Quality Assessment and Performance Improvement Plans. In accordance with Section 2.13.B.5 of the Contract, MCOs must submit to EOHHS an annual QI workplan that broadly describes MCO QI initiatives that are conducted as part of the plan’s comprehensive quality assurance and performance improvement (QAPI) program. The QI plan should minimally include the QIPs and performance measures referenced in Appendix B. Exhibit 1: Performance Measures # Measure Name Measure Description Data Source Measure Xxxxxxx NQF No. Reporting Level* 1 Childhood Immunization Status Percentage of members who received all recommended immunizations by their 2nd birthday Hybrid NCQA 0038 MCO 2 Immunizations for Adolescents Percentage of members 13 years of age who received all recommended vaccines, including the HPV series Hybrid NCQA 1407 MCO 3 Timeliness of Prenatal Care Percentage of deliveries in which the member received a prenatal care visit in the first trimester or within 42 days of enrollment Hybrid NCQA 1517 MCO 4 Oral Health Evaluation Percentage of members under age 21 years who received a comprehensive or periodic oral evaluation during the year Claims ADA DQA 2517 MCO (calculated by EOHHS) 5 Asthma Medication Ratio Percentage of members 5 to 64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater Claims NCQA 1800 MCO 6 Controlling High Blood Pressure Percentage of members 18 to 64 years of age with hypertension and whose blood pressure was adequately controlled Hybrid NCQA 0018 MCO 7 Comprehensive Diabetes Care: A1c Poor Control Percentage of members 18 to 64 years of age with diabetes whose most recent HbA1c level demonstrated poor control (> 9.0%) Hybrid NCQA 0059 MCO # Measure Name Measure Description Data Source Measure Xxxxxxx NQF No. Reporting Level* 8 Metabolic Monitoring for Children and Adolescents on Antipsychotics Percentage of members 1 to 17 years of age who had two or more antipsychotic prescriptions and received metabolic testing Claims NCQA 2800 MCO 9 ED Visits for Individuals with Mental Illness, Addiction, or Co- occurring Conditions Risk adjusted ratio (obs/exp) of ED visits for members 18 to 64 years of age identified with a diagnosis of serious mental illness, substance addiction, or co-occurring conditions Claims EOHHS NA MCO (calculated by EOHHS) 10 Follow-Up After Emergency Department Visit for Mental Illness (7 days) Percentage of ED visits for members 6 to 64 years of age with a principal diagnosis of mental illness, where the member received follow-up care within 7 days of ED discharge Claims NCQA 2605 MCO 11 Follow-Up After Hospitalization for Mental Illness (7 days) Percentage of discharges for members 6 to 64 years of age, hospitalized for mental illness, where the member received follow- up with a mental health practitioner within 7 days of discharge Claims NCQA 0576 MCO 12 Hospital Readmissions (Adult) Case-mix adjusted rate of acute unplanned hospital readmissions within 30 days of discharge for members 18 to 64 years of age Claims NCQA 1768 MCO 13 Behavioral Health Community Partner Engagement Percentage of members 18 to 64 years of age who engaged with a BH Community Partner and received a treatment plan within 4 months (122 days) of Community Partner assignment Claims EOHHS NA MCO (calculated by EOHHS) # Measure Name Measure Description Data Source Measure Xxxxxxx NQF No. Reporting Level* 14 Long-Term Services and Supports Community Partner Engagement Percentage of members 3 to 64 years of age who engaged with an LTSS Community Partner and received a care plan within 4 months (122 days) of Community Partner assignment Claims EOHHS NA MCO (calculated by EOHHS) 15 Community Tenure: BH and LTSS Members Risk adjusted ratio (obs/exp) of eligible days that members with BH diagnoses and/or at least 3 consecutive months of LTSS utilization 0 to 64 years of age reside in their home or in a community setting without utilizing acute, chronic, or post-acute institutional health care services during the measurement year Claims EOHHS NA MCO (calculated by EOHHS) 16 Initiation and Engagement of Alcohol, or Other Drug Abuse or Dependence Treatment Percentage of members 13 to 64 years of age who are diagnosed with a new episode of alcohol, opioid, or other drug abuse or dependency who initiate treatment within 14 days of diagnosis (“Initiation”) and