CMS-10398 (#26) Medicaid Adult Core Set Measures Reporting Template in C

OMB Control Number 0938-1148

Expiration date: 10/31/2014

Reporting of the Initial Core Set of Health Care Quality Measures for Medicaid-Eligible Adults (Medicaid Adult Core Set)

BACKGROUND
The Affordable Care Act (Section 1139B) required the Secretary of the Department of Health and Human Services (HHS) to identify and publish an initial core set of health quality measures for adult Medicaid enrollees (Medicaid Adult Core Set). Additionally, the law required the development of a standardized reporting format for states that volunteer to report on the Medicaid Adult Core measures. This CARTS template will be used for standardized reporting on these measures.

The Technical Specifications and Resource Manual for the Medicaid Adult Core Set can be found at:
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/Medicaid-Adult-Core-Set-Manual.pdf

Measure	Measure Steward	Measure Description
Flu Shots for Adults Ages 50 to 64	NCQA/HEDIS (http://www.ncqa.org)	Rolling average represents the percentage of Medicaid enrollees ages 50 to 64 that received an influenza vaccination between September 1 of the measurement year and the date when the CAHPS 5.0H survey was completed
Adult Body Mass Index (BMI) Assessment	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 18 to 74 that had an outpatient visit and whose BMI was documented during the measurement year or the year prior to the measurement year
Breast Cancer Screening	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid-enrolled women ages 42 to 69 that received a mammogram in the measurement year or the year prior to the measurement year
Cervical Cancer Screening	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid-enrolled women ages 24 to 64 that received one or more PAP tests during the measurement year or the two years prior to the measurement year
Medical Assistance With Smoking and Tobacco Use Cessation	NCQA/HEDIS (http://www.ncqa.org)	Rolling average represents the percentage of Medicaid enrollees age 18 and older that were current smokers or tobacco users and who received advice to quit, discussed or were recommended cessation medications, and discussed or were provided cessation methods or strategies during the measurement year
Screening for Clinical Depression and Follow-Up Plan	CMS (http://www.usqualitymeasures.org)	Percentage of patients age 18 and older screened for clinical depression using a standardized tool, and if positive, a follow-up plan is documented on the date of the positive screen
Plan All-Cause Readmission Rate	NCQA/HEDIS (http://www.ncqa.org)	For Medicaid enrollees age 18 and older, the number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission
PQI 01: Diabetes Short-Term Complications Admission Rate	AHRQ (http://www.qualityindicators.ahrq.gov)	Number of discharges for diabetes short-term complications per 100,000 Medicaid enrollees age 18 and older
PQI 05: Chronic Obstructive Pulmonary Disease (COPD) Admission Rate	AHRQ (http://www.qualityindicators.ahrq.gov)	Number of discharges for COPD per 100,000 Medicaid enrollees age 18 and older
PQI 08: Congestive Heart Failure (CHF) Admission Rate	AHRQ (http://www.qualityindicators.ahrq.gov)	Number of discharges for CHF per 100,000 Medicaid enrollees age 18 and older
PQI 15: Adult Asthma Admission Rate	AHRQ (http://www.qualityindicators.ahrq.gov)	Number of discharges for asthma per 100,000 Medicaid enrollees age 18 and older
Chlamydia Screening in Women Ages 21 to 24	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrolled women ages 21 to 24 that were identified as sexually active and that had at least one test for Chlamydia during the measurement year
Follow-Up After Hospitalization for Mental Illness	NCQA/HEDIS (http://www.ncqa.org)	Percentage of discharges for Medicaid enrollees age 21 and older that were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days of discharge and within 30 days of discharge
PC-01: Elective Delivery	The Joint Commission (http://www.jointcommission.org)	Percentage of Medicaid and CHIP enrolled females with elective vaginal deliveries or elective cesarean sections delivering newborns with >= 37 and < 39 weeks of gestation completed
PC-03: Antenatal Steroids	The Joint Commission (http://www.jointcommission.org)	Percentage of Medicaid and CHIP enrolled females at risk of preterm delivery with a full course of antenatal steroids completed prior to delivery of a preterm infant
Annual HIV/AIDS Medical Visit	NCQA (http://www.ncqa.org)	Percentage of Medicaid enrollees age 18 and older with a diagnosis of HIV/AIDS and with at least two medical visits during the measurement year, with a minimum of 90 and 180 days between each visit
Controlling High Blood Pressure	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 18 to 85 that had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90) during the measurement year
Comprehensive Diabetes Care: LDL-C Screening	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 18 to 75 with diabetes (type 1 and type 2) that had a LDL-C screening test
Comprehensive Diabetes Care: Hemoglobin A1c Testing	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 18 to 75 with diabetes (type 1 and type 2) that had a Hemoglobin A1c test
Antidepressant Medication Management	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees age 18 and older with a diagnosis of major depression, that were newly treated with antidepressant medication, and who remained on an antidepressant medication treatment for at least 84 days (12 weeks) and for at least 180 days (6 months)
Adherence to Antipsychotics for Individuals with Schizophrenia	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 19 to 64 with schizophrenia that were dispensed and remained on an antipsychotic medication for at least 80 percent of their treatment period
Annual Monitoring for Patients on Persistent Medications	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees age 18 and older that received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent and that received annual monitoring for the therapeutic agent during the measurement year
CAHPS Health Plan Survey 5.0H – Adult Questionnaire	AHRQ NCQA/HEDIS (http://www.ncqa.org)	Survey on adult Medicaid enrollees’ age 18 and older experiences with care
Care Transition – Transition Record Transmitted to Health Care Professional	American Medical Association/Physician Consortium for Performance Improvement (PCPI) (http://www.ama-assn.org)	Percentage of Medicaid enrollees age 18 and older discharged from an inpatient facility to home or any other site of care for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees age 18 and older with a new episode of alcohol or other drug (AOD) dependence who: (a) Initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of the diagnosis (b) Initiated treatment and had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit
Postpartum Care Rate	NCQA/HEDIS (http://www.ncqa.org)	Percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year that had a postpartum visit on or between 21 and 56 days after delivery

