departmental owners. All Horizon staff have 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 Regulatory Affairs Department for submission to the state. The state annually reviews the listing of applicable policies and issues any updates for the contractually required submissions. Such policies which require state/DMAHS review and approval (with substantive policy changes or state requested annual reviews) require a DMAHS acceptance stamp on the policy and are required to be submitted for review 90 days prior to their recertification date or the change effective date.

5.5 Delegation Oversight

Delegated managed care entities that administer services, which would otherwise be performed by the health plan, 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, efforts to identify indicated preventive and chronic care services captured in HEDIS which do not appear to have been delivered and to promote the delivery of such services, diagnostic imaging and other diagnostic 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 effective monitoring and oversight activities are performed to promote delivery of and access to quality and cost-effective health care and services to members. The Delegate Vendor Oversight Committee is responsible for (a) assessing ongoing monitoring and evaluation activities performed collaboratively and independently by business units, (b) evaluation of delegate/vendor performance results to ensure business goals and outcomes are achieved, and (c) ensuring delegate/vendor compliance with contractual obligations as outlined in their service agreements with Horizon, 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 of 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 measures and the status of any delegate/vendor CAP oversight monitoring, and must highlight matters of significance 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

Horizon 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 quality of services provided to members.

  • CONFIDENTIALITY EXECUTIVE MEDICAL DIRECTORS
    Horizon's processes ensure confidentiality of Protected Health Information (PHI). Documents containing PHI that are created and reviewed as part of health plan operations are confidential. Such 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 are required to maintain the Horizon standards of ethics and confidentiality regarding both member information and proprietary company information. All employees (and non-employees who are granted access to PHI and proprietary company information) are required to sign a confidentiality statement or Business Associate Agreement. In addition, certain business associates perform business functions on behalf of Horizon involving the use, disclosure or receipt of member PHI. These third parties also sign a Business Associate Agreement to protect the privacy and safeguard the security of PHI when assisting with administrative functions or providing services for or on behalf of the Plan.

  • MEMBER RIGHTS, RESPONSIBILITIES AND PATIENT ENGAGEMENT
    Horizon is committed to maintaining a mutually respectful relationship with its members that promotes the delivery of effective health care. Horizon makes clear its expectation for the rights and responsibilities of members and sets forth 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 members' families and their health care practitioner. Horizon complies with all applicable Federal civil rights laws and does not discriminate against, exclude or treat people 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 offers members the right to voice grievances (complaints) and to appeal any health plan coverage or benefit determination with which they do not agree.

  • REGULATORY COMPLIANCE

    The QI Program through the QIC:

    • Monitors adherence to regulatory requirements for quality management and compliance;
    • Ensures that the appropriate actions are taken when instances of non-adherence to established requirements by the quality management program are identified; and
    • Ensures that the quality management reporting system provides adequate information for determining that Horizon satisfies the regulatory, external review and accreditation requirements to which Horizon is obligated and to which Horizon voluntarily subjects itself.

    Medicaid Regulatory Requirements:

    • Monitors compliance with applicable regulations including the Medicaid Contract, and state and federal legislation, rules and regulations;
    • Assists with remediation of any identified deficiencies in compliance with applicable law and contractual obligations; and
    • Interacts with state regulators in demonstrating compliance with applicable laws and contractual obligations, including responding to inquiries, supplying reports, and related activities in furtherance of demonstrating compliance to specific standards.

    Medicare Advantage Regulatory Requirements:

    • Reviews and appropriately disseminates CMS guidance and communications to business stakeholders, thereby promoting the timely and accurate implementation of business practices necessary to meet new and revised requirements;
    • Coordinates and facilitates all regulatory audits and external reviews to demonstrate compliance with applicable regulatory requirements and avoid adverse actions;
    • Identifies, assesses, and discloses regulatory risks pertaining to the Medicare Advantage line of business; and
    • Reviews Medicare Advantage marketing and communication materials to ensure clear, truthful, and regulatory-compliant language

  • ETHICS
    The program functions as a key component in the promotion of integrity and corporate values in the care and services provided to members. Our corporate values drive our work and culture. They include striving for a culture of excellence, remaining member-focused and thinking innovatively. 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.

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. Accreditation specialists provide education, assessment and feedback to business areas for continuous readiness throughout reaccreditation cycles. The Quality Management Department monitors compliance with standards on an ongoing basis and reports the status of accreditation activities at least quarterly to the QIC. Horizon notifies DMAHS annually of its accreditation status for the Medicaid line of business.

