Form CMS-10398 (#1) CMS-10398 (#1) FRAMEWORK FOR THE ANNUAL REPORT

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

#1 - CARTS Template [rev 12-15-2014]

#1: CHIP Annual Report Template System (CARTs)

OMB: 0938-1148

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1148 can be found here:

Document [doc]

Download: doc | pdf

FRAMEWORK FOR THE ANNUAL REPORT OF

THE CHILDREN’S HEALTH INSURANCE PLANS

UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

Preamble

Section 2108(a) and Section 2108(e) of the Act provides that the State and Territories^must assess the operation of the State child health plan in each Federal fiscal year, and report to the Secretary, by January 1 following the end of the Federal fiscal year, on the results of the assessment. In addition, this section of the Act provides that the State must assess the progress made in reducing the number of uncovered, low-income children. The State is out of compliance with CHIP statute and regulations if the report is not submitted by January 1. The State is also out of compliance if any section of this report relevant to the State’s program is incomplete.

The framework is designed to:

Recognize the diversity of State approaches to CHIP and allow States flexibility to highlight key accomplishments and progress of their CHIP programs, AND

Provide consistency across States in the structure, content, and format of the report, AND

Build on data already collected by CMS quarterly enrollment and expenditure reports, AND

Enhance accessibility of information to stakeholders on the achievements under Title XXI

The CHIP Annual Report Template System (CARTs) is organized as follows:

Section I: Snapshot of CHIP Programs and Changes

Section II; Program’s Performance Measurement and Progress

Section III: Assessment of State Plan and Program Operation

Section IV: Program Financing for State Plan

Section V: 1115 Demonstration Waivers (Financed by CHIP)

Section VI: Program Challenges and Accomplishments

* - When “State” is referenced throughout this template, “State” is defined as either a state or a territory.

PRA Disclosure Statement. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #1). The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

FRAMEWORK FOR THE ANNUAL REPORT OF

THE CHILDREN’S HEALTH INSURANCE PLANS

UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

DO NOT CERTIFY YOUR REPORT UNTIL ALL SECTIONS ARE COMPLETE.

State/Territory:
	(Name of State/Territory)
The following Annual Report is submitted in compliance with Title XXI of the Social Security Act (Section 2108(a) and Section 2108(e)).
Signature:

CHIP Program Name(s):

CHIP Program Type:
		CHIP Medicaid Expansion Only
		Separate Child Health Program Only
		Combination of the above

Reporting Period:		2011		Note: Federal Fiscal Year 2011 starts 10/1/2010 and ends 9/30/2011.
Contact Person/Title:
Address:

City:			State:				Zip:
Phone:	( )				Fax:	( )
Email:
Submission Date:

(Due to your CMS Regional Contact and Central Office Project Officer by January 1^st of each year)

Section I: Snapshot of CHIP Program and Changes

To provide a summary at-a-glance of your CHIP program characteristics, please provide the following information. You are encouraged to complete this table for the different CHIP programs within your state, e.g., if you have two types of separate child health programs within your state with different eligibility rules. If you would like to make any comments on your responses, please explain in narrative below this table. Please note that the numbers in brackets, e.g., [500] are character limits in the Children’s Health Insurance Program (CHIP) Annual Report Template System (CARTS). You will not be able to enter responses with characters greater than the limit indicated in the brackets.

	CHIP Medicaid Expansion Program				Separate Child Health Program
	* Upper % of FPL are defined as Up to and Including
	Gross or Net Income: ALL Age Groups as indicated below
	Is income calculated as gross or net income?		Income Net of Disregards			Is income calculated as gross or net income?		Gross Income
	Is income calculated as gross or net income?		Income Net of Disregards			Is income calculated as gross or net income?		Income Net of Disregards
Eligibility						From	% of FPL conception to birth		% of FPL *
	From	% of FPL for infants		% of FPL*		From	% of FPL for infants		% of FPL *
	From	% of FPL for children ages 1 through 5		% of FPL*		From	% of FPL for children ages 1 through 5		% of FPL *
	From	% of FPL for children ages 6 through 16		% of FPL*		From	% of FPL for children ages 6 through 16		% of FPL *
	From	% of FPL for children ages 17 and 18		% of FPL*		From	% of FPL for children ages 17 and 18		% of FPL *
						From	%of FPL for Pregnant Women age 19 and above.		% of FPL

Is presumptive eligibility provided for children?

Yes, for whom and how long?

[1000]

Yes – Please describe below [1000]

For which populations (include the FPL levels)

Average number of presumptive eligibility periods granted per individual and average duration of the presumptive eligibility period

Brief description of your presumptive eligibility policies

N/A

Is retroactive eligibility available?

Yes, for whom and how long?

[1000]

Yes, for whom and how long?

[1000]

N/A

Does your State Plan contain authority to implement a waiting list?	Not applicable	No
		Yes
		N/A

Please check all the methods of application utilized by your state.	Mail-in application		Mail-in application
	Phoned-in application		Phoned-in application
	Program has a web-based application that can be printed, completed, and mailed in		Program has a web-based application that can be printed, completed, and mailed in
	Applicant can apply for your program on-line		Applicant can apply for your program on-line
		Signature page must be printed and mailed in		Signature page must be printed and mailed in
		Family documentation must be mailed (i.e., income documentation)		Family documentation must be mailed (i.e., income documentation)
		Electronic signature is required		Electronic signature is required
				No Signature is required

Does your program require a face-to-face interview during initial application	No	No
	Yes	Yes
	N/A	N/A

Does your program require a child to be uninsured for a minimum amount of time prior to enrollment (waiting period)?		No			No
		Yes			Yes
	Specify number of months			Specify number of months
				To which groups (including FPL levels) does the period of uninsurance apply? [1000]
				List all exemptions to imposing the period of uninsurance
			N/A			N/A

Does your program match prospective enrollees to a database that details private insurance status?	No		No
	Yes		Yes
		If yes, what database? [1000]
	N/A		N/A

Does your program provide period of continuous coverage regardless of income changes?			No			No
			Yes			Yes
	Specify number of months			Specify number of months
	Explain circumstances when a child would lose eligibility during the time period in the box below			Explain circumstances when a child would lose eligibility during the time period in the box below
	[1000]			[1000]
		N/A			N/A

Does your program require premiums or an enrollment fee?

Yes

Enrollment fee amount

Premium amount

If premiums are tiered by FPL, please breakout by FPL.

Premium Amount

Range from

Range to

From

Range from

Range to

From

$______

% of FPL

$______

% of FPL

$______

% of FPL

$______

% of FPL

$______

% of FPL

$______

% of FPL

$______

% of FPL

$______

% of FPL

If premiums are tiered by FPL, please breakout by FPL.

Yearly Maximum Premium Amount per Family

$_________________

Yearly Maximum Premium Amount per Family

$_________________

Range from

Range to

From

Range from

Range to

From

$______

% of FPL

$______

% of FPL

$______

% of FPL

$______

% of FPL

$______

% of FPL

$______

% of FPL

$______

% of FPL

$______

% of FPL

If yes, briefly explain fee structure in the box below

If yes, briefly explain fee structure in the box below (including premium/enrollment fee amounts and include Federal poverty levels where appropriate)

[500]

N/A

Does your program impose copayments or coinsurance?	No	No
	Yes	Yes
	N/A	N/A

Does your program impose deductibles?	No	No
	Yes	Yes
	N/A	N/A

Does your program require an assets test?		No		No
		Yes		Yes
	If Yes, please describe below		If Yes, please describe below
	[500]		[500]
		N/A			N/A
	If Yes, do you permit the administrative verification of assets?		If Yes, do you permit the administrative verification of assets?
		No			No
		Yes			Yes
		N/A			N/A

Does your program require income disregards? (Note: if you checked off net income in the eligibility question, you must complete this question)		No		No
		Yes		Yes
	If Yes, please describe below		If Yes, please describe below
	[1000]		[1000]
		N/A		N/A

Which delivery system(s) does your program use?		Managed Care		Managed Care
		Primary Care Case Management		Primary Care Case Management
		Fee for Service		Fee for Service
	Please describe which groups receive which delivery system [500]		Please describe which groups receive which delivery system [500]

Is a preprinted renewal form sent prior to eligibility expiring?	No		No
	Yes, we send out form to family with their information pre-completed and		Yes, we send out form to family with their information pre-completed and
		We send out form to family with their information pre-completed and ask for confirmation		We send out form to family with their information pre-completed and ask for confirmation


		We send out form but do not require a response unless income or other circumstances have changed		We send out form but do not require a response unless income or other circumstances have changed


	N/A		N/A

Comments on Responses in Table:

Is there an assets test for children in your Medicaid program?

Yes

N/A

Is it different from the assets test in your separate child health program?

Yes

N/A

Are there income disregards for your Medicaid program?

Yes

N/A

Are they different from the income disregards in your separate child health program?

Yes

N/A

Is a joint application (i.e., the same, single application) used for your Medicaid and separate child health program?

Yes

N/A

If you have a joint application, is the application sufficient to determine eligibility for both Medicaid and CHIP?

Yes

N/A

8. Indicate what documentation is required at initial application for

	Self-Declaration	Self-Declaration with internal verification	Documentation Required
Income
Citizenship
Insured Status
Residency
Use of Income Disregards

9. Have you made changes to any of the following policy or program areas during the reporting period? Please indicate “yes” or “no change” by marking appropriate column.