who receive at ≥2 additional services within 30 days of the initiation visit (“Engagement”) Claims NCQA 0004 MCO *Reporting Level indicates the population for which plans will report rates. As such, administrative and hybrid measures will be reported by the health plan at the MCO contract level and may require the stratification of HEDIS rates reported to NCQA. Non-NCQA claims measures are calculated by EOHHS and reported at the MCO contract level. Listed below are the Per Member Per Month (PMPM) Base Capitation Rates for Contract Year 5 (January 1, 2022, through December 31, 2022) (also referred to as Rate Year 2022 or RY22), subject to state appropriation and all necessary federal approvals. Base Capitation Rates do not include EOHHS adjustments described in Sections 4.2.C and 4.2.E. of the Contract. In addition to the Base Capitation Rates tables below, additional tables include the add-ons for the Contract Year for CBHI Services as described in Section 4.5.D, for ABA Services as described in Section 4.5.E, and for SUD Risk Sharing Services as described in Section 4.5.I. The add-ons for CBHI Services, ABA Services and SUD Risk Sharing Services are the same for all Regions and will be added to the Risk Adjusted Capitation Rates as defined in Section 4.2.E. Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month)
Appears in 2 contracts
Samples: Standard Contract, Standard Contract
Quality Assessment and Performance Improvement Plans. In accordance with Section 2.13.B.5 of the Contract, MCOs must submit to EOHHS an annual QI workplan that broadly describes MCO QI initiatives that are conducted as part of the plan’s comprehensive quality assurance and performance improvement (QAPI) program. The QI plan should minimally include the QIPs and performance measures referenced in Appendix B. Exhibit 1: Performance Measures # Measure Name Measure Description Data Source Measure Xxxxxxx NQF No. Reporting Level* 1 Childhood Immunization Status Percentage of members who received all recommended immunizations by their 2nd birthday Hybrid NCQA 0038 MCO 2 Immunizations for Adolescents Percentage of members 13 years of age who received all recommended vaccines, including the HPV series Hybrid NCQA 1407 MCO 3 Timeliness of Prenatal Care Percentage of deliveries in which the member received a prenatal care visit in the first trimester or within 42 days of enrollment Hybrid NCQA 1517 MCO 4 Oral Health Evaluation Percentage of members under age 21 years who received a comprehensive or periodic oral evaluation during the year Claims ADA DQA 2517 MCO (calculated by EOHHS) 5 Asthma Medication Ratio Percentage of members 5 to 64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater Claims NCQA 1800 MCO 6 Controlling High Blood Pressure Percentage of members 18 to 64 years of age with hypertension and whose blood pressure was adequately controlled Hybrid NCQA 0018 MCO 7 Comprehensive Diabetes Care: A1c Poor Control Percentage of members 18 to 64 years of age with diabetes whose most recent HbA1c level demonstrated poor control (> 9.0%) Hybrid NCQA 0059 MCO # Measure Name Measure Description Data Source Measure Xxxxxxx NQF No. Reporting Level* 8 Metabolic Monitoring for Children and Adolescents on Antipsychotics Percentage of members 1 to 17 years of age who had two or more antipsychotic prescriptions and received metabolic testing Claims NCQA 2800 MCO 9 ED Visits for Individuals with Mental Illness, Addiction, or Co- occurring Conditions Risk adjusted ratio (obs/exp) of ED visits for members 18 to 64 years of age identified with a diagnosis of serious mental illness, substance addiction, or co-occurring conditions Claims EOHHS NA MCO (calculated by EOHHS) 10 Follow-Up After Emergency Department Visit for Mental Illness (7 days) Percentage of ED visits for members 6 to 64 years of age with a principal diagnosis of mental illness, where the member received follow-up care within 7 days of ED discharge Claims NCQA 2605 MCO 11 Follow-Up After Hospitalization for Mental Illness (7 days) Percentage of discharges for members 6 to 64 years of age, hospitalized for mental illness, where the member received follow- up with a mental health practitioner within 7 days of discharge Claims NCQA 0576 MCO 12 Hospital Readmissions (Adult) Case-mix adjusted rate of acute unplanned hospital