GUIDANCE FOR REPORTING

States should report performance measurement data for the current year (to the extent that data are available). Additional instructions for completing each section of the template are provided below. Data entry in all fields is required unless otherwise specified.

Did you Report on this Measure?

States should indicate whether or not they are reporting the measure by selecting either Yes or No.

If Data Not Reported, Please Explain Why:

If your state cannot report a specific measure, please check the box that applies to why data are not being reported for each measure. The user may select any applicable reason why data are not being reported, but must select at least one response as follows.

• Service not covered: Check this box if your program does not cover this service.

• Population not covered: Check this box if your program does not cover the population included in the measure. If this box is selected, users will also need to indicate whether the entire population or partial population was covered under its program. A detailed explanation is required if partial population is not covered.

• Data not available: Check this box if data are not available for this measure in your state. If this box is selected, users will also need to explain why data are not available for reporting. Reasons may include “Budget Constraints”, “Staff Constraints”, “Data Inconsistencies/Accuracy”, “Data Source Not Easily Accessible”, “Information Not Collected” and “Other”.

• Small Sample Size (less than 30): Check this box if the denominator size for this measure is less than 30. If the denominator size is less than 30, your state is not required to report a rate on the measure. However, the state will need to indicate the exact denominator size in the space provided.

• Other: Please specify if there is another reason why your state cannot report the measure.
  
  

Although the Medicaid Adult Core Set measures are voluntarily reported, if the state does not report data on a specific measure, it is important for CMS to understand why each state is not reporting on specific measures. Your selection of a reason for not reporting and/or provision of an “Other” reason for not reporting will assist CMS in that understanding.

