As 2016 comes to a close, I am proud to report that QualCarehas experienced another successful year of growth andexpansion. We have launched new initiatives that hold greatpromise for the future including the Community CareNetwork (CCN) in New Jersey and our participation inCareAllies which will have a national presence. In addition,we have added new hospital and health system clients acrossthe country by creating new patient driven, communitycentered health plan options.

Being part of the Cigna organization has presented QualCarewith the opportunity to offer our platform to provider groupsacross the country. Specifically, we have been able to createnew patient-centered, locally tailored options for clientsoutside of New Jersey, like Piedmont Healthcare and SetonHealth Plan. In the short 18 months that we have become partof the Cigna family, QualCare has added 43,000 new coveredlives in Texas, Georgia, California, Massachusetts, Marylandand elsewhere; this expansion is anticipated to continuethroughout 2017 across all product lines.

While we continue to grow our business across the country,we are very excited about the expansion of new products herein New Jersey. QualCare recently launched the CommunityCare Network (CCN) which offers small and mid-sizedemployers more affordable healthcare options. The AffiliatedPhysicians and Employers Health Plan (APEHP-MEWA) willoffer four new health plan options, which will access theCommunity Care Network. The CCN is comprised of eightmajor Health Systems (15 facilities total) and over 9,000physicians, participating in QualCare’s Regional HMOProvider Network. We believe this collaboration between

hospitals, healthcare payors and physicians will give membersaccess to high quality, affordable care.

In June of this year, David Cordani, Cigna’s CEO, announcedthe formation of CareAllies, a United States based population health company focused on helping physicians and deliverysystems improve their patients’ health outcomes, as theynavigate the transition toward value-based care. QualCare will be one of several Cigna companies that will come together under the CareAllies umbrella to offer providertransformation services. We are excited to be part of theCareAllies team!

As I look ahead, I am thrilled to highlight the expansion ofQualCare within New Jersey and across the country. Whilemany questions remain about the impact of the elections upon the Affordable Care Act, we believe QualCare is wellpositioned as part of the CareAllies team to continue to growand evolve as an organization. Thank you to all of ourproviders for your ongoing support. We are proud to have youas our partners in delivering high quality, affordable care.

President’s Message:

Health Plans That Care About Your Health Care Winter 2016-2017

Sharon SeitzmanPresidentQualCare, Inc.

InfoLineProvider

InfoLineProvider

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2 Winter 2016-2017

The Affiliated Physicians and Employers Health Plan (APEHP) has introduced four new innovative Community Care Network (CCN) Health Plans (APEHP Advantage Plans) to their existing plan portfolio, to help small and mid-size employers access more affordable, high quality health care. These new plans are in addition to APEHP’s existing 21 plan offerings.

The new Community Care Network (CCN) was developed by QualCare in partnership with eight local hospital systems, comprised of 15 hospitals and over 9,000 New Jersey based physicians participating in QualCare’s HMO Provider Network. The CCN utilizes value-based contracting strategies to increase quality, reduce medical expenditures and improve outcomes, with the goal of giving small businesses the ability to purchase high quality coverage at an affordable price point.

The new Community Care Network is in partnership with the following Tier 1 Hospitals:

• Atlantic Health SystemMorristown Memorial Hospital

Chilton Medical Center

Hackettstown Medical Center

Overlook Medical Center

Newton Medical Center

Goryeb Children’s Hospital

• CentraState Medical Center• East Orange General Hospital • Holy Name Medical Center• Saint Peter’s University Hospital • St. Joseph’s Healthcare System

St. Joseph’s Regional Medical Center

St. Joseph’s Children’s Hospital

St. Joseph’s Wayne Hospital

• Trinitas Regional Medical Center • The Valley Hospital

The Community Care Network Tier 1 also consists of a select group of physicians affiliated with these Tier 1 hospitals, who also participate in QualCare’s HMO Network. Members enrolled in one of these new Community Care Network plans will incur lower cost-sharing responsibility when they obtain services from a Tier 1 provider at their highest benefit level. Members may also obtain services from any other non-Tier 1 provider participating in QualCare’s Regional HMO Network, at their Tier 2 benefit level.

