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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 Supplement, Medicare Advantage HMO, MA PPO and Part D product lines. Horizon Healthcare of New Jersey is the contracting entity for the Horizon NJ TotalCare (HMO D-SNP) and Horizon NJ Health (Medicaid) 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 to the Vice President and Chief Medical Officer (VP/CMO) who has authority over and responsibility for the development and implementation of all QI Program activities. The Director of Quality Performance and Stars, 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 QI Program.

4.2 Committees

The organizational structure of the committees supports the implementation of the QI 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 (based on race, ethnicity, cultural background, sexual orientation, gender identity etc.) across the plan. The workgroup brings together staff from multiple departments (including CM, UM, Quality and Population Health) 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 and include participation from external physicians

  • 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 the QIC 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 Horizon provides 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 Horizon's behalf related to health care delivery and customer service. 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 intended to improve the quality and customer experience of the care and services provided to Medicare beneficiaries. The committee coordinates efforts that focus on improving the plan's performance as measured by the Medicare Star Rating and CAHPS scores.

  • HEDIS WORKGROUP
    The HEDIS Workgroup is an interdisciplinary team with representation from the Quality, Case Management, Utilization Management, Behavioral Health, Dental, Pharmacy, Delegate and Vendor Oversight Departments. The workgroup 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 for reviewing 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. This committee includes active involvement from external physicians.

  • 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 (FIDE-SNP) COMMITTEE
    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. The APA committee meets monthly.

  • 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 Horizon members. QPRC reviews both medical and behavioral health quality of care issues, and a behavioral health practitioner is actively involved in the review of behavioral healthcare issues. The QPRC includes participation from external physicians.

  • 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)
    The purpose of the CHAC is to provide a vehicle for member feedback and to provide members with health care education, outreach and information. Meetings include presentations by community partners and often highlight speakers serving diverse populations. The CHAC meets quarterly and reports into the Member Services Satisfaction Committee.

  • PROVIDER SERVICE SATISFACTION COMMITTEE (PSSC)
    The purpose of the PSSC is to oversee and ensure provider satisfaction with the Plan. The PSSC 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, 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 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 Organizational Chart

Organizational Chart information is reserved for internal use only.

4.5 QI Program's Resources

Horizon's executive leadership and all departments serving Horizon Healthcare of NJ and Horizon Healthcare Services contribute to the success of the QI Program through their focus on quality in their daily activities and their participation in the QIC. Horizon 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 Horizon that support the QI Program.

QI Programs Staffing:

  • VICE PRESIDENT AND CHIEF MEDICAL OFFICER (VP/CMO)
    The VP & Chief Medical Officer (VP/CMO) of Horizon is a board-certified New Jersey licensed physician, experienced in health insurance, managed care plan operations, NCQA accreditation and pharmacy benefit administration. 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. These initiatives include accreditation and CMS Star programs, as well as furnishing strategic and Utilization Management (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 CLINICAL BEHAVIORAL HEALTH
    The Senior Medical Directors, Medical Directors, Director of Clinical 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, quality of care referrals, HEDIS/Stars/CAHPS/HOS initiatives and corrective action plans (CAPs). A senior medical director also serves as the Chairperson the QIC.

  • QUALITY IMPROVEMENT COMMITTEE CHAIRPERSON
    The Quality Improvement Chairperson (or Chair Designee) 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 chairperson is responsible for the creation and execution of the QI Program Description, work plan, and annual evaluation, as well as all of the functions carried out by the Quality Management Department. The Chairperson or designee chairs the QIC and is a voting member of select QIC subcommittees. The chairperson's representation and voting rights on QIC subcommittees may be delegated to medical directors within Horizon or a director within the Quality Management Department.

  • DIRECTOR, QUALITY PERFORMANCE AND STARS
    The Director of Quality Performance and Stars 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 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 leads and directs processes and overall quality improvement activities that produce better patient care and more efficient operations. The Director is also responsible for the oversight of the business areas within the Quality Management Department including HEDIS, Star Ratings, Pay-for-Performance and population health. The Director represents the Quality Management Department in committee meetings and may serve as the Quality Management Medical Director's co-chair.

  • DIRECTOR OF QUALITY MANAGEMENT PERFORMANCE AND REPORTING OPERATIONS
    The Director of Horizon Quality Management Performance and Reporting Operations acting as Horizon BCBSNJ's resource in operating the Horizon Quality Program performance reporting requirements and reports directly to the Director of Quality Performance and Stars. The Director has a Bachelor of Arts degree and maintains expertise in HEDIS Reporting and Quality Data Management across multiple products and programs. The Director is responsible for strategic and tactical leadership for quality improvement and reporting across the organization as required by NCQA, DMAHS, CMS and reported through the Inovalon ONE® Platform. They also direct the design and implementation of quality health measure reporting and their associated activities required by NCQA, DMAHS and CMS, including HEDIS initiatives and related activities assigned for all Horizon products.

  • DIRECTOR, QUALITY MANAGEMENT PERFORMANCE IMPROVEMENT
    Horizon's Director of Quality Management Performance Improvement reports to the Director of Quality Performance and Stars. The Director has experience leading HEDIS performance improvement strategies and has extensive knowledge of NCQA, CMS and State regulatory requirements. The Director develops and monitors performance improvement strategies for Horizon with specific goals for quality improvement. The Director oversees member communication initiatives as it relates to HEDIS gap closure, which include member and provider education and monitoring the effectiveness of all campaigns. The Director develops departmental reports and presents these reports to the leadership group directly and through the committee reporting structure.

  • 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. Quality Managers are nurses, social workers and non-clinicians with backgrounds in quality assurance, compliance, analytics and regulatory affairs. 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-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.

  • PERFORMANCE IMPROVEMENT PROJECT SPECIALISTS
    The Quality Department responsible for the design, implementation, execution, analysis, and reporting of New Jersey Division of Medical Assistance and Health Services (DMAHS) and Centers for Medicare & Medicaid Services (CMS) required Performance Improvement Projects. 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.

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:

  • NETWORK CONTRACTING & SERVICING
    Network Contracting & Servicing 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
    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
    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 Division 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 NJ TotalCare (HMO D-SNP). Annually, IPRO conducts an assessment of Horizon's operations to determine if the plans have implemented and operationalized State-mandated contractual requirements. The Quality Management Department is responsible for preparation, the submission of documentation and the coordination of the annual review by IPRO. After the annual assessment is completed and Horizon 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.

Additionally, as a follow up to the Annual Assessment and Quality Improvement Project reports, the plan receives a request for responses to annual recommendations from IPRO that aggregate and analyze 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 DMAHS' annual Quality Technical Report. IPRO also reviews the results of Horizon's provider audits, HEDIS performance, CAHPS performance and Performance Improvement Projects (PIPS) to evaluate the quality of care received by members.

In addition to the external quality reviews performed by IPRO, 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 evaluated by NCQA as part of the health plan accreditation process.

4.7 Behavioral Health

The Behavioral Health Program ensures the provision of quality behavioral health care for members. 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 Network Contracting & Servicing Department reviews 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.