The Information for this Measure is Being Provided to Meet the Requirements for the Adult Medicaid Quality Measures Grant:

States should indicate whether they are reporting a specific measure: to fulfill the requirements of the Adult Medicaid Quality Measures Grant Program (“Yes”), for voluntary reporting of the Medicaid Adult Core Set (“No”), or for purposes of both the Adult Medicaid Quality Measures Grant program and voluntary reporting of the Medicaid Adult Core Set (“Both”).

Status of Data Reported:

Please indicate the status of the data you are reporting, as follows:

• Provisional: Check this box if you are reporting data for a measure, but the data are currently being modified, verified, or may change in any other way before you finalize them for the current CARTS reporting period.

• Final: Check this box if the data you are reporting are considered final for the current CARTS reporting period.
  
  
  
  

Measurement Specification:

For each measure, the state should indicate whether a measure adheres to the technical specifications provided by the measure steward (e.g., NCQA, AHRQ) or “Other” measurement specifications. If NCQA is selected, the HEDIS® Version field must be completed (with the exception of the annual HIV/AIDS medical visits measure). If “Other” measurement specification is selected, an explanation must be provided.

CMS encourages states to use the technical specifications outlined in the Technical Specifications and Resource Manual.

• HEDIS® Version:
  Please specify HEDIS® Version (example HEDIS 2011, HEDIS 2012). This field must be completed only when a user selects the NCQA measurement specification.

• “Other” Measurement Specification Explanation:
  The explanation field must be completed when “Other” measurement specification has been selected.

Data Source:

Data for the Medicaid Adult Core Set measures may come from several sources, including medical claims and medical records. For each measure, the state must indicate the source of data or methodology used to calculate the measure using the following options (some options are unavailable for some measures):

• Administrative Data: Medical claims and encounter data. If this box is selected, the user must then indicate whether the administrative data for a measure are coming from the Medicaid Management Information System (MMIS) or describe another administrative data source.

• Hybrid: A combination of administrative and medical records data. An explanation box is available for the state to provide more detailed information about how the two sources were used to create the rate.

• Survey Data: The state should specify the survey used.

• Other: An explanation box is available for the state to describe specify the other source of data.
  
  

Date Range:

Define the date range for the reporting period based on the “From” time period as the month and year that corresponds to the beginning period in which utilization took place and please report the “To” time period as the month and year that corresponds to the end period in which utilization took place. Do not report the year in which data were collected for the measure, or the version of HEDIS® used to calculate the measure, both of which may be different from the period corresponding to utilization of services.

Definition of Population Included in the Measure:

Definition of the Denominator:

Indicate the definition of the population included in the denominator for each measure by checking one box to indicate whether the data are for the Medicaid population only (Title XIX), the CHIP population only (e.g., pregnant women; Title XXI), the Medicare and Medicaid dually-eligible populations, or another population using the “Other” check box. If “Other” is selected, state must specify the population.

Does this Denominator Represent your Total Eligible Population as Defined by the Technical Specification for this Measure?

States should indicate whether the denominator selected in the preceding question represents your state’s total eligible population as defined by the Technical Specifications for the measure by selecting either Yes or No.

Which Delivery Systems are Represented in the Denominator?

For each measure, the state is asked to indicate which delivery systems are represented in the denominator, the percentage of the population is represented in the delivery system, and the number of health plans represented in the delivery system (where applicable) across the following options:

• Fee-for-Service

• Primary Care Case Management (PCCM)

• Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP)

• Integrated Care Models (ICM)

• Other
  
  

Deviation from Measure Specifications:

Did your Calculation of this Measure Deviate from the Measure Specifications in any way?

If the data provided for a measure deviate from the measure technical specifications, please select the type(s) of measure specification deviation. When one or more of the types of deviations are selected, states are required to provide an explanation.

The three types (and examples) of deviations are:

• Numerator (e.g., coding issues),

• Denominator (e.g., different age groups, definition of continuous enrollment),

• Other (please describe in detail).