	Medicaid Expansion CHIP Program			Separate Child Health Program
	Yes	No Change	N/A	Yes	No Change	N/A
Applicant and enrollee protections (e.g., changed from the Medicaid Fair Hearing Process to State Law)
Application
Application documentation requirements
Benefits
Cost sharing (including amounts, populations, & collection process)
Crowd out policies
Delivery system
Eligibility determination process
Implementing an enrollment freeze and/or cap
Eligibility levels / target population
Assets test
Income disregards i
Eligibility redetermination process
Enrollment process for health plan selection
Family coverage
Outreach (e.g., decrease funds, target outreach)
Premium assistance
Prenatal care eligibility expansion (Sections 457.10, 457.350(b)(2), 457.622(c)(5), and 457.626(a)(3) as described in the October 2, 2002 Final Rule)
Expansion to “Lawfully Residing” children
Expansion to “Lawfully Residing” pregnant women
Pregnant Women State Plan Expansion
Waiver populations (funded under title XXI)
Parents
Pregnant women
Childless adults*

Methods and procedures for prevention, investigation, and referral of cases of fraud and abuse
Other – please specify
	[50]
	[50]
	[50]

8. For each topic you responded yes to above, please explain the change and why the change was made, below:

Applicant and enrollee protections

(e.g., changed from the Medicaid Fair Hearing Process to State Law)

Application

Application documentation requirements

Benefits

e) Cost sharing (including amounts, populations, & collection process)

f) Crowd out policies

g) Delivery system

h) Eligibility determination process
i) Implementing an enrollment freeze and/or cap
j) Eligibility levels / target population
j) Eligibility levels / target population

k) Assets test in Medicaid and/or CHIP

l) Income disregards in Medicaid and/or CHIP

m) Eligibility redetermination process

n) Enrollment process for health plan selection

o) Family coverage

p) Outreach

q) Premium assistance

r) Prenatal care eligibility expansion (Sections 457.10, 457.350(b)(2), 457.622(c)(5), and 457.626(a)(3) as described in the October 2, 2002 Final Rule)

s) Expansion to “Lawfully Residing” children

t) Expansion to “Lawfully Residing” pregnant women

u) Pregnant Women State Plan Expansion

v) Waiver populations (funded under title XXI)
Parents

Pregnant women

Childless adults

w) Methods and procedures for prevention, investigation, and referral of cases of fraud and abuse

x) Other – please specify
a. [50]

b. [50]

c. [50]

Enter any Narrative text below. [7500]

Section II: Program’s Performance Measurement and Progress

This section consists of three subsections that gather information on the initial core set of children’s health care quality measures for the CHIP and/or Medicaid program as well as your State’s progress toward meeting its general program strategic objectives and performance goals. Section IIA captures data on the initial core set of measures to the extent data are available. Section IIB captures your enrollment progress as well as changes in the number and/or rate of uninsured children in your State. Section IIC captures progress towards meeting your State’s general strategic objectives and performance goals.

Section IIA: Reporting of the Initial Core Set of Children’s Health Care QualityMeasures

Section 401(a) of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) (Pub.L. 111-3) required the Secretary of the Department of Health and Human Services to identify an initial core set of child health care quality measures for voluntary use by State programs administered under titles XIX and XXI, health insurance issuers and managed care entities that enter into contract with such programs, and providers of items and services under such programs. Additionally, Section 401(a)(4) required the development of a standardized reporting format for states that volunteer to report on the initial core set of measures. This section of CARTS will be used for standardized reporting on the initial core set of measures.

States that volunteer are required to report using the standardized methodologies and specifications and report on the populations to which the measures are applied. Below are the measure stewards and general description of the measures. Please reference the Technical Specifications and Resource Manual for the Initial Core Set of Children’s Health Care Quality Measures for detailed information for standardized measure reporting.

The Technical Specifications and Resource Manual for the Initial Core Set of Children’s Health Care Quality Measures can be found: http://www.cms.gov/MedicaidCHIPQualPrac/Downloads/CHIPRACoreSetTechManual.pdf

The reporting of the Initial Care Set of Measures 1-23 is voluntary. Title XXI programs are required to report results from the CAHPS Child Medicaid Survey and the Supplemental Items for the Child Questionnaires on dental care, access to specialist care, and coordination of care from other health providers, by December 31, 2013.

	Measure	Measure Steward	Description	Reporting
1	Prenatal and Postpartum Care: Timeliness of Prenatal Care	NCQA/HEDIS	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 that received a prenatal care visit in the first trimester or within 42 days of enrollment	Measure is voluntary.
2	Frequency of Ongoing Prenatal Care	NCQA/HEDIS	Percentage of deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that received the following number of visits: < 21 percent of expected visits 21 percent – 40 percent of expected visits 41 percent – 60 percent of expected visits 61 percent – 80 percent of expected visits ≥ 81 percent of expected visits	Measure is voluntary.
3	Percentage of live births weighing less than 2,500 grams	CDC	Percentage of resident live births that weighed less than 2,500 grams in the State reporting period	Measure is voluntary.
4	Cesarean rate for nulliparous singleton vertex	California Maternal Care Collaborative	Percentage of women who had a cesarean section (C-section) among women with first live singleton births (also known as nulliparous term singleton vertex [NTSV] births) at 37 weeks of gestation or later	Measure is voluntary.
5	Childhood Immunization Status	NCQA/HEDIS	Percentage of children who turned 2 years old during the measurement year who had specific vaccines by their second birthday.	Measure is voluntary.
6	Immunizations for Adolescents	NCQA/HEDIS	Percentage of adolescents who turned 13 years old during the measurement year who had specific vaccines by their thirteenth birthday.	Measure is voluntary.
7	Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: BMI Assessment for Children/Adolescents	NCQA/HEDIS	Percentage of children, 3 through 17 years of age, whose weight is classified based on BMI percentile for age and gender.	Measure is voluntary.
8	Developmental Screening in the First Three Years of Life	Child and Adolescent Health Measurement Initiative and NCQA	Percentage of children screened for risk development, behavioral, and social delays using a standardized, screening tool in the first, second, and third year of life	Measure is voluntary.
9	Chlamydia Screening	NCQA/HEDIS	Percentage of women 16- 20 who were identified as sexually active who had at least one test for Chlamydia during the measurement year	Measure is voluntary.
10	Well Child Visits in the First 15 Months of Life	NCQA/HEDIS	Percentage of children who had zero, one, two, three, four, five, and six or more well child visits with a primary care practitioner during their first 15 months of life	Measure is voluntary.
11	Well Child Visits in the 3^rd, 4^th, 5^th, and 6^th Years of Life	NCQA/HEDIS	Percentage of children age 3 to 6 years old who had one or more well-child visits with a primary care practitioner during the measurement year.	Measure is voluntary.
12	Adolescent Well-Care Visits	NCQA/HEDIS	Percentage of adolescents age 12 through 21 years who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during the measurement year.	Measure is voluntary.
13	Percentage of Eligibles who Received Preventive Dental Services	CMS	Percentage of eligible children ages 1-20 who received preventive dental services	Measure is voluntary.
14	Child and Adolescent Access to Primary Care Practitioners	NCQA/HEDIS	Percentage of children and adolescents 12 months – 19 years of age who had a visit with a primary care practitioner (PCP). Four separate percentages are reported: Children 12- 24 months and 25 months – 6 years who had a visit with a PCP during the measurement year Children 7 – 11 years and adolescents 12 –19 years who had a visit with a PCP during the measurement year or the year prior to the measurement year	Measure is voluntary.
15	Appropriate Testing for Children with Pharyngitis	NCQA/HEDIS	Percentage of children who were diagnosed with pharyngitis, dispensed an antibiotic and who received a group A streptococcus test for the episode	Measure is voluntary.
16	Otitis media with effusion – avoidance of inappropriate use of systemic antimicrobials in children – ages 2-12	American Medical Association/ Physician Consortium for Performance Improvement	Percentage of children ages 2 months through 12 years with a diagnosis of otitis media with effusion (OME) who were not prescribed systemic antimicrobials	Measure is voluntary.
17	Percentage of Eligibles who Received Dental Treatment Services	CMS	Percentage of eligible children Ages 1-20 who received dental treatment services	Measure is voluntary.
18	Ambulatory Care: Emergency Department Visits	NCQA/HEDIS	The number of emergency department visits per child/adolescent per year as a function of all children and adolescents enrolled and eligible during the measurement year	Measure is voluntary.
19	Pediatric central-line associated blood stream infections – NICU and PICU	CDC	Rate of central line-associated blood stream infections (CLABSI) in the pediatric and neonatal intensive care units during periods selected for surveillance	Measure is voluntary.
20	Annual percentage of asthma patients (2-20 yo) with 1 or more asthma-related emergency room visits	Alabama Medicaid	Percentage of children 2-20 years of age diagnosed with asthma during the measurement year with one or more asthma-related ER visits	Measure is voluntary.
21	Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication	NCQA/HEDIS	Percentage of children newly prescribed ADHD medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days from the time when the first ADHD medication was dispensed. Two rates are reported: one for the initiation phase and one for the continuation and maintenance phase	Measure is voluntary.
22	Annual Pediatric hemoglobin A1C testing	NCQA	Percentage of children with diabetes and an HbA1c test during the measurement year.	Measure is voluntary.
23	Follow-up after hospitalization for mental illness	NCQA/HEDIS	Percentage of discharges for children 6 years of age 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	Measure is voluntary.
24	Consumer Assessment Of Healthcare Providers And Systems (CAHPS®) Health Plan Survey 4.0H (Child version including Medicaid and Children with Chronic Conditions supplemental items)	NCQA/HEDIS	Survey on parents’ experience with their child’s care	Reporting Required in 2013 Title XXI programs are required^¹ to report results from the CAHPS Child Medicaid Survey and the Supplemental Items for the Child Questionnaires on dental care, access to specialist care, and coordination of care from other health providers, by December 31, 2013. If States are already working with the Agency for Healthcare Research and Quality (AHRQ) to report CAHPS, they can continue doing so. We ask that States indicate in CARTS that they have submitted CAHPS data to AHRQ and using the CARTS attachment facility, provide a copy of the CAHPS results to CMS (do not submit raw data on CAHPS to CMS).

This section contains templates for reporting performance measurement data for each of the core child health measures. Please report performance measurement data for the three most recent years (to the extent that data are available). In the first and second columns, data from the previous to years’ annual reports (FFY 2009 and FFY 2010) will be populated with data from previously reported data in CARTS; enter data in these columns only if changes must be made. If you previously reported no data for either of those years, but you now have recent data for them, please enter the data. In the third column, please report the most recent data available at the time you are submitting the current annual report (FFY 2011). Additional instructions for completing each row of the table are provided below.