readmissions within 30 days of discharge for members 18 to 64 years of age Claims NCQA 1768 MCO 13 Behavioral Health Community Partner Engagement Percentage of members 18 to 64 years of age who engaged with a BH Community Partner and received a treatment plan within 4 months (122 days) of Community Partner assignment Claims EOHHS NA MCO (calculated by EOHHS) # Measure Name Measure Description Data Source Measure Xxxxxxx NQF No. Reporting Level* 14 Long-Term Services and Supports Community Partner Engagement Percentage of members 3 to 64 years of age who engaged with an LTSS Community Partner and received a care plan within 4 months (122 days) of Community Partner assignment Claims EOHHS NA MCO (calculated by EOHHS) 15 Community Tenure: BH and LTSS Members Risk adjusted ratio (obs/exp) of eligible days that members with BH diagnoses and/or at least 3 consecutive months of LTSS utilization 0 to 64 years of age reside in their home or in a community setting without utilizing acute, chronic, or post-acute institutional health care services during the measurement year Claims EOHHS NA MCO (calculated by EOHHS) 16 Initiation and Engagement of Alcohol, or Other Drug Abuse or Dependence Treatment Percentage of members 13 to 64 years of age who are diagnosed with a new episode of alcohol, opioid, or other drug abuse or dependency who initiate treatment within 14 days of diagnosis (“Initiation”) and who receive at ≥2 additional services within 30 days of the initiation visit (“Engagement”) Claims NCQA 0004 MCO *Reporting Level indicates the population for which plans will report rates. As such, administrative and hybrid measures will be reported by the health plan at the MCO contract level and may require the stratification of HEDIS rates reported to NCQA. Non-NCQA claims measures are calculated by EOHHS and reported at the MCO contract level. Listed below are the Per Member Per Month (PMPM) Base Capitation Rates for Contract Year 5 (January 1, 2022, through December 31, 2022) (also referred The Contractor shall provide to as Rate Year 2022 or RY22), subject to state appropriation and all necessary federal approvals. Base Capitation Rates do not include EOHHS adjustments described in Sections 4.2.C and 4.2.E. each Enrollee each of the Contract. In addition to the Base Capitation Rates tables belowMCO Covered Services listed below in an amount, additional tables include the add-ons for the Contract Year for CBHI Services as described in Section 4.5.D, for ABA Services as described in Section 4.5.Eduration, and for SUD Risk Sharing Services as described in Section 4.5.I. The add-ons for CBHI Services, ABA Services and SUD Risk Sharing Services are the same for all Regions and will be added to the Risk Adjusted Capitation Rates scope that is Medically Necessary (as defined in Section 4.2.E. Effective January 1 of this Contract), provided that the Contractor is not obligated to provide any MCO Covered Service in excess of any service limitation expressly set forth below. Except to the extent that such service limitations are set forth below, the general descriptions below of MCO Covered Services do not limit the Contractor’s obligation to provide all Medically Necessary services. Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Special Kids Special Care Acupuncture Treatment - the insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, an electric current, heat to the needles or skin, or both, for pain relief or anesthesia. ✓ ✓ ✓ ✓ Acute Inpatient Hospital –all inpatient services such as daily physician intervention, surgery, obstetrics, radiology, laboratory, and other diagnostic and treatment procedures. Coverage of acute inpatient hospital services shall include Administratively Necessary Days. Administratively Necessary Day shall be defined as a day of Acute Inpatient Hospitalization on which an Enrollee’s care needs can be provided in a setting other than an Acute Inpatient Hospital and on which an Enrollee is clinically ready for discharge. ✓ ✓ ✓ ✓ Ambulatory Surgery/Outpatient Hospital Care - outpatient surgical, related diagnostic, medical and dental services. ✓ ✓ ✓ ✓ Audiologist – audiologist exams and evaluations. See related hearing aid services. ✓ ✓ ✓ ✓ Behavioral Health Services – see Appendix C, Exhibit 3. ✓ ✓ ✓ ✓ Breast Pumps – to expectant and new