These new cost-effective Community Care Network health plans are focused on prevention and an individual’s overall health, as each of the participating hospitals offer a unique menu of wellness programs. Additionally, members enrolled in one of the new APEHP Advantage Plans have added benefits including Fraud Resolution Protection, Wellness Rewards Programs, Tele-Health Services, Virtual Consults and Gym/Wellness discounts.

If you have any questions about the new Community Care Network, please do not hesitate to contact QualCare’s Provider Relations team at 1-800-992-6613 ext. 7830. If you would like a quote or would like to learn more about the APEHP Advantage Plans, please contact the Affiliated Physicians and Employers Health Plan sales at 1-888-670-8135 or via email at MEWASales@qualcareinc.com.

QualCare Launches Community CareNetwork; Affiliated Physicians and Employers Health Plan Introduces Four New Health Plans

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Winter 2016-2017 3

We are pleased to announce that on September 16, 2016,QualCare, Inc. was awarded National Committee for QualityAssurance (NCQA) Interim Heath Plan accreditation. Thisaccreditation recognizes the ongoing commitment of ourcompany to provide high quality health care to our membersand that we continuously incorporate quality improvementsthroughout our organization. Among the notable qualitymeasures QualCare has in place are the following:

Member Rights andResponsibilitiesQualCare is committed to treat members in a manner thatrespects their rights:

• A right to receive information about the organization, itsservices, its practitioners and providers and memberrights and responsibilities.

• A right to be treated with respect and recognition of theirdignity and their right to privacy.

• A right to participate with practitioners in makingdecisions about their health care.

• A right to a candid discussion of appropriate or medicallynecessary treatment options for their conditions,regardless of cost or benefit coverage.

• A right to voice complaints or appeals about theorganization or the care it provides.

• A right to make recommendations regarding theorganization’s member rights and responsibilities policy.

• A responsibility to supply information (to the extentpossible) that the organization and its practitioners andproviders need in order to provide care.

• A responsibility to follow plans and instructions for carethat they have agreed to with their practitioners.

• A responsibility to understand their health problems andparticipate in developing mutually agreed upontreatment goals, to the degree possible.

Affirmative StatementQualCare’s Participating Providers shall have the right tocommunicate openly with our members with respect to allappropriate diagnostic and treatment options, regardless ofcoverage limitations.

Care Management decision-making is based only onappropriateness of care and services, along with the existenceof coverage. QualCare does not reward practitioners or otherindividuals for issuing denials of coverage or provide financialincentives for care management decisions. Decision makersdo not influence decisions that result in underutilization.

Language Assistance for MembersQualCare’s Customer Service advocates have the ability toassist hearing impaired members via TTY/TDD program. Wealso provide interpreter or bilingual services as needed to ourmembers.

Appeals ProcessQualCare members, or authorized designees have the right toappeal any adverse medical necessity and benefit decision. Ifnot satisfied with QualCare’s appeal outcome, members havethe right to an Independent External Review. Please callQualCare Customer Service for details.

Quality CornerQualCare Receives National Committee for Quality Assurance (NCQA)Health Plan Accreditation

QualCare’s Exclusive Commercial Laboratory

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4 Winter 2016-2017

Electronic Funds Transfer (EFT)QualCare offers EFT payments to providers via Emdeon. If you have not yet enrolledin EFT, you can do so online at www.emdeon.com/payment/enrollment. If you haveany questions regarding EFT enrollment, please call 1-866-506-2830 to speak with anEmdeon representative.

NaviNet QualCare’s Navinet Plan Central offers quick and convenientaccess to eligibility and benefits, claim status and referralsubmission inquiries. If you are not already registered withNaviNet, you may do so via www.navinet.net.