Beginning in 2011, the CARTS application will require States to provide information on why they chose not to report a measure(s) in Section IIA. The CARTS user will be prompted to provide this information for each measure during data entry. If the CARTS User skips these questions during the data entry process, he/she will be prompted to respond to them before being able to certify the Annual Report.

If Data Not Reported, Please Explain Why:

If you cannot provide a specific measure, please check the box that applies to your State for each measure as follows:

Population not covered: Check this box if your program does not cover the population included in the measure.
Data not available: Check this box if data are not available for a particular measure in your State. Please provide an explanation of why the data are currently not available.
Small sample size: Check this box if the denominator size for a particular 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, please 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 Initial Core Set of Measures is voluntarily reported, if the State is not reporting data on a specific measure, it is important to complete the reason why the State is not reporting the measure. It is important for CMS to understand why each State and why all States as a group may not be 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.

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.

Explanation of Provisional Data – When the value of the Status of Data Reported field is selected as “Provisional”, the State must specify why the data are provisional and when the State expects the data will be final.

Final: Check this box if the data you are reporting are considered final for the current CARTS reporting period.
Same data as reported in a previous year’s annual report: Check this box if the data you are reporting are the same data that your State reported in another annual report. Indicate in which year’s annual report you previously reported the data.

Measurement Specification:

For each measure, please indicate whether the measure is based on HEDIS® technical specifications or another source. If HEDIS® is selected, the HEDIS® Version field must be completed. If “Other” measurement specification is selected, the explanation field must be completed. States should use the technical specifications outlined in the Technical Specifications and Resource Manual for the Initial Core Set of Children’s Health Care Quality Measures.

HEDIS® Version:

Please specify HEDIS® Version (example 2009, 2010). This field must be completed only when a user selects the HEDIS® measurement specification.

“Other” measurement specification explanation:

If “Other”, measurement specification is selected, please complete the explanation of the “Other” measurement specification. The explanation field must be completed when “Other” measurement specification has been selected,

Data Source:

For each measure, please indicate the source of data or methodology used to calculate the measure – administrative data (such as claims and encounters) (specify the kind of administrative data used); hybrid methods (combining administrative data and medical records) (specify how the two were used to create the rate); survey data (specify the survey used); or other source (specify the other source).

Definition of Population included in the Measure:

Numerator: Please indicate the definition of the population included in the numerator for each measure.

Denominator: Please 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 CHIP population only, the Medicaid population only, or include both CHIP and Medicaid (Title XIX) children combined.

If the denominator reported is not fully representative of the population defined above (the CHIP population only, the Medicaid population only, or the CHIP and Medicaid (Title XIX) populations combined), please further define the denominator, including those who are excluded from the denominator. For example, please note if the denominator excludes children enrolled in managed care in certain counties or certain plans or if it excludes children in fee-for-service or PCCM. Also, please report the number of children excluded. The provision of this information is important and will provide CMS with a context so that comparability of denominators can be assessed across the States and over time.

Deviation from Measure Technical Specification

If the data provided for a measure deviates from the measure technical specification, please select the type(s) of measure specification deviation. The types of deviation parallel the measure specification categories for each measure. Each type of deviation is accompanied by a comment field that States must use to explain in greater detail or further specify the deviation when a deviation(s) from a measure is selected.

The five types (and examples) of deviations are:

Year of Data (e.g., partial year),

Data Source (e.g., use of different data sources among health plans or delivery systems),

Numerator (e.g., coding issues),

Denominator (e.g., exclusion of MCOs, different age groups, definition of continuous

enrollment),

Other (please describe in detail).

When one or more of the types are selected, States are required to provide an explanation.

Year of Data: not available for the 2011 CARTS reporting period.

Please report the year of data for each measure. The year (or months) should correspond to the 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.

Date Range: available for 2011 CARTS reporting period.

Please define the date range for the reporting period based 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.

Initial Core Set Measurement Data (HEDIS® or Other):

In this section, please report the numerators and denominators, rates for each measure (or component). The template provides two sections for entering the data, depending on whether you are reporting using HEDIS® or other methodologies. 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.

Note: 2011 CARTS will calculate the rate when you enter the numerator and denominator.

For CARTS versions prior to 2011 States were able to enter a rate without entering a numerator and denominator (If you typically calculate separate rates for each health plan or delivery system, report the aggregate state-level rate for each measure [or component]. The preferred method is to calculate a single state-level “weighted rate” based on the distribution of the eligible population included in each separate rate.) Beginning in 2011, CARTS will be requiring States to report numerators and denominators rather than providing them the option of only reporting the rate. If States reported a rate in years prior to 2011, that data will be able to be edited if the need arises.

Explanation of Progress:

The intent of this section is to allow your State to demonstrate how you are using the measures. Please highlight progress and describe any quality improvement activities that may have contributed to your progress. If improvement has not occurred over time, this section can be used to discuss potential reasons for why progress was not seen and to describe future quality improvement plans. In this section, your State is also asked to set annual performance objectives for FFY 2012, 2013, and 2014. Based on your recent performance on the measure (from FFY 2009 through 2011), use a combination of expert opinion and “best guesses” to set objectives for the next three years. Please explain your rationale for setting these objectives. For example, if your rate has been increasing by 3 or 4 percentage points per year, you might project future increases at a similar rate. On the other hand, if your rate has been stable over time, you might set a target that projects a small increase over time. If the rate has been fluctuating over time, you might look more closely at the data to ensure that the fluctuations are not an artifact of the data or the methods used to construct a rate. You might set an initial target that is an average of the recent rates, with slight increases in subsequent years.

In future annual reports, you will be asked to comment on how your actual performance compares to the objective your State set for the year, as well as any quality improvement activities that have helped or could help your State meet future objectives.

Other Comments on Measure:

Please use this section to provide any other comments on the measure, such as data limitations or plans to report on a measure in the future.

NOTE: Please do not reference attachments in this table. If details about a particular measure are located in an attachment, please summarize the relevant information from the attachment in the space provided for each measure.

CHIPRA Quality Demonstration States have the option of reporting State developed quality measures through CARTS. Instructions may be found on page 25 in the web-based template and after core measure 24 on the Word template.

EQRO Requirement: States with CHIP managed care that have existing external quality review organization (EQRO) reports are required to submit EQRO reports as an attachment.

Is the State submitting an EQRO report as an attachment to the 2011 CARTS?

Yes No

If yes, please provide a further description of the attachment. [7500]

If the State is not submitting an EQRO report as an attachment to the 2011 CARTS, please explain. [7500]

Category I - PREVENTION AND HEALTH PROMOTION

Prenatal/Perinatal

MEASURE 1: Timeliness of prenatal care

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data: Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 1: Timeliness of prenatal care (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

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 received a prenatal care visit in the first trimester or within 42 days of enrollment

HEDIS Performance Measurement Data:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

What quality improvement activities that involve the Medicaid and/or CHIP program and benefit Medicaid and/or CHIP enrollees help enhance your ability to report on this measure, improve your results for this measure, or make progress toward your goal?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

MEASURE 2: Frequency of ongoing prenatal care

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 2: Frequency of ongoing prenatal care (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

Percentage of deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that received the following number of visits:

< 21 percent of expected visits

21 percent – 40 percent of expected visits

41 percent – 60 percent of expected visits

61 percent – 80 percent of expected visits

≥ 81 percent of expected visits

HEDIS Performance Measurement Data:

Percentage of deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that received the following number of visits:

< 21 percent of expected visits

21 percent – 40 percent of expected visits

41 percent – 60 percent of expected visits

61 percent – 80 percent of expected visits

≥ 81 percent of expected visits

HEDIS Performance Measurement Data:

Percentage of deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that received the following number of visits:

< 21 percent of expected visits

21 percent – 40 percent of expected visits

41 percent – 60 percent of expected visits

61 percent – 80 percent of expected visits

≥ 81 percent of expected visits

< 21 percent of expected visits

Numerator:

Denominator:

Rate:

21 percent – 40 percent of expected visits

Numerator:

Denominator:

Rate:

41 percent – 60 percent of expected visits

Numerator:

Denominator:

Rate:

61 percent – 80 percent of expected visits

Numerator:

Denominator:

Rate:

≥ 81 percent of expected visits

Numerator:

Denominator:

Rate:

< 21 percent of expected visits

Numerator:

Denominator:

Rate:

21 percent – 40 percent of expected visits

Numerator:

Denominator:

Rate:

41 percent – 60 percent of expected visits

Numerator:

Denominator:

Rate:

61 percent – 80 percent of expected visits

Numerator:

Denominator:

Rate:

≥ 81 percent of expected visits

Numerator:

Denominator:

Rate:

< 21 percent of expected visits

Numerator:

Denominator:

Rate:

21 percent – 40 percent of expected visits

Numerator:

Denominator:

Rate:

41 percent – 60 percent of expected visits

Numerator:

Denominator:

Rate:

61 percent – 80 percent of expected visits

Numerator:

Denominator:

Rate:

≥ 81 percent of expected visits

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

MEASURE 3: Percentage of live births weighing less than 2,500 grams

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE- 3: Percentage of live births weighing less than 2,500 grams (continued)

FFY 2009

FFY 2010

FFY 2011

Performance Measurement Data:

Percentage of resident live births that weighed less than 2,500 grams in the State reporting period

Performance Measurement Data:

Percentage of resident live births that weighed less than 2,500 grams in the State reporting period

Performance Measurement Data:

Percentage of resident live births that weighed less than 2,500 grams in the State reporting period

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

MEASURE 4: Cesarean Rate for Nulliparous Singleton Vertex Low-risk First Birth Women

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator: .