mothers as specifically prescribed by their attending physician, consistent with the provisions of the Affordable Care Act of 2010 and Section 274 of Chapter 165 of the Acts of 2014, including but not limited to double electric breast pumps one per birth or as medically necessary. ✓ ✓ ✓ ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Special Kids Special Care Certain COVID-19 Specimen Collection and Testing – Specimen collection codes G2023 and G2024 billed with modifier CG, used when provider 1) has a qualified ordering clinician present at the specimen collection site available to order medically necessary COVID-19 diagnostic tests; and 2) ensures the test results are provided to the patient (along with any initial follow-up counseling, as appropriate), either directly or through the patient’s ordering clinician. ✓ ✓ ✓ ✓ Chiropractic Services – The Contractor is responsible for providing chiropractic manipulative treatment, office visits, and radiology services for all Enrollees. The Contractor may establish a per Enrollee per Contract Year service limit of 20 office visits or chiropractic manipulative treatments, or any combination of office visits and chiropractic manipulative treatments. ✓ ✓ ✓ ✓ Chronic, Rehabilitation Hospital or Nursing Facility Services – services, for all levels of care, including for eligible Enrollees under the age of 22 in accordance with applicable state requirements, provided at either a nursing facility, chronic or rehabilitation hospital, or any combination thereof, 100 days per Contract Year per Enrollee. The 100-day limitation shall not apply to Enrollees receiving Hospice services and the Contractor may not request disenrollment of Enrollees receiving Hospice services based on the length of time in a nursing facility. The Contractor shall use the following MassHealth admission/coverage criteria for admission into a chronic hospital, rehabilitation hospital and nursing facility, and may not request disenrollment of any Enrollee who meets such coverage criteria until the Enrollee exhausts such 100-day limitation described above. For the applicable criteria, see 130 CMR 456.408, 456.409, 456.410 and 435.408, 435.409 and 435.410 (rehabilitation hospitals). In addition, for Enrollees under the age of 22, the Contractor shall ensure that its contracted nursing facilities comply with the relevant provisions of 105 CMR 150.000, et seq. The Contractor must ensure that its contracted nursing facilities establish and follow a written policy regarding its bed-hold period, consistent with the MassHealth bed-hold policy. For applicable criteria, see 130 CMR 456.425. For clarification purposes, an Enrollee’s stay while recovering from COVID-19 in a nursing facility or chronic or rehabilitation hospital, or any combination thereof, shall ✓ ✓ ✓ ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Special Kids Special Care count towards the 100-day per Contract Year per Enrollee coverage described in this section; provided, however for an Enrollee’s stays in a Commonwealth-designated COVID- 19 nursing facility, see non-MCO Covered Services in Exhibit 2 below. Dental - Emergency related dental services as described under Emergency Services in Appendix C, Exhibit 1 and oral surgery which is Medically Necessary to treat a medical condition performed in any setting, including but not limited to an outpatient setting, as described in Ambulatory Surgery/Outpatient Hospital Care in Appendix C, Exhibit 1, 2022 as well as a clinic or office setting. ✓ ✓ ✓ ✓ Diabetes Self-Management Training – June 30diabetes self-management training and education services furnished to an individual with pre-diabetes or diabetes by a physician or certain accredited mid-level providers (e.g., 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective January 1registered nurses, 2022 physician assistants, nurse practitioners, and licensed dieticians). ✓ ✓ ✓ ✓ Dialysis – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month)laboratory; prescribed drugs; tubing change; adapter change; and training related to hemodialysis; intermittent peritoneal dialysis; continuous cycling peritoneal dialysis; continuous ambulatory peritoneal dialysis. ✓ ✓ ✓ ✓
Appears in 2 contracts
Samples: Managed Care Organization Plan Contract, Managed Care Organization Plan Contract