QualCare, Inc. continuously monitors quality indicatorsdesigned to reveal trends and performance opportunities inareas such as re-admissions, non-emergent use of emergencyrooms (ER), never events, mental health admissions andpsychotropic medication usage. We analyze this data to facilitateplan-wide improvement and also to set improvement objectives.We are pleased to report that QualCare not only met its 2015goals, but was also better than or equal to National Committeefor Quality Assurance (NCQA) results in most instances.

In 2015, QualCare continued tracking and trending our post-discharge call program to demonstrate that post-dischargefollow-up calls are proven to reduce re-admissions. It is ourgoal that all members receive a post discharge call to ensurethey have the necessary follow-up appointments, haveprescribed prescriptions filled with instructions and havereceived any necessary durable medical equipment. A safedischarge is of utmost importance to us. In the 3rd Quarter of 2015, we initiated a telephone campaign to enhance our results.

We also worked to decrease the non-emergent use of hospitalemergency rooms by 3% and were able to achieve an overall6% reduction in 2015. We utilized a telephonic informationalmessage for members that had a non-emergent ER visit,reminding the member of alternative treatment options fortheir non-emergent condition. We are striving to steer patients

appropriately to their primary care physician or urgent carefacility versus the emergency room.

Members engaged in Chronic Condition Management, orDisease Management, showed a 2% decrease in inpatient rateper 1,000, compared to the rate for non-engaged members,which increased 7%. The Healthcare Effectiveness Data andInformation Set (HEDIS) based metrics that demonstratedimprovement for engaged versus non-engaged membersinclude: Hgb A1C at 89.9% versus 81.5% and Retinal Eye exam at 42.5% versus 24.1%. The engagement rates for theseprograms are up to 65% engagement per client.

QualCare identified only one occurrence of a preventableadverse event or ‘never event’ in 2015. In 2016, we willcontinue to ensure we are capturing data about any of thesequality issues should they occur. Our team also compared ourresults for Antidepressant Medication Management againstthe standards put forth under the HEDIS by NCQA, whichshowed QualCare was on target with the National NCQA data.A review of HEDIS measures for Inpatient Mental HealthFollow-Up for 7 Day Follow-Up, the NCQA percentage was53% and QualCare achieved 53%.

We are pleased with our 2015 results but are always seeking toimprove. In the year ahead, QualCare will continue to look atopportunities to advance the quality of care for its members.

QualCare’s Quality Improvement Program’s 2015 Results

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Winter 2016-2017 5

QualCare has engaged eviCore healthcare (eviCore) tomanage certain non-emergent, outpatient, high-technologyradiology and diagnostic cardiology services for members of the Affiliated Physicians and Employers Health Plan(APEHP). eviCore is a leading health care benefitmanagement company with a proven industry track record, a commitment to quality and dual national accreditation from both the National Committee for Quality Assurance(NCQA) and the Utilization Review and AccreditationCommission (URAC).

Effective October 1, 2016, APEHP members will need tosecure prior authorizations from eviCore for the followingservices:

• CT, MR, PET,

• Nuclear Cardiac/MPI

• Diagnostic Health Catheterization

• Stress Echo

Services performed without prior authorization may be deniedfor payment (where applicable).

NOTE: Services performed in conjunction with an inpatient

stay, 23 hour observation or emergency room visit are not subject

to this authorization requirement.

To request an authorization:

1. Log onto www.evicore.com/pages/ProviderLogin.aspx

2. Call eviCore directly at 1-888-693-3211 (7 AM to 7 PM EST)

3. Fax an eviCore healthcare request form (availableonline) to 1-888-693-3210

For urgent requests where services are needed in less than 48hours due to a medically urgent condition, please call eviCore’stoll free number to request an expedited authorization review.Please be sure to let the representative know the authorizationis for medically urgent care.

It is highly recommended that the ordering physician who secures the member’s authorization(s) provide theauthorization number(s) to the rendering facility at the timeof scheduling. If you have any questions, please feel free to callthe eviCore Customer Service Department at 1-888-693-3211.