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

.Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Range of Data:

From: (mm/yyyy) To: (mm/yyyy)

Range of Data:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 4: Cesarean Rate for Nulliparous Singleton Vertex Low-risk First Birth Women (continued)

FFY 2009

FFY 2010

FFY 2011

Performance Measurement Data:

Percentage of women who had a cesarean section (C-section) among women with first live singleton births (also known as nulliparous term singleton vertex [NTSV] births) at 37 weeks of gestation or later

Performance Measurement Data:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Immunizations

MEASURE 5: Childhood Immunization Status

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 5: Childhood Immunization Status (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

Percentage of children who turned 2 years old during the measurement year who had specific vaccines by their second birthday

HEDIS Performance Measurement Data:

Percentage of children who turned 2 years old during the measurement year who had specific vaccines by their second birthday

HEDIS Performance Measurement Data:

Percentage of children who turned 2 years old during the measurement year who had specific vaccines by their second birthday

DTap

Numerator:

Denominator:

Rate:

IPV

Numerator:

Denominator:

Rate:

MMR

Numerator:

Denominator:

Rate:

HiB

Numerator:

Denominator:

Rate:

Hep B

Numerator:

Denominator:

Rate:

VZV

Numerator:

Denominator:

Rate:

PCV

Numerator:

Denominator:

Rate:

Hep A

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Flu

Numerator:

Denominator:

Rate:

Combo 2

Numerator:

Denominator:

Rate:

Combo 3

Numerator:

Denominator:

Rate:

Combo 4

Numerator:

Denominator:

Rate:

Combo 5

Numerator:

Denominator:

Rate:

Combo 6

Numerator:

Denominator:

Rate:

Combo 7

Numerator:

Denominator:

Rate:

Combo 8

Numerator:

Denominator:

Rate:

Combo 9

Numerator:

Denominator:

Rate:

Combo 10

Numerator:

Denominator:

Rate:

DTap

Numerator:

Denominator:

Rate:

IPV

Numerator:

Denominator:

Rate:

MMR

Numerator:

Denominator:

Rate:

HiB

Numerator:

Denominator:

Rate:

Hep B

Numerator:

Denominator:

Rate:

VZV

Numerator:

Denominator:

Rate:

PCV

Numerator:

Denominator:

Rate:

Hep A

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Flu

Numerator:

Denominator:

Rate:

Combo 2

Numerator:

Denominator:

Rate:

Combo 3

Numerator:

Denominator:

Rate:

Combo 4

Numerator:

Denominator:

Rate:

Combo 5

Numerator:

Denominator:

Rate:

Combo 6

Numerator:

Denominator:

Rate:

Combo 7

Numerator:

Denominator:

Rate:

Combo 8

Numerator:

Denominator:

Rate:

Combo 9

Numerator:

Denominator:

Rate:

Combo 10

Numerator:

Denominator:

Rate:

DTap

Numerator:

Denominator:

Rate:

IPV

Numerator:

Denominator:

Rate:

MMR

Numerator:

Denominator:

Rate:

HiB

Numerator:

Denominator:

Rate:

Hep B

Numerator:

Denominator:

Rate:

VZV

Numerator:

Denominator:

Rate:

PCV

Numerator:

Denominator:

Rate:

Hep A

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Flu

Numerator:

Denominator:

Rate:

Combo 2

Numerator:

Denominator:

Rate:

Combo 3

Numerator:

Denominator:

Rate:

Combo 4

Numerator:

Denominator:

Rate:

Combo 5

Numerator:

Denominator:

Rate:

Combo 6

Numerator:

Denominator:

Rate:

Combo 7

Numerator:

Denominator:

Rate:

Combo 8

Numerator:

Denominator:

Rate:

Combo 9

Numerator:

Denominator:

Rate:

Combo 10

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

MEASURE 6: Immunizations for Adolescents

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 6: Immunizations for Adolescents (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

The percentage of adolescents 13 years of age who had specific vaccines by their 13th birthday.

HEDIS Performance Measurement Data:

The percentage of adolescents 13 years of age who had specific vaccines by their 13th birthday.

HEDIS Performance Measurement Data:

The percentage of adolescents 13 years of age who had specific vaccines by their 13th birthday.

Meningococcal

Numerator:

Denominator:

Rate:

Tdap/Td

Numerator:

Denominator:

Rate:

Combination (Meningococcal, Tdap/Td)

Numerator:

Denominator:

Rate:

Meningococcal

Numerator:

Denominator:

Rate:

Tdap/Td

Numerator:

Denominator:

Rate:

Combination (Meningococcal, Tdap/Td)

Numerator:

Denominator:

Rate:

Meningococcal

Numerator:

Denominator:

Rate:

Tdap/Td

Numerator:

Denominator:

Rate:

Combination (Meningococcal, Tdap/Td)

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Screening

MEASURE 7: BMI Assessment for Children/Adolescents

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 7: BMI Assessment for Children/Adolescents (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

Percentage of children 3 through 17 years of age whose weight is classified based on BMI percentile for age and gender.

HEDIS Performance Measurement Data:

Percentage of children 3 through 17 years of age whose weight is classified based on BMI percentile for age and gender.

HEDIS Performance Measurement Data:

Percentage of children 3 through 17 years of age whose weight is classified based on BMI percentile for age and gender.

3-11 years

Numerator:

Denominator:

Rate:

12 – 17 years

Numerator:

Denominator:

Rate:

Total

Numerator:

Denominator:

Rate:

3-11 years

Numerator:

Denominator:

Rate:

12 – 17 years

Numerator:

Denominator:

Rate:

Total

Numerator:

Denominator:

Rate:

3-11 years

Numerator:

Denominator:

Rate:

12 – 17 years

Numerator:

Denominator:

Rate:

Total

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

MEASURE 8: Developmental Screening in the First Three Years of Life

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 8: Developmental Screening in the First Three Years of Life (continued)

FFY 2009

FFY 2010

FFY 2011

Performance Measurement Data:

Percentage of children screened for risk development, behavioral, and social delays using a standardized tool in the first, second, or third year of life

Performance Measurement Data:

Percentage of children screened for risk development, behavioral, and social delays using a standardized tool in the first, second, or third year of life

Performance Measurement Data:

Percentage of children screened for risk development, behavioral, and social delays using a standardized tool in the first, second, or third year of life

Children screened by 12 months of age

Numerator:

Denominator:

Rate:

Children screened by 24 months of age

Numerator:

Denominator:

Rate:

Children screened by 36 months of age

Numerator:

Denominator:

Rate:

Children screened by 12 months of age

Numerator:

Denominator:

Rate:

Children screened by 24 months of age

Numerator:

Denominator:

Rate:

Children screened by 36 months of age

Numerator:

Denominator:

Rate:

Children screened by 12 months of age

Numerator:

Denominator:

Rate:

Children screened by 24 months of age

Numerator:

Denominator:

Rate:

Children screened by 36 months of age

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

MEASURE 9: Chlamydia screening 16-20 females

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 9: Chlamydia screening 16-20 females (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

Percentage of 16-20 year old females who were identified as sexually active and who had at least one test for Chlamydia during the measurement year

HEDIS Performance Measurement Data:

Percentage of 16-20 year old females who were identified as sexually active and who had at least one test for Chlamydia during the measurement year

HEDIS Performance Measurement Data:

Percentage of 16-20 year old females who were identified as sexually active and who had at least one test for Chlamydia during the measurement year

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Well-child Care Visits (WCV)

MEASURE 10: Well Child Visits in the First 15 Months of Life

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 10: Well Child Visits in the First 15 Months of Life (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

Percentage of children who had zero, one, two, three, four, five, and six or more well child visits with a primary care practitioner during their first 15 months of life

HEDIS Performance Measurement Data:

Percentage of children who had zero, one, two, three, four, five, and six or more well child visits with a primary care practitioner during their first 15 months of life

HEDIS Performance Measurement Data:

Percentage of children who had zero, one, two, three, four, five, and six or more well child visits with a primary care practitioner during their first 15 months of life

0 visits

Numerator:

Denominator:

Rate:

1 visit

Numerator:

Denominator:

Rate:

2 visits

Numerator:

Denominator:

Rate:

3 visits

Numerator:

Denominator:

Rate:

4 visits

Numerator:

Denominator:

Rate:

5 visits

Numerator:

Denominator:

Rate:

6+ visits

Numerator:

Denominator:

Rate:

0 visits

Numerator:

Denominator:

Rate:

1 visit

Numerator:

Denominator:

Rate:

2 visits

Numerator:

Denominator:

Rate:

3 visits

Numerator:

Denominator:

Rate:

4 visits

Numerator:

Denominator:

Rate:

5 visits

Numerator:

Denominator:

Rate:

6+ visits

Numerator:

Denominator:

Rate:

0 visits

Numerator:

Denominator:

Rate:

1 visit

Numerator:

Denominator:

Rate:

2 visits

Numerator:

Denominator:

Rate:

3 visits

Numerator:

Denominator:

Rate:

4 visits

Numerator:

Denominator:

Rate:

5 visits

Numerator:

Denominator:

Rate:

6+ visits

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

MEASURE 11: Well-Child Visits in Children the 3rd, 4th, 5th, and 6th Years of Life

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 11 : Well-Child Visits in Children the 3rd, 4th, 5th, and 6th Years of Life (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

Percentage of children age 3 to 6 years old who had one or more well-child visits with a primary care practitioner during the measurement year.

HEDIS Performance Measurement Data:

Percentage of children age 3 to 6 years old who had one or more well-child visits with a primary care practitioner during the measurement year.

HEDIS Performance Measurement Data:

Percentage of children age 3 to 6 years old who had one or more well-child visits with a primary care practitioner during the measurement year.

Percent with 1+ visits

Numerator:

Denominator:

Rate:

Percent with 1+ visits

Numerator:

Denominator:

Rate:

Percent with 1+ visits

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

MEASURE 12: Adolescent Well-Care Visits

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 12: Adolescent Well-Care Visits (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

Percentage of adolescents age 12 through 21 years who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during the measurement year.