Performance Measure:

Report the numerators and denominators, rates for each measure (or component) in this section. The template provides two sections for entering the data, depending on whether you are reporting using the technical specifications provided by the measure steward for each measure or another methodology. The form fields have been set up to facilitate entering numerators and denominators for each measure. If the form fields do not give you enough space to fully report on the measure, please use the “additional notes” section. “Additional Notes/Comments on Measure” may be entered but is not required.

The reporting unit for each measure is the state as a whole. If states calculate rates for multiple reporting units (e.g., individual health plans, different health care delivery systems), states must aggregate data from all these sources into one state-level rate before reporting the data to CMS. In the situation where a state combines data across multiple reporting units, all or some of which use the hybrid method to calculate the rates, the state should enter zeroes in the “Numerator” and “Denominator” fields. In these cases, it should report the state-level rate in the “Rate” field and, when possible, include individual reporting unit numerators, denominators, and rates in the field labeled “Additional Notes on Measure,” along with a description of the method used to derive the state-level rate. For additional guidance on developing a state-level rate, refer to the Technical Assistance Brief “Approaches to Developing State-Level Rates for Children’s Health Care Quality Measures Based on Data from Multiple Sources,” available at: http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/TA2-StateRates.pdf.

Other Performance Measure:

If the state selected “Other” in the “Measure Specification” section of the template, and is thus reporting using another methodology, the user is required to provide a description of the measure, along with the numerator, denominator, and rate in the “Other Performance Measure” section. If reporting with another methodology, and the form fields do not give you enough space to fully report on the measure, please use please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range. “Additional Notes/Comments on Measure” may be entered but is not required.

Optional Measure Stratification:

If states are able to stratify data for a measure by race (non-Hispanic), ethnicity, sex, primary spoken language, disability status, or geography, states may provide these data in the “Optional Measure Stratification” section. While reporting in this section is not required (unless reporting to meet the requirements of the Adult Quality Grants), this information will help CMS track and monitor health and health care disparities both nationally and within states.

If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications your state wants to report that are not specified in the form provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.

Certification

After a state has completed data entry, certify the data submission on the certification page. Once data are certified, no further data entry or editing is allowed unless a request is made to CMS to uncertify these data.

Measure 1: Flu Shots for Adults

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered. Population not covered. Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available. Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final.
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: CAHPS 5.0H Other. Explain:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure A rolling average represents the percentage of Medicaid enrollees 50-64 years of age who received an influenza vaccine between September 1 of the measurement year and the date when the CAHPS 5.0H adult survey was completed.
	Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 2: Adult BMI Assessment

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered. Population not covered. Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available. Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional. Final.
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information System (MMIS) Other Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Hybrid (administrative and medical records data) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees ages 18-74 who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.
	Age Range 18-64 Numerator:       Denominator:       Rate:       Age Range 65-74 Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      					Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
			Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      					Not Hispanic or Latino Numerator:       Denominator:       Rate:      
		Sex
Male Numerator:       Denominator:       Rate:      					Female Numerator:       Denominator:       Rate:      
		Primary Spoken Language
English Numerator:       Denominator:       Rate:      					Spanish Numerator:       Denominator:       Rate:      
			Disability Status
SSI Numerator:       Denominator:       Rate:      					Non-SSI Numerator:       Denominator:       Rate:      
				Geography
Urban Numerator:       Denominator:       Rate:      					Rural Numerator:       Denominator:       Rate:      

Measure 3: Breast Cancer Screening

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Select all that apply (Must select at least one): Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information System (MMIS) Other Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Hybrid (Administrative and Medical Records Data) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid-enrolled women ages 42-69 who received a mammogram to screen for breast cancer.
	Age Range: 42-64 Numerator:       Denominator:       Rate:       Age Range: 65-69 Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      			Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
		Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      			Not Hispanic or Latino Numerator:       Denominator:       Rate:      
		Primary Spoken Language
English Numerator:       Denominator:       Rate:      			Spanish Numerator:       Denominator:       Rate:      
		Disability Status
SSI Numerator:       Denominator:       Rate:      			Non-SSI Numerator:       Denominator:       Rate:      
		Geography
Urban Numerator:       Denominator:       Rate:      			Rural Numerator:       Denominator:       Rate:      