5.8 Credentialing and Re-credentialing

Horizon's credentialing and re-credentialing activities are managed by the Credentialing Department through a process that determines whether physicians, other health care professionals, and organizational providers of services meet all applicable state licensing standards, maintain minimum professional liability insurance coverage, are in good standing with relevant licensure, professional organizations, and state and federal health care programs, and are qualified to provide the care or services for which they have been admitted to the Horizon participating provider network. All physicians, other health care professionals and organizational providers are subject to credentialing upon initial application to join our Networks and are subject to re-credentialing every 36 months thereafter. The Credentialing Department coordinates ongoing monitoring on a monthly basis to ensure that physicians, other health care professionals and organizational providers maintain their applicable licensure and remain in good standing in the medical community. 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 considered at the time of re-credentialing. Horizon maintains oversight of credentialing and re-credentialing activities through the QIC.

5.9 Clinical Practice Guidelines (CPGs)

CPGs are evidenced-based practice standards adopted 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 the standards and guidelines promulgated by respected professional organizations and governmental bodies and published in credible medical references. The guidelines are reviewed and updated at a minimum of every two years and they are presented to the UM/CM Committee for review and 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 Horizon website, and upon request by calling the Member Services Department.

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 related to gender, age, race, ethnicity, disability, gender identity or sexual orientation. Horizon utilizes data from multiple sources to identify disparities in health care and health outcomes, using this information to develop and implement efforts that address 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 when interacting with the Plan or health care providers. 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:

  • Providing training on cultural competency for employees and providers
  • Promoting diversity in recruiting and hiring
  • 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
  • Promoting health equity

In evaluating cultural, racial, ethnic and linguistic needs, Horizon:

  • Identifies linguistic needs and cultural backgrounds of members by using U.S. Census data, language preference data collected at enrollment, language line utilization, analysis of grievances and member feedback from surveys
  • Conducts population assessments annually to assess the cultural, racial, ethnic and linguistic needs of its member populations
  • Identifies languages spoken by 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.

Additionally, case managers identify member cultural, physical, behavioral health, 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 for the Medicare and Medicaid lines of business. 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. Various sources of information are used to aid in monitoring and identifying fraud, waste and abuse. These include daily queries, SAS analytical software (used for statistical analysis and fraud identification), 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.

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 reviews and, after deliberation and any indicated revisions, 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 by the QIC 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 2022 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 to identify issues or problems, which then become the focus for improvement activities. Interventions are monitored to ensure they are driving the intended improvements. The Plan develops and conducts PIPs to examine and improve care or services for members in areas that have been determined to contain deficiencies following analysis of performance against a specific standard.

The Quality Management Department 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 duration of each PIP.

5.12.2.1 Medicaid PIPs (DMAHS PIPs)

Horizon conducts six performance improvement projects (PIPs) specific to its Medicaid membership. The focus for these PIPs are determined by DMAHS and include: (1) MLTSS reducing admissions, readmissions and deficiencies in receipt of generally indicated services for members with congestive heart failure in the Horizon MLTSS Medicaid population; (2) FIDE-SNP PCP Access and Availability; (3) Core Medicaid PCP Access and Availability; (4) MLTSS Improving Care Coordination after Mental Health Hospitalization; (5) MCO Adolescent Risk Behavior and Depression Collaborative; (6) Core Medicaid Improving Childhood Immunizations and Well-Child Visits. Twice per year, Horizon submits reports to DMAHS 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 outcomes.

5.12.2.2 Medicare PIPs (CMS PIPs/CCIPs)

Horizon participates in ongoing quality improvement programs for each Medicare Advantage 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 currently in place. Three CCIPs are established 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 monitors CCIPs internally and submits an attestation that confirms the projects are in place.

5.12.3 Healthcare Effectiveness Data and Information Set (HEDIS)

Performance on HEDIS measures for Medicare, FIDE-SNP and Medicaid is evaluated and analyzed monthly. Initiatives are developed, revised, and/or enhanced based on measured performance. Initiatives and outreach activities are addressed with stakeholders in HEDIS Workgroup meetings. HEDIS performance results are reported annually to DMAHS, and, NCQA and internally to QIC and at the Quality Committee of the Board as part of the review of the QI Program Evaluation.

Annually, Horizon creates a new work plan to address NJ Medicaid plan HEDIS measures that fall below the 50th percentile of national HEDIS health plan performance, with the exception of 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 15th each year. Existing initiatives and outreach areas are evaluated for their impact and, if appropriate, 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. Responsibility for performance on 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 DMAHS (FIDE-SNP product only), to the QIC, and to the Quality Committee of the Board through review of the QI Program Evaluation.