HEDIS Performance Measurement Data:

Percentage of adolescents age 12 through 21 years who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during the measurement year.

HEDIS Performance Measurement Data:

Percentage of adolescents age 12 through 21 years who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during the measurement year.

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Dental

MEASURE 13: Percentage of eligible children ages one through twenty years old receiving preventive dental services (CMS Form 416)

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 13: Percentage of eligible children ages one through twenty years old receiving preventive dental services (CMS Form 416) (continued)

FFY 2009

FFY 2010

FFY 2011

Performance Measurement Data:

Percentage of eligible children ages 1-20 who received preventive dental services

Performance Measurement Data:

Percentage of eligible children ages 1-20 who received preventive dental services

Performance Measurement Data:

Percentage of eligible children ages 1-20 who received preventive dental services

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Access

MEASURE 14: Children and Adolescents’ Access to Primary Care

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

.Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data: 

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 14: Children and Adolescents’ Access to Primary Care (continued)

HEDIS Performance Measurement Data:

Percentage of children and adolescents who had a visit with a primary care practitioner

HEDIS Performance Measurement Data:

Percentage of children and adolescents who had a visit with a primary care practitioner

HEDIS Performance Measurement Data:

Percentage of children and adolescents who had a visit with a primary care practitioner

12-24 months

Numerator:

Denominator:

Rate:

25 months-6 years

Numerator:

Denominator:

Rate:

7-11 years

Numerator:

Denominator:

Rate:

12-19 years

Numerator:

Denominator:

Rate:

12-24 months

Numerator:

Denominator:

Rate:

25 months-6 years

Numerator:

Denominator:

Rate:

7-11 years

Numerator:

Denominator:

Rate:

12-19 years

Numerator:

Denominator:

Rate:

12-24 months

Numerator:

Denominator:

Rate:

25 months-6 years

Numerator:

Denominator:

Rate:

7-11 years

Numerator:

Denominator:

Rate:

12-19 years

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2010 compare with the Annual Performance Objective documented in your 2010 Annual Report?

What quality improvement activities that involve the CHIP program and benefit CHIP enrollees help enhance your ability to report on this measure, improve your results for this measure, or make progress toward your goal?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Category II - MANAGEMENT OF ACUTE CONDITIONS

Upper Respiratory -- Appropriate Use of Antibiotics

MEASURE 15: Appropriate Testing for Children with Pharyngitis

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 15: Appropriate Testing for Children with Pharyngitis (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

Percentage of children ages 2-18 who were diagnosed with pharyngitis, dispensed an antibiotic and who received a group A streptococcus test for the episode

HEDIS Performance Measurement Data:

Percentage of children ages 2-18 who were diagnosed with pharyngitis, dispensed an antibiotic and who received a group A streptococcus test for the episode

HEDIS Performance Measurement Data:

Percentage of children ages 2-18 who were diagnosed with pharyngitis, dispensed an antibiotic and who received a group A streptococcus test for the episode

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

MEASURE 16: Otitis Media with Effusion - avoidance of inappropriate use of systemic antimicrobials

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 16: Otitis Media with Effusion - avoidance of inappropriate use of systemic antimicrobials (continued)

FFY 2009

FFY 2010

FFY 2011

Performance Measurement Data:

Percentage of children ages 2 months through 12 years with a diagnosis of Otitis Media with Effusion (OME) who were not prescribed systemic antimicrobials

Performance Measurement Data:

Percent ageof children ages 2 months through 12 years with a diagnosis of Otitis Media with Effusion (OME) who were not prescribed systemic antimicrobials

Performance Measurement Data:

Percent ageof children ages 2 months through 12 years with a diagnosis of Otitis Media with Effusion (OME) who were not prescribed systemic antimicrobials

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Dental

MEASURE 17: Percentage of eligible children ages one through twenty who received dental treatment services (CMS Form 416)

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 17: Percentage of eligible children ages one through twenty who received dental treatment services (CMS Form 416) (continued)

FFY 2009

FFY 2010

FFY 2011

Performance Measurement Data:

Percentage of eligible children ages 1-20 who received dental treatment services

Performance Measurement Data:

Percentage of eligible children ages 1-20 who received dental treatment services

Performance Measurement Data:

Percentage of eligible children ages 1-20 who received dental treatment services

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Emergency Department

MEASURE 18: Ambulatory Care: Emergency Department Visits

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 18: Ambulatory Care: Emergency Department Visits

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

The number of emergency department visits per child/adolescent per year as a function of all children and adolescents enrolled and eligible during the measurement year

HEDIS Performance Measurement Data:

The number of emergency department visits per child/adolescent per year as a function of all children and adolescents enrolled and eligible during the measurement year

HEDIS Performance Measurement Data:

The number of emergency department visits per child/adolescent per year as a function of all children and adolescents enrolled and eligible during the measurement year

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Inpatient

MEASURE 19: Pediatric central-line associated bloodstream infection rates (PICU and NICU)

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 19: Pediatric central-line associated blood stream infection rates (PICU and NICU) (continued)

FFY 2009

FFY 2010

FFY 2011

Performance Measurement Data:

Rate of central line-associated blood stream infections (CLABSI) in the pediatric and neonatal intensive care units during periods selected for surveillance

Performance Measurement Data:

Rate of central line-associated blood stream infections (CLABSI) in the pediatric and neonatal intensive care units during periods selected for surveillance

Performance Measurement Data:

Rate of central line-associated blood stream infections (CLABSI) in the pediatric and neonatal intensive care units during periods selected for surveillance

Pediatric Intensive Care Unit

Numerator:

Denominator:

Rate:

Neonatal Intensive Care Unit

Numerator:

Denominator:

Rate:

Pediatric Intensive Care Unit

Numerator:

Denominator:

Rate:

Neonatal Intensive Care Unit

Numerator:

Denominator:

Rate:

Pediatric Intensive Care Unit

Numerator:

Denominator:

Rate:

Neonatal Intensive Care Unit

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Category III - MANAGEMENT OF CHRONIC CONDITIONS

Asthma

MEASURE 20: Annual percentage of asthma patients 2 through 20 years old with one or more asthma-related emergency room visits

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 20: Annual percentage of asthma patients 2 through 20 years old with one or more asthma-related emergency room visits (continued)

FFY 2009

FFY 2010

FFY 2011

Performance Measurement Data:

Percentage of children 2-20 years of age diagnosed with asthma during the measurement year with one or more asthma-related ED visits.

Performance Measurement Data:

Percentage of children 2-20 years of age diagnosed with asthma during the measurement year with one or more asthma-related ED visits.

Performance Measurement Data:

Percentage of children 2-20 years of age diagnosed with asthma during the measurement year with one or more asthma-related ED visits.

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Attention-Deficit/Hyperactivity Disorder

MEASURE 21: Follow-up care for children prescribed attention-deficit/hyperactivity disorder (ADHD) medication

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 21: Follow-up care for children prescribed attention-deficit/hyperactivity disorder (ADHD) medication (continued)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

Initiation Phase: Percentage of children 6 - 12 years of age as of the Index Prescription Episode Start Date (IPSD) with an ambulatory prescription for ADHD dispensed who had one follow up visit with a practitioner with prescribing authority during the 30 day initiation phase.

Continuation and Maintenance (C&M) Phase: Percentage of members 6 - 12 years of age as of the IPSD with an ambulatory prescriptionwho remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase had at least two follow-up visits with practitioner within 270 days (9 months) after the initiation phase ended.

HEDIS Performance Measurement Data:

Continuation and Maintenance (C&M) Phase: Percentage of members 6 - 12 years of age as of the IPSD with an ambulatory prescription who remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase had at least two follow-up visits with practitioner within 270 days (9 months) after the initiation phase ended.

HEDIS Performance Measurement Data:

Continuation and Maintenance (C&M) Phase: Percentage of members 6 - 12 years of age as of the IPSD with an ambulatory prescription who remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase had at least two follow-up visits with practitioner within 270 days (9 months) after the initiation phase ended.

Initiation Phase

Numerator:

Denominator:

Rate:

Continuation and Maintenance (C&M) Phase:

Numerator:

Denominator:

Rate:

Initiation Phase

Numerator:

Denominator:

Rate:

Continuation and Maintenance (C&M) Phase:

Numerator:

Denominator:

Rate:

Initiation Phase

Numerator:

Denominator:

Rate:

Continuation and Maintenance (C&M) Phase:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Diabetes

MEASURE 22: Annual pediatric hemoglobin A1C testing

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 22: Annual pediatric hemoglobin A1C testing (continued)

FFY 2009

FFY 2010

FFY 2011

Performance Measurement Data:

Percentage of children (5-17 years old) with diabetes and a HBA1c test during the measurement year period

Performance Measurement Data:

Percentage of children (5-17 years old) with diabetes and a HBA1c test during the measurement year period

Performance Measurement Data:

Percentage of children (5-17 years old) with diabetes and a HBA1c test during the measurement year period

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Mental Health

MEASURE 23: Follow-up after hospitalization for mental illness

FFY 2009

FFY 2010

FFY 2011

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Did you report on this measure?

Yes

If Data Not Reported, Please Explain Why:

Population not covered.

Data not available. Explain:

Small sample size (less than 30).