Measure 4: Cervical Cancer Screening

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered. Population not covered. Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available. Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information System (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid-enrolled ages women 21-64 who received one or more Pap tests to screen for cervical cancer.
	Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 5: Medical Assistance with Smoking and Tobacco Use

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered. Population not covered. Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available. Select all that apply (Must select at least one): Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: CAHPS5.OH Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure A rolling average represents the percentage of Medicaid enrollees age 18 and older who were current smokers or tobacco users and who received medical assistance during the measurement year. The following components of this measure assess different facets of providing medical assistance with smoking and tobacco use cessation and are reported as three separate rolling averages: Advising Smokers and Tobacco Users to Quit; Discussing Cessation Medications; and Discussing Cessation Strategies.
	Advising smokers and tobacco users to quit Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Discussing Cessation Medications Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Discussing Cessation Strategies Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 6: Screening for Clinical Depression and Follow-Up Plan

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: CMS Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure Percentage of Medicaid enrollees age 18 and older screened for clinical depression using a standardized depression screening tool and, if positive, a follow-up plan is documented on the date of the positive screen.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 7: Plan All-Cause Readmission Rate

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure For Medicaid enrollees 18 years and older, the number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories: Count of Index Hospital Stays (IHS) (denominator) Count of 30-Day Readmissions (numerator) Average Adjusted Probability of Readmission
	Additional notes/comments on measure. If using a risk-adjustment methodology, describe:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Table _ Per Measure 7

Age	Sex	Count of Index Stays (Den)	Count of 30-Day Readmissions (Num)	Observed Readmission (Num/Den)	Average Adjusted Probability	Total Variance	O/E/ Ratio (Observed Readmission/Average Adjusted Probability)
18-44	Male
	Female
	Total
45-54	Male
	Female
	Total
55-64	Male
	Female
	Total
Total	Male
	Female
	Total
Age	Sex	Count of Index Stays (Den)	Count of 30-Day Readmissions (Num)	Observed Readmission (Num/Den)	Average Adjusted Probability	Total Variance	O/E/ Ratio (Observed Readmission/Average Adjusted Probability)
65-74	Male
	Female
	Total
75-84	Male
	Female
	Total
85+	Male
	Female
	Total
Total	Male
	Female
	Total

Measure 8: PQI 01: Diabetes, Short-term Complications Admission Rate

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: AHRQ Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The number of discharges for diabetes short-term complications per 100,000 Medicaid enrollees ages 18 and older.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 9: PQI 05: Chronic Obstructive Pulmonary Disease (COPD) Admission Rate

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Select all that apply (Must select at least one): Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: AHRQ Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information System (MMIS) Other Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The number of discharges for chronic obstructive pulmonary disease (COPD) per 100,000 Medicaid enrollees age 18 and older.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
	Male Numerator:       Denominator:       Rate:      	Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 10: PQI 08: Congestive Heart Failure (CHF) Admission Rate

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Select all that apply (Must select at least one): Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: AHRQ Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information System (MMIS) Other Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The number of discharges for congestive heart failure (CHF) per 100,000 Medicaid enrollees age 18 and older.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      			Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      			Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
	Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      			Spanish Numerator:       Denominator:       Rate:      
		Disability Status
SSI Numerator:       Denominator:       Rate:      			Non-SSI Numerator:       Denominator:       Rate:      
		Geography
Urban Numerator:       Denominator:       Rate:      			Rural Numerator:       Denominator:       Rate:      