QualCare Partners with eviCore healthcare toProvide Authorization Services for Members of theAffiliated Physicians and Employers Health Plan

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This update summarizes changes to QualCare, Inc. medicalpolicies over the past six months as well as some instanceswhere there is no change in policy position, but the specificservice, device or procedure continues to be non-covered afterreview of current published evidence. The full policies,including those indicated as new, are available on our websitewww.QualCareinc.com via the Provider link.

Ambulatory and Video EEG:No changes to the policy statement.

Anti-Tumor Necrosis Factor Therapy:New policy addressing condition – specific coverage criteriafor anti-TNF agents and incorporates the former infliximabpolicy.

Bronchial Thermoplasty:No changes to the policy statement- remains investigational.

Continuous Glucose Monitoring:For replacement requests, documentation must be receivedfrom a physician that includes both of the following: a clinicalevaluation within the previous sixth months by the physicianincluding a recommendation for continued use of acontinuous glucose monitor, and documentation that themonitor or component is malfunctioning, is no longer underwarranty and cannot be repaired.

The following devices or products are not covered as they havenot been demonstrated to improve health outcomes and aretherefore not medically necessary: remote glucose monitoring(my Sentry) and diabetes management software fordownloading and/or analyzing blood glucose monitoringresults.

Eculizumab (Soliris):Removed sucrose lysis and Ham test from diagnostic criteria.Coverage for treatment and prevention of post renal transplant

atypical hemolytic uremic syndrome added whencriteria are met.

Foot Care:No changes to the policy statement.

Gastric Bypass and Other Bariatric Surgical Procedures: Specified the following endoscopic/surgical procedures asnon-covered: vagus nerve blocking, vagus nerve stimulation,trans-oral gastroplasty, duodenal-jejunal bypass liner, intra-gastric balloon.

Genetic Testing-Susceptibility to Colorectal Cancer:Expanded covered condition to include juvenile polyposissyndrome, peutz-Jeghers syndrome and Cowden syndrome.Minimum number of polyps for FAP and MAP specified as10. Clarifications to the representation of the Amsterdamcriteria and Bethesda guidelines .

Insulin Pump Therapy (ContinuousSubcutaneous Insulin Infusion - CSII): Added statements regarding non-coverage for pump upgradeto the most current technology if the current pump isfunctioning and under warranty, non-coverage of additionalsoftware/ hardware for data transfer to mobile devices andnon-coverage of disposable insulin delivery systems under themedical plan.

Intraocular Lens:No changes to the policy statement.

Intra-coronary Brachytherapy: No changes to the policy statement.

Intra-operative Neurophysiology Monitoring: Specified that evoked potentials, electromyogram,electroencephalogram, nerve conduction studies are separatestudies reportable in addition the monitoring codes.

Keloid Treatment and Scar Revision:Specified covered treatments, when basic criteria are met, ascompression/pressure therapy, intra-lesional corticosteroidinjections, silicone gel sheeting, intra-lesional 5-FU, radiation,laser therapy, and surgery.

Laser Therapy for Psoriasis:No change to the policy statement.

From the Doctor’s Office:

QualCare Medical Policy Update

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Winter 2016-2017 7

Lung Cancer Screening by LDCT:

Coverage added for individuals ≥ 50 yrs of age, with ≥20 PYsmoking history and one additional risk factor as specified.

Lyme Disease:

No changes to the policy statement.

Mastectomy for Gynecomastia:

No changes to the policy statement of non-coverage.

Moderate Sedation:

No changes to the policy statement.

Naltrexone Injectable:

Coverage for opioid dependence added when criteria are met.

Negative Pressure Wound Therapy:

Specifies required previous therapy for pressure andneuropathic ulcers for a minimum 30 days of standardintervention including appropriate pressure relief/repositioning, debridement, moisture/incontinence controland non-weight-bearing ( where appropriate). Covered supplyquantity specified as follows-up to 15 dressing kits (A6550)and 10 canister sets (A7000) are covered per month as medicalnecessary unless there is documentation of a large volume ofdrainage (i.e., > 90 ml of exudate per day) or the wound sizerequires more than one dressing kit for each dressing change.