Specify sample size:

Other. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data). Specify:

Hybrid (claims and medical record data). Specify:

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes Medicaid population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

MEASURE 23: Follow-up after hospitalization for mental illness (continued)

FFY 2009

FFY 2010

FFY 2011

Performance Measurement Data:

Percentage of discharges for children aged 6 years and older who were hospitalized for treatment of a mental health disorder and who had an outpatient visit, intensive outpatient encounter, or partial hospitalization with a mental health practitioner

Performance Measurement Data:

Percentage of discharges for children aged 6 years and older who were hospitalized for treatment of a mental health disorder and who had outpatient visit, intensive outpatient encounter, or partial hospitalization with a mental health practitioner

7 Day Follow-Up

Numerator:

Denominator:

Rate:

30 Day Follow-Up

Numerator:

Denominator:

Rate:

7 Day Follow-Up

Numerator:

Denominator:

Rate:

30 Day Follow-Up

Numerator:

Denominator:

Rate:

7 Day Follow-Up

Numerator:

Denominator:

Rate:

30 Day Follow-Up

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:  

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

MEASURE 24: Consumer Assessment Of Healthcare Providers And Systems (CAHPS®) Health Plan Survey 4.0H

(Child version including Medicaid and Children with Chronic Conditions supplemental items)

	FFY 2010	FFY 2011
	Did you report on this measure? Yes No If yes, how did you report this measure? Submitted raw data to AHRQ Submitted a summary report to CMS using the CARTS attachment facility (NOTE: do not submit raw CAHPS data to CMS) If no, explain why data were not reported: Population not covered. Data not available. Explain: Small sample size (less than 30). Specify sample size: Other. Explain:	Did you report on this measure? Yes No If yes, how did you report this measure? Submitted raw data to AHRQ Submitted a summary report to CMS using the CARTS attachment facility (NOTE: do not submit raw CAHPS data to CMS) If no, explain why data were not reported: Population not covered. Data not available. Explain: Small sample size (less than 30). Specify sample size: Other. Explain:
	Definition of Population Included in the Measure: Definition of denominator: Denominator includes CHIP population only. Denominator includes Medicaid population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:	Definition of Population Included in the Measure: Definition of denominator: Denominator includes CHIP population only. Denominator includes Medicaid population only. Denominator includes CHIP and Medicaid (Title XIX). If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:
Explanation of Progress: How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report? What quality improvement activities that involve the Medicaid and/or CHIP program and benefit Medicaid and/or CHIP enrollees help enhance your ability to report on this measure, improve your results for this measure, or make progress toward your goal? Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data. Annual Performance Objective for FFY 2012: Annual Performance Objective for FFY 2013: Annual Performance Objective for FFY 2014: Explain how these objectives were set:
Other Comments on Measure:

Reporting of State-specific measures:

In addition to reporting the CHIPRA core set quality measures, if your State has developed State-specific quality measures as part of the CHIPRA Quality Demonstration Grant project, the State may report that data in CARTS. The State may attach documents/data regarding the state-specific measures by using the CARTS attachment facility. Please provide a brief description of the attachment in the space provided when submitting the attachment.

Is the State attaching any state-specific quality measures as a CARTS attachment?

Yes No

Section IIB: Enrollment And Uninsured Data

The information in the table below is the Unduplicated Number of Children Ever Enrolled in CHIP in your State for the two most recent reporting periods. The enrollment numbers reported below should correspond to line 7 (Unduplicated # Ever Enrolled Year) in your State’s 4^th quarter data report (submitted in October) in the CHIP Statistical Enrollment Data System (SEDS). The percent change column reflects the percent change in enrollment over the two-year period. If the percent change exceeds 10 percent (increase or decrease), please explain in letter A below any factors that may account for these changes (such as decreases due to elimination of outreach or increases due to program expansions). This information will be filled in automatically by CARTS through a link to SEDS. Please wait until you have an enrollment number from SEDS before you complete this response.

Program	FFY 2010	FFY 2011	Percent change FFY 2010-2011
CHIP Medicaid Expansion Program
Separate Child Health Program

Please explain any factors that may account for enrollment increases or decreases exceeding 10 percent.

[7500]

The table below shows trends in the three-year averages for the number and rate of uninsured children in your State based on the Current Population Survey (CPS), along with the percent change between 1996-1998 and 2009-2010. Significant changes are denoted with an asterisk (*). If your state uses an alternate data source and/or methodology for measuring change in the number and/or rate of uninsured children, please explain in Question #3. CARTS will fill in this information automatically, but in the meantime, please refer to the CPS data attachment that was sent with the FFY 2011 Annual Report Template.

	Uninsured Children Under Age 19 Below 200 Percent of Poverty		Uninsured Children Under Age 19 Below 200 Percent of Poverty as a Percent of Total Children Under Age 19
Period	Number (In Thousands)	Std. Error	Rate	Std. Error
1996-1998
1998-2000
2000-2002
2002–2004
2003–2005
2004–2006
2005–2007
2006-2008
2007-2009
2008-2010
Percent change 1996-1998 vs. 2008-2010

Please explain any activities or factors that may account for increases or decreases in your number and/or rate of uninsured children.

[7500]

Please note any comments here concerning CPS data limitations that may affect the reliability or precision of these estimates. [7500]

Please indicate by checking the box below whether your State has an alternate data source and/or methodology for measuring the change in the number and/or rate of uninsured children.

Yes (please report your data in the table below)

No (skip to Question #4)

Please report your alternate data in the table below. Data are required for two or more points in time to demonstrate change (or lack of change). Please be as specific and detailed as possible about the method used to measure progress toward covering the uninsured.

Data source(s)
Reporting period (2 or more points in time)
Methodology
Population (Please include ages and income levels)
Sample sizes
Number and/or rate for two or more points in time
Statistical significance of results

Please explain why your State chose to adopt a different methodology to measure changes in the number and/or rate of uninsured children.

[7500]

What is your State’s assessment of the reliability of the estimate? Please provide standard errors, confidence intervals, and/or p-values if available.

[7500]

What are the limitations of the data or estimation methodology?

[7500]

How does your State use this alternate data source in CHIP program planning?

[7500]

How many children do you estimate have been enrolled in Medicaid as a result of CHIP outreach activities and enrollment simplification? Describe the data source and method used to derive this information.

[7500]

Section IIC: State Strategic Objectives And Performance Goals

This subsection gathers information on your State’s general strategic objectives, performance goals, performance measures and progress towards meeting goals, as specified in your CHIP State Plan. (If your goals reported in the annual report now differ from Section 9 of your CHIP state plan, please indicate how they differ in “Other Comments on Measure.” Also, the state plan should be amended to reconcile these differences). The format of this section provides your State with an opportunity to track progress over time. This section contains templates for reporting performance measurement data for each of five categories of strategic objectives, related to:

Reducing the number of uninsured children
CHIP enrollment
Medicaid enrollment
Increasing access to care
Use of preventative care (immunizations, well child care)

Please report performance measurement data for the three most recent years for which data are available (to the extent that data are available). In the first two columns, data from the previous two years’ annual reports (FFY 2009 and FFY 2010) will be populated with data from previously reported data in CARTS. If you previously reported data in the 2 previous years reports (2009 and/or 2010) and you want to update/change the data, please enter that data. If you previously reported no data for either of those years, but you now have recent data available for them, please enter the data. In the third column, please report the most recent data available at the time you are submitting the current annual report (FFY 2011).

Note that the term performance measure is used differently in Section IIA versus IIC. In Section IIA, the term refers to the 24 core child health measures. In this section, the term is used more broadly, to refer to any data your State provides as evidence towards a particular goal within a strategic objective. For the purpose of this section, “objectives” refer to the five broad categories listed above, while “goals” are State-specific, and should be listed in the appropriate subsections within the space provided for each objective.

NOTES: Please do not reference attachments in this section. If details about a particular measure are located in an attachment, please summarize the relevant information from the attachment in the space provided for each measure.

In addition, please do not report the same data that were reported in Sections IIA or IIB. The intent of this section is to capture goals and measures that your State did not report elsewhere in Section II.

Additional instructions for completing each row of the table are provided below.

Goal:

For each objective, space has been provided to report up to three goals. Use this section to provide a brief description of each goal you are reporting within a given strategic objective. All new goals should include a direction and a target. For clarification only, an example goal would be: “Increase (direction) by 5 percent (target) the number of CHIP beneficiaries who turned 13 years old during the measurement year who had a second dose of MMR, three hepatitis B vaccinations and one varicella vaccination by their 13^th birthday.”

Type of Goal:

For each goal you are reporting within a given strategic objective, please indicate the type of goal, as follows:

New/revised: Check this box if you have revised or added a goal. Please explain how and why the goal was revised.
Continuing: Check this box if the goal you are reporting is the same one you have reported in previous annual reports.
Discontinued: Check this box if you have met your goal and/or are discontinuing a goal. Please explain why the goal was discontinued.

Status of Data Reported:

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

Provisional: Check this box if you are reporting performance measure data for a goal, but the data are currently being modified, verified, or may change in any other way before you finalize them for FFY 2011.

Final: Check this box if the data you are reporting are considered final for FFY 2011.
Same data as reported in a previous year’s annual report: Check this box if the data you are reporting are the same data that your State reported for the goal in another annual report. Indicate in which year’s annual report you previously reported the data.

Measurement Specification:

This section is included for only two of the objectives— objectives related to increasing access to care, and objectives related to use of preventative care—because these are the two objectives for which States may report using the HEDIS® measurement specification. In this section, for each goal, please indicate the measurement specification used to calculate your performance measure data (i.e., were the measures calculated using the HEDIS® specifications or some other method unrelated to HEDIS®).

Please indicate whether the measure is based on HEDIS® technical specifications or another source. If HEDIS® is selected, the HEDIS® Version field must be completed. If “Other” measurement specification is selected, the explanation field must be completed.

HEDIS® Version:

Please specify HEDIS® Version (example 2009, 2010). This field must be be completed only when a user select the HEDIS® measurement specification.

“Other” measurement specification explanation:

Data Source:

For each performance measure, please indicate the source of data. The categories provided in this section vary by objective. For the objectives related to reducing the number of uninsured children and CHIP or Medicaid enrollment, please indicate whether you have used eligibility/enrollment data, survey data (specify the survey used), or other source (specify the other source). For the objectives related to access to care and use of preventative care, please indicate whether you used administrative data (claims) (specify the kind of administrative data used), hybrid data (claims and medical records) (specify how the two were used to create the data source), survey data (specify the survey used), or other source (specify the other source). In all cases, if another data source was used, please explain the source.

Definition of Population Included in Measure:

Numerator: Please indicate the definition of the population included in the numerator for each measure (such as the number of visits required for inclusion, e.g., one or more visits in the past year).