Measure 11: PQI 15: Adult Asthma Admission Rate

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional. Final.
	Measurement Specification: AHRQ Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The number of discharges for asthma in adults per 100,000 Medicaid enrollees age 18 and older.
	Age Range 18-64 Numerator:       Denominator:       Rate:       Age Range 65 and older Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 12: Chlamydia Screening in Women Ages 21 to 24

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid-enrolled women 21-24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year.
	Numerator (Ages 21-24):       Denominator (Ages 21-24):       Rate (Ages 21-24):      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 13: Follow-Up After Hospitalization for Mental Illness

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of discharges for Medicaid enrollees age 21 years and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: Percentage of discharges for which the patient received follow-up within 30 days of discharge. Percentage of discharges for which the patient received follow-up within seven days of discharge.
	Age Range: 21-64 Follow-up within seven days of discharge: Numerator:       Denominator:       Rate:       Age Range: 65 and older Follow-up within seven days of discharge: Numerator:       Denominator:       Rate:       Age Range: 21-64 Follow-up within 30 days of discharge: Numerator:       Denominator:       Rate:       Age Range: 65 and older Follow-up within 30 days of discharge: Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 14: PC-01 Elective Delivery

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: The Joint Commission Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid and CHIP-enrolled females with elective vaginal deliveries or elective cesarean sections at ≥ 37 and < 39 weeks of gestation completed.
	Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range.”)
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 15: PC-03 Antenatal Steroids

		FFY 2013
		Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
		The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
		Status of Data Reported: Provisional Final
		Measurement Specification: The Joint Commission Other. Explain:      
		Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
		Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
		Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
		Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
		Performance Measure The percentage of Medicaid and CHIP enrolled females at risk of preterm delivery at ≥24 and <32 weeks gestation that received antenatal steroids prior to delivering preterm newborns.
		Numerator:       Denominator:       Rate:      
		Additional notes/comments on measure:      
		Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
		Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
		Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      			Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
		Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      			Not Hispanic or Latino Numerator:       Denominator:       Rate:      
		Primary Spoken Language
English Numerator:       Denominator:       Rate:      			Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      			Non-SSI Numerator:       Denominator:       Rate:      
		Geography
Urban Numerator:       Denominator:       Rate:      			Rural Numerator:       Denominator:       Rate:      

Measure 16: Annual HIV/AIDS Medical Visit

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Hybrid (Administrative and Medical Records Data) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees age 18 and older with a diagnosis of HIV/AIDS and with at least two medical visits during the measurement year, with a minimum of 90 and 180 days between each visit.
	Enrollees with at least two medical visits during the measurement year, with a minimum of 90 days between each visit: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Enrollees with at least two medical visits during the measurement year, with a minimum of 180 days between each visit: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 17: Controlling High Blood Pressure

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Hybrid (Administrative and Medical Records Data) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90) during the measurement year. Use the Hybrid Method for this measure.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65-85 Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 18: Comprehensive Diabetes Care: LDL-C Screening

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees 18-75 years of age with diabetes (type 1 and type 2) who had a LDL-C screening test.
	Age Range 18-64 Numerator:       Denominator:       Rate:       Age Range 65-75 Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 19: Comprehensive Diabetes Care: Hemoglobin A1c Testing

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Hybrid (Administrative and Medical Records Data) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees 18-75 years of age with diabetes (type 1 and type 2) who had a hemoglobin A1c (HbA1c) test.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65-75 Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 20: Antidepressant Medication Management

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees age 18 and older with a diagnosis of major depressions who were newly treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported. Effective Acute Phase Treatment. The percentage of newly diagnosed and treated Medicaid enrollees who remained on an antidepressant medication for at least 84 days(12 weeks). Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated Medicaid enrollees who remained on an antidepressant medication for at least 180 days (6 months).
	Effective Acute Phase Treatment: Remained on medication for at least 84 days(12 weeks): Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Effective Continuation Phase Treatment: Remained on medication for at least 180 days(6 months): Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      			Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      			Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 21: Adherence to Antipsychotics for Individuals with Schizophrenia