Obstetrical Ultrasound:

No changes to the policy statement.

Omalizumab (Xolair®):

Coverage for chronic idiopathic urticaria added when criteriaare met.

17-P to Prevent Pre-term Delivery:

Onset of treatment changed from 12 week to 16 weeksconsistent with current recommendations. Specified non-coverage for multiple gestation.

Prolotherapy:

No changes to the policy statement of non-coverage.

Recurrent Pregnancy Loss:

Added coverage statement for beta 2 glycoprotein 1 antibodytesting in evaluation of antiphospholipid syndrome.

Refractive Eye Surgery:

Incorporated INTACS medical policy into this policy withoutchanges to coverage criteria.

Sacral Nerve Stimulation (SNS) for Incontinence:No changes to the policy statement.

Skeletal Manipulation Under Anesthesia: Added TMJ to list of joints not covered for MUA.

Sural Nerve Graft with RadicalProstatectomy:No changes to the policy statement of non-coverage.

Trigger Point Injections:Added statements of non-coverage of ultrasound guidance forTPI and for dry needling of trigger points. TPIs withanesthetic and/or corticosteroid are reimbursable whencriteria are met.

Transcranial Magnetic Stimulation: Changed from investigational to coverable for major depressivedisorder- moderate to severe, that has failed to respond toadequate trials of pharmacotherapy and psychotherapy asoutlined in the criteria Remains investigational for all other uses.

Vertebral Axial Decompression: No changes to policy statement - remains investigational.

Viscosupplementation:Specified conservative measures to be attempted prior to useincluding exercise, weight loss, physical therapy, simpleanalgesics such as acetaminophen, oral or topical NSAIDs, orintra-articular corticosteroid injections.

Weight Loss Treatment (non-surgical):Added additional drug classes coverable, with comorbidityrequirement for BMI >25 <30 per labeling.

Whole Body Cutaneous Photography(WBCP): No changes to the policy statement.

Your comments and feedback on medical policy content arewelcome and are given full consideration. Please don’t hesitateto call me directly at 732-562-7802.

Michael McNeil, MDMedical Director

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For more information visit us at www.qualcareinc.comFor PPO questions contact 1.800.992.6613

For HMO and POS questions contact 1.800.254.0130For Provider Relations contact 1.800.992.6613

30 Knightsbridge RoadPiscataway, NJ 08854

Health Republic of New JerseyEarlier this year, the Health Republic Insurance of New Jersey(HRINJ) announced that they will wind down operations andno longer sell or renew health plans in New Jersey in 2017.

The $46.3 million dollar Risk Adjustment payment beingimposed under the Affordable Care Act (ACA), resulted in“considerable financial strain” for HRINJ leading to the filingof an order of rehabilitation by the New Jersey Department ofBanking and Insurance (NJDOBI). Until this point, HRINJwas on course to expand and grow its operations in 2016.

Under the rehabilitation plan, current policies will remain inforce and HRINJ has committed to pay all claims for incurredservices and meet all financial obligations through December31, 2016. Members are being transitioned to new plans for2017 during the open enrollment period.

Oscar InsuranceOscar Insurance announced late in 2016 that it will withdrawits health insurance plans from the New Jersey marketplace in 2017. They have assured all members that coverage willcontinue through December 31, 2016, and all claims will bepaid for services rendered in 2016 even if the claim is notreceived until 2017. Oscar primarily served the individualmarketplace and noted that they, along with other largeinsurers, have found it difficult to deliver access to qualityhealthcare with the present market forces.

Health Republic Insurance of New Jerseyand Oscar Insurance Exit the New JerseyMarketplace for 2017

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PRSRT STDU.S. Postage

PAIDNew Brunswick, NJ

Permit No. 1512