Denominator: Please indicate the definition of the population included in the denominator for each measure

For measures related to increasing access to care and use of preventative care, please

check one box to indicate whether the data are for the CHIP population only, or include both CHIP and Medicaid (Title XIX) children combined.

If the denominator reported is not fully representative of the population defined above (the CHIP population only,or the CHIP and Medicaid (Title XIX) populations combined), please further define the denominator. For example, denominator includes only children enrolled in managed care in certain counties, technological limitations preventing reporting on the full population defined, etc.). Please report information on exclusions in the definition of the denominator (including the proportion of children excluded), The provision of this information is important and will provide CMS with a context so that comparability of denominators across the States and over time can occur.

Deviations from Measure

For the measures related to increasing access to care and use of preventative care.

If the data provided for a measure deviates from the measure specification, please select the type(s) of measure specification deviation. The types of deviation parallel the measure specification categories for each measure. Each type of deviation is accompanied by a comment field that States must use to explain in greater detail or further specify the deviation when a deviation(s) from a measure is selected..

The five types (and examples) of deviations are:

Year of Data (e.g., partial year),

Data Source (e.g., use of different data sources among health plans or delivery systems),

Numerator (e.g., coding issues),

Denominator (e.g., exclusion of MCOs, different age groups, definition of continuous

enrollment),

Other.

When one or more of the types are selected, states are required to provide an explanation.

Year of Data: not available for the 2011 CARTS reporting period.

Please report the year of data for each performance measure. The year (or months) should correspond to the period in which enrollment or 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 enrollment or utilization of services.

Date Range: available for 2011 CARTS reporting period.

Please define the date range for the reporting period based on the “From” time period as the month and year which corresponds to the beginning period in which utilization took place and please report the “To” time period as the month and year which 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.

Performance Measurement Data (HEDIS® or Other):

In this section, please report the numerators and denominators, rates for each measure (or component). The template provides two sections for entering the performance measurement data, depending on whether you are reporting using HEDIS® or other methodologies. 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.

Note: CARTS will calculate the rate when you enter the numerator and denominator.

For CARTS versions prior to 2011 States were able to enter a rate without entering a numerator and denominator (If you typically calculate separate rates for each health plan, report the aggregate state-level rate for each measure [or component]. The preferred method is to calculate a “weighted rate” by summing the numerators and denominators across plans, and then deriving a single state-level rate based on the ratio of the numerator to the denominator.) Beginning in 2011, CARTS will be requiring States to report numerators and denominators rather than providing them the option of only reporting the rate. If States reported a rate in years prior to 2011, that data will be able to be edited if the need arises.

Explanation of Progress:

The intent of this section is to allow your State to highlight progress and describe any quality-improvement activities that may have contributed to your progress. Any quality-improvement activity described should involve the CHIP program, benefit CHIP enrollees, and relate to the performance measure and your progress. An example of a quality-improvement activity is a state-wide initiative to inform individual families directly of their children’s immunization status with the goal of increasing immunization rates. CHIP would either be the primary lead or substantially involved in the project. If improvement has not occurred over time, this section can be used to discuss potential reasons for why progress was not seen and to describe future quality-improvement plans. In this section, your State is also asked to set annual performance objectives for FFY 2012,, 2013, and 2014. Based on your recent performance on the measure (from FFY 2009 through 2011), use a combination of expert opinion and “best guesses” to set objectives for the next three years. Please explain your rationale for setting these objectives. For example, if your rate has been increasing by 3 or 4 percentage points per year, you might project future increases at a similar rate. On the other hand, if your rate has been stable over time, you might set a target that projects a small increase over time. If the rate has been fluctuating over time, you might look more closely at the data to ensure that the fluctuations are not an artifact of the data or the methods used to construct a rate. You might set an initial target that is an average of the recent rates, with slight increases in subsequent years. In future annual reports, you will be asked to comment on how your actual performance compares to the objective your State set for the year, as well as any quality-improvement activities that have helped or could help your State meet future objectives.

Other Comments on Measure:

Please use this section to provide any other comments on the measure, such as data limitations, plans to report on a measure in the future, or differences between performance measures reported here and those discussed in Section 9 of the CHIP state plan.

Objectives Related to Reducing the Number of Uninsured Children (Do not report data that was reported in Section IIB, Questions 2 & 3)

FFY 2009

FFY 2010

FFY 2011

Goal #1 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to Reducing the Number of Uninsured Children (Do not report data that was reported in Section IIB, Questions 2 & 3) (Continued)

FFY 2009

FFY 2010

FFY 2011

Goal #2 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Data Source:

Eligibility/Enrollment data

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to Reducing the Number of Uninsured Children (Do not report data that was reported in Section IIB, Questions 2 & 3) (Continued)

FFY 2009

FFY 2010

FFY 2011

Goal #3 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Data Source:

Eligibility/Enrollment data

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to CHIP Enrollment

FFY 2009

FFY 2010

FFY 2011

Goal #1 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related CHIP Enrollment (Continued)

FFY 2009

FFY 2010

FFY 2011

Goal #2 (Describe)

Type of Objective:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Objective:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Objective:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to CHIP Enrollment (Continued)

FFY 2009

FFY 2010

FFY 2011

Goal #3 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to Medicaid Enrollment

FFY 2009

FFY 2010

FFY 2011

Goal #1 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Year of Data:  

:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to Medicaid Enrollment (Continued)

FFY 2009

FFY 2010

FFY 2011

Goal #2 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to Medicaid Enrollment (Continued)

FFY 2009

FFY 2010

FFY 2011

Goal #3 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Data Source:

Eligibility/Enrollment data.

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Definition of Population Included in the Measure:

Definition of denominator:

Definition of numerator:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Performance Measurement Data:

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related Increasing Access to Care (Usual Source of Care, Unmet Need)

FFY 2009

FFY 2010

FFY 2011

Goal #1 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS)

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to Increasing Access to Care (Usual Source of Care, Unmet Need) (Continued)

FFY 2009

FFY 2010

FFY 2011

Goal #2 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify Version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

D1efinition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

 

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS)

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to Increasing Access to Care (Usual Source of Care, Unmet Need) (Continued)

FFY 2009

FFY 2010

FFY 2011

Goal #3 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS)

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to Use of Preventative Care (Immunizations, Well Child Care)

FFY 2009

FFY 2010

FFY 2011

Goal #1 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify Version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS)

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to Use of Preventative Care (Immunizations, Well Child Care) (Continued)

FFY 2009

FFY 2010

FFY 2011

Goal #2 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

FFY 2009

FFY 2010

FFY 2011

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS)

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

Objectives Related to Use of Preventative Care (Immunizations, Well Child Care) (Continued)

FFY 2009

FFY 2010

FFY 2011

Goal #3 (Describe)

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Type of Goal:

New/revised. Explain:

Continuing.

Discontinued. Explain:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Status of Data Reported:

Provisional.

Explanation of Provisional Data:

Final.

Same data as reported in a previous year’s annual report.

Specify year of annual report in which data previously reported:

Measurement Specification:

HEDIS. Specify version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version version of HEDIS used:

HEDIS-like. Specify version of HEDIS used:

Explain how HEDIS was modified:

Other. Explain:

Measurement Specification:

HEDIS. Specify HEDIS® Version used:

Other. Explain:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Data Source:

Administrative (claims data).

Hybrid (claims and medical record data).

Survey data. Specify:

Other. Specify:

Definition of Population Included in the Measure:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of numerator:

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

Definition of Population Included in the Measure:

Definition of numerator:

Definition of denominator:

Denominator includes CHIP population only.

Denominator includes CHIP and Medicaid (Title XIX).

If denominator is a subset of the definition selected above, please further define the Denominator, please indicate the number of children excluded:

Year of Data:  

Date Range:

From: (mm/yyyy) To: (mm/yyyy)

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS/HEDIS-like methodology)

Numerator:

Denominator:

Rate:

HEDIS Performance Measurement Data:

(If reporting with HEDIS)

Numerator:

Denominator:

Rate:

Deviations from Measure Specifications;

Year of Data, Explain

Data Source, Explain

Numerator, Explain

Denominator, Explain

Other, Explain

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Other Performance Measurement Data:

(If reporting with another methodology)

Describe what is being measured:

Numerator:

Denominator:

Rate:

Additional notes on measure:

Explanation of Progress:

How did your performance in 2011 compare with the Annual Performance Objective documented in your 2010 Annual Report?

Please indicate how CMS might be of assistance in improving the completeness or accuracy of your reporting of the data.

Annual Performance Objective for FFY 2012:  

Annual Performance Objective for FFY 2013:  

Annual Performance Objective for FFY 2014:  

Explain how these objectives were set:  

Other Comments on Measure:

1. What other strategies does your State use to measure and report on access to, quality, or outcomes of care received by your CHIP population? What have you found? [7500]

2. What strategies does your CHIP program have for future measurement and reporting on access to, quality, or outcomes of care received by your CHIP population? When will data be available? [7500]

3. Have you conducted any focused quality studies on your CHIP population, e.g., adolescents, attention deficit disorder, substance abuse, special heath care needs or other emerging health care needs? What have you found? [7500]

4. Please attach any additional studies, analyses or other documents addressing outreach, enrollment, access, quality, utilization, costs, satisfaction, or other aspects of your CHIP program’s performance. Please include any analyses or descriptions of any efforts designed to reduce the number of uncovered children in the state through a state health insurance connector program or support for innovative private health coverage initiatives. [7500]

Please list attachments here and summarize findings or list main findings. [7500]

Enter any Narrative text below.

[7500]

Section III: Assessment of State Plan and Program Operation

Please reference and summarize attachments that are relevant to specific questions

Outreach

How have you redirected/changed your outreach strategies during the reporting period? [7500]
What methods have you found most effective in reaching low-income, uninsured children (e.g., T.V., school outreach, word-of-mouth)? How have you measured effectiveness?
Which of the methods described in Question 2 would you consider a best practice(s)? [7500]
Is your state targeting outreach to specific populations (e.g., minorities, immigrants, and children living in rural areas)?