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees ages 19-64 with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period.
	Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      			Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      			Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      			Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      			Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 22: Annual Monitoring for Patients on Persistent Medications

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees 18 and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and received annual monitoring for the therapeutic agent in the measurement year. Report each of the four rates separately and as a total rate. Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). Annual monitoring for members on digoxin. Annual monitoring for members on diuretic. Annual monitoring for members on anticonvulsants. Total rate (the sum of the four numerators divided by the sum of the four denominators).
	Annual Monitoring for Members on ACE Inhibitors or ARBs (ages 18-64): Numerator:       Denominator:       Rate:       Annual Monitoring for Members on ACE Inhibitors or ARBs (ages 65 and older): Numerator:       Denominator:       Rate:       Annual Monitoring for Members on Digoxin (ages 18-64): Numerator:       Denominator:       Rate:       Annual Monitoring for Members on Digoxin (ages 65 and older): Numerator:       Denominator:       Rate:       Annual monitoring for members on diuretic (ages 18-64): Numerator:       Denominator:       Rate:       Annual Monitoring for Members on Diuretic (ages 65 and older): Numerator:       Denominator:       Rate:       Annual Monitoring for Members on Anti-convulsants (ages18-64): Numerator:       Denominator:       Rate:       Annual Monitoring for Members on Anti-convulsants (ages 65 and older): Numerator:       Denominator:       Rate:       Total Rate for Four Rates (ages 18-64): Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 23: CAHPS Health Plan Survey 5.0H – Adult Questionnaire

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Measurement Specification: AHRQ & NCQA Other. Explain:      
	Data Source: CAHPS 5.0H Other Which Supplemental Item Sets were Included in the Survey? No supplemental item sets were included Supplemental items for Adult Survey 5.0H Other CAHPS item set Explain:       Which Administrative Protocol was Used to Administer the Survey? NCQA HEDIS CAHPS 5.OH administrative protocol AHRQ CAHPS administrative protocol Other administrative protocol Explain:      
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:      
Please submit a CAHPS summary report to CMS using the CARTS attachment facility (Note: do NOT submit raw CAHPS data to CMS). States should calculate survey results for two age groups (as applicable): ages 18 to 64 and ages 65 and older.

Measure 24: Care Transition – Transition Record Transmitted to Health Care Professional

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: AMA/PCPI Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Medical Records Data Must select one if Medical Records Data is selected: Electronic Health Record (EHR) Data Paper Both (EHR and Paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure Percentage of Medicaid enrollees age 18 years and older discharged from an inpatient facility to home or any other site of care for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 64 and older Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 25: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Hybrid (Administrative and Medical Record Data) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure Percentage of Medicaid enrollees age 18 and older with a new episode of alcohol or other drug (AOD) dependence who received the following. Two rates are reported: Initiation of AOD Treatment: The percentage of Medicaid enrollees who initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. Engagement of AOD Treatment: The percentage of Medicaid enrollees who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.
	Initiation of AOD Treatment (ages 18-64) Numerator:       Denominator:       Rate:       Initiation of AOD Treatment (ages 65 and older) Numerator:       Denominator:       Rate:       Engagement of AOD Treatment (ages 18-64) Numerator:       Denominator:       Rate:       Engagement of AOD Treatment (ages 65 and older) Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure 26: Postpartum Care Rate

	FFY 2013
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not identified as key priority area for this year Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided to meet the requirements for the Adult Medicaid Quality Measures Grant: Yes (to fulfill grant requirement) No (this information is for voluntary core set reporting) Both (grant requirement and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Hybrid (Administrative and Medical Record Data) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that apply (Must select at least one): Fee-for-Service Percentage of population represented:       Primary Care Case Management (PCCM) Percentage of population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of population represented:       Integrated Care Models (ICM) Percentage of population represented:       Other Describe:       Percentage of population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year who had a postpartum visit on or between 21 and 56 days after delivery.
	Numerator:       Denominator:       Rate:      
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

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