5.12.5 Consumer Assessment of Healthcare Providers and Systems (CAHPS)

The CAHPS survey captures information about member-reported experiences and how well the Plan and providers are meeting members' expectations and goals. The Quality Management Department coordinates efforts intended to improve performance on CAHPS survey items for members enrolled in Medicare Advantage plans, Medicaid plans and FIDE-SNP for both adults and children. The planning, work and results of these efforts are reported to the QIC. Specific CAHPS work plans are created for each line of business. Horizon has determined that in 2022, the 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 for NJ Medicaid and FIDE-SNP are reported to DMAHS. If Horizon conducts an additional non-CAHPS member satisfaction survey of Medicaid members, those results are also submitted to DMAHS.

5.12.6 Health Outcomes Survey (HOS)

The Health Outcomes Survey (HOS) provides an assessment of how Horizon's Medicare members describe changes in their health status over time. The survey is administered by SPH Analytics, a CMS Certified vendor, to a random sample of Medicare beneficiaries. Horizon's Customer Experience Department analyzes the results and presents them to the QIC for discussion and recommendations for interventions to improve survey results. Review of the HOS survey results is included in QI Program Work Plan.

5.13 New Initiatives

In 2022, 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 Q3 of 2021 an online Provider Resource Center was created for network providers to access resources and materials related to quality improvement. This initiative began in 2021, however additional efforts will be taken in 2022 to ensure that providers are aware of this resource.

  • Horizon NJ TotalCare (HMO D-SNP) will conduct an internal study on FIDE SNP members with chronic conditions in 2022. The study will look at members' utilization of healthy food benefits to see if there is any correlation to readmission rates and/or member satisfaction rates.

  • Horizon Quality Task Force, which seeks to streamline Quality programs for key Provider Alliance partners.

  • In 2022, a pre-delegation evaluation will be completed for TurningPoint Healthcare Solutions to provide utilization management services for the Medicaid population.

  • An interactive voice message is being created to inform members of the benefits of care coordination between medical and behavioral health providers.

  • Horizon will take an inventory of maternal health initiatives, conduct an opportunity analysis, identify disparities related to race and social barriers and propose potential solutions as part of the Pledge to Maternal Health Disparities in 2022.

  • The Compliance and Grievance Departments will work together in 2022 to develop an employee training module designed to improve identification and classification of grievances.

  • Horizon's Quality Department developed two new Performance Improvement Projects that will be initiated in 2022:
    • Improving Childhood Immunization and Well-Child Rates While Strengthening the Relationship to a Pediatric Medical Home in the Horizon NJ Health Population.
      • By the end of each measurement year, Horizon NJ Health aims to increase the rate of members 30 months of age and younger whose well-child visits were completed at the primary provider's office by 5%. In addition, Horizon plans to improve member adherence to pediatric preventive health guidelines calling for completion of Combination 10 immunizations by 24 months of age by 3% each measurement year.


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    • Improving Coordination of Care and Follow-up After Mental Health Hospitalization in the MLTSS Home and Community Based (HCBS) Populations. This PIP is specific to MLTSS HCBS members 7 years of age or older with a HEDIS-defined mental health diagnosis.
      • By the end of each measurement year (2022 is measurement year 1), Horizon NJ Health aims to improve the performance on the proportion of continuously enrolled members that had a well visit, improve performance on the proportion of members that had outreach by an MLTSS case manager following a mental health related inpatient admission, improve follow up with a PCP or mental health specialist after an inpatient admission, and reduce the proportion of members that had a mental health related readmission.

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:

  • Completion of quarterly surveys of new Medicaid enrollees to ensure they understand available services and Plan procedures

  • Improving provider compliance with appointment availability standards

  • Improving provider compliance with after-hours access standards

  • Implementing initiatives focused on improving Star Ratings

  • Improving lead screening rates across all counties

  • Reducing the volume of providers whose lead testing rates are under 80% for year end 2021

  • Improving the rates of preventive vaccines for all populations

  • Improving Medicaid member access to dental care in counties where a network deficiency has been identified

  • Expanding the MLTSS provider network to include at least two providers of adult social day care in each county where two such entities offering such services exist

  • Improving clinical performance with a focus on measures that fell below the NCQA 50th Percentile

  • Improving Medicaid HEDIS performance to reduce the number of items on the DMAHS work plan

  • Addressing 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 2022 and include updates to activities in the QI Program Work Plan to monitor, track and trend progress toward goals.