Yes No

Have these efforts been successful, and how have you measured effectiveness? [7500]

What percentage of children below 200 percent of the Federal poverty level (FPL) who are eligible for Medicaid or CHIP have been enrolled in those programs? [5]

(Identify the data source used). [7500]

Substitution of Coverage (Crowd-out)

All states should answer the following questions. Please include percent calculations in your responses when applicable and requested.

Do you have substitution prevention policies in place?

Yes No

If yes, indicate if you have the following policies:

Imposing waiting periods between terminating private coverage and enrolling in CHIP

Imposing cost sharing in approximation to the cost of private coverage

Monitoring health insurance status at the time of application

Other, please explain [7500]

2. Describe how substitution of coverage is monitored and measured and how the State evaluates the effectiveness of its policies. [7500]

3. Identify the trigger mechanism or point at which your substitution prevention policy is instituted or modified if you currently have a substitution policy. [7500]

All States must complete the following questions

4. At the time of application, what percent of CHIP applicants are found to have Medicaid [(# applicants found to have Medicaid/total # applicants) * 100] [5] and what percent of applicants are found to have other group health insurance [(# applicants found to have other insurance/total # applicants) * 100] [5]? Provide a combined percent if you cannot calculate separate percentages. [5]

5. What percent of CHIP applicants cannot be enrolled because they have group health plan coverage? [5]

a. Of those found to have had other, private insurance and have been uninsured for only a portion of the state’s waiting period, what percent meet your state’s exemptions to the waiting period (if your state has a waiting period and exemptions) [(# applicants who are exempt/total # of new applicants who were enrolled)*100]? [5]

6. Does your State have an affordability exception to its waiting period?

Yes No

If yes, please respond to the following questions. If no, skip to question 7.

Has the State established a specific threshold for defining affordability (e.g., when the cost of the child’s portion of the family’s employer-based health insurance premium is more than X percent of family income)?

Yes No

If the State has established a specific threshold, please provide this figure and whether this applies to net or gross income. If no, how does the State determine who meets the affordability exception? [7500]

What expenses are counted for purposes of determining when the family exceeds the affordability threshold? (e.g., Does the State consider only premiums, or premiums and other cost-sharing charges? Does the State base the calculation on the total premium for family coverage under the employer plan or on the difference between the amount of the premium for employee-only coverage and the amount of the premium for family coverage? Other approach?) [7500]
What percentage of enrollees at initial application qualified for this exception in the last Federal Fiscal Year? (e.g., Number of applicants who were exempted because of affordability exception/total number of applicants who were enrolled). [5]
Does the State conduct surveys or focus groups that examine whether affordability is a concern?

Yes No

If yes, please provide relevant findings. [7500]

7. If your State does not have an affordability exception, does your State collect data on the cost of health insurance for an individual or family? [7500]

8. Does the State’s CHIP application ask whether applicants have access to private health insurance?

Yes No

If yes, do you track the number of individuals who have access to private insurance?

Yes No

If yes, what percent of individuals that enrolled in CHIP had access to private health insurance at the time of application during the last Federal Fiscal Year [(# of individuals that had access to private health insurance/total # of individuals enrolled in CHIP)*100]? [5]

C. Eligibility

(This subsection should be completed by all States. Medicaid Expansion states should complete applicable responses and indicate those questions that are non-applicable with N/A.

Section IIIC: Subpart A: Overall CHIP and Medicaid Eligibility Coordination

Does the State use a joint application for establishing eligibility for Medicaid or CHIP?

Yes No

If no, please describe the screen and enroll process. [7500]

Please explain the process that occurs when a child’s eligibility status changes from Medicaid to CHIP and from CHIP to Medicaid. Have you identified any challenges? If so, please explain. [7500]
Are the same delivery systems (such as managed care or fee for service,) or provider networks used in Medicaid and CHIP?

Yes No

If no, please explain. [7500]

Do you have authority in your CHIP State plan to provide for presumptive eligibility, and have you implemented this? Yes No

If yes

What percent of children are presumptively enrolled in CHIP pending a full eligibility determination? [5]
Of those children who are presumptively enrolled, what percent of those children are determined eligible and enrolled upon completion of the full eligibility determination those children are determined eligible and enrolled? [5]

Section IIIC: Subpart B: Initial Eligibility, Enrollment, and Renewal for

CHIP (Title XXI) and Medicaid (Title XIX) Programs

Table B1

This section is designed to assist CMS and the States track progress on the “5 out of 8” eligibility and enrollment milestones. It will not be used to determine CHIPRA performance bonus payments.

Program Feature	Question	Medicaid	CHIP
Continuous Eligibility	1. Does the State provide continuous eligibility for 12 months for children regardless of changes in circumstances other than the situations identified below: a. child is no longer a resident of the State; b. death of the child; c. child reaches the age limit; d. child/representative requests disenrollment; e. child enrolled in a separate CHIP program files a Medicaid application, is determined eligible for Medicaid and is enrolled in Medicaid without a coverage gap.	In accordance with section 1902(e)(12) of the Act Yes No	Yes No
Liberalization of Asset (or Resource Test) Requirements	2. Does the State have an assets test?	Yes No	Yes No
	3. If there is an assets test, does the State allow administrative verification of assets?	Yes No N/A	Yes No N/A
Elimination of In-Person Interview	4. Does the State require an in-person interview to apply?	Yes No	Yes No
	5. Has the State eliminated an in-person requirement for renewal of CHIP eligibility?	Yes No
Use of Same Application and Renewal Forms and Procedures for Medicaid and CHIP	6. Does the State use the same application form, supplemental forms, and information verification process for establishing eligibility for Medicaid and CHIP?	Yes No
	7. Does the State use the same application form, supplemental forms, and information verification process for renewing eligibility for Medicaid and CHIP?	Yes No
Automatic/Administrative Renewal	8. For renewals of Medicaid or CHIP eligibility, does the State provide a preprinted form populated with eligibility information available to the State, to the child or the child’s parent or other representative, along with a notice that eligibility will be renewed and continued based on such information unless the State is provided other information that affects eligibility?	Yes No			Yes No
	9. Does the State do an ex parte renewal? Specifically, does the State renew Medicaid or CHIP eligibility to the maximum extent possible based on information contained in the individual’s Medicaid file or other information available to the State, before it seeks any information from the child’s parent or representative?	Yes No			Yes No
		If exparte is used, is it used for All applicants Yes No A subset of applicants Yes No			If exparte is used, is it used for All applicants Yes No A subset of applicants Yes No
Presumptive Eligibility	10. Does the State provide presumptive eligibility to children who appear to be eligible for Medicaid and CHIP to enroll pending a full determination of eligibility?	Yes No
Express Lane Eligibility	11. Are you utilizing the Express Lane option in making eligibility determinations and/or renewals for both Medicaid and CHIP?	Yes No
		If yes, which Express Lane Agencies are you using? Supplemental Nutrition Assistance Program (SNAP), formerly Food Stamps Tax/Revenue Agency Unemployment Compensation Agency Women, Infants, and Children (WIC) Free, Reduced School Lunch Program Subsidized Child Care Program Other, please explain. [7500]
		If yes, what information is the Express Lane Agency providing? Income Resources Residency Age Citizenship Other, please explain. [7500]
Premium Assistance	12. Has the State implemented premium assistance as added or modified by CHIPRA?	In accordance with section 2105(c)(10) of the Act, as added by section 301(a)(1) of CHIPRA. Yes No		In accordance with section 2105(c)(10) of the Act, as added by section 301(a)(1) of CHIPRA. Yes No

Section IIIC: Subpart C: Eligibility Renewal and Retention

1. What additional measures, besides those described in Tables B1 or C1, does your State employ to simplify an eligibility renewal and retain eligible children in CHIP?

	Conducts follow-up with clients through caseworkers/outreach workers
	Sends renewal reminder notices to all families
	How many notices are sent to the family prior to disenrolling the child from the program? [500]
	At what intervals are reminder notices sent to families (e.g., how many weeks before the end of the current eligibility period is a follow-up letter sent if the renewal has not been received by the State?) [500]
	Other, please explain: [500]

2. Which of the above strategies appear to be the most effective? Have you evaluated the effectiveness of any strategies? If so, please describe the evaluation, including data sources and methodology. [7500]

Section IIIC: Subpart D: Eligibility Data

Table 1. Application Status of Title XXI Children in FFY 2011

States are required to report on questions 1 and 2 in FFY 2011. Reporting on questions 2.a., 2.b., and 2.c. is voluntary in FFY 2011, FFY 2011, and FFY 2012. Reporting on questions 2.a., 2.b., and 2.c. is required in 2013. Please enter the data requested in the table below and the template will tabulate the requested percentages.

	Number	Percent
Total number of title XXI applicants		100%
Total number of application denials
Total number of procedural denials
Total number of eligibility denials
Total number of applicants denied for title XXI and enrolled in title XIX
(Check here if there are no additional categories Total number of applicants denied for other reasons Please indicate: _______________________________

3. Please describe any limitations or restrictions on the data used in this table: ____________________________________________________________________________

Definitions:

The “total number of title XXI applicants,” including those that applied using a joint application form, is defined as the total number of applicants that had an eligibility decision made for title XXI in FFY 2011. This measure is for applicants that have not been previously enrolled in title XXI or they were previously enrolled in title XXI but had a break in coverage, thus requiring a new application. Please include only those applicants that have had a Title XXI eligibility determination made in FFY 2011 (e.g., an application that was determined eligible in September 2011, but coverage was effective October 1, 2011 is counted in FFY 2011).
The “the total number of denials” is defined as the total number of applicants that have had an eligibility decision made for title XXI and denied enrollment for title XXI in FFY 2011. This definition only includes denials for title XXI at the time of initial application (not redetermination).

The “total number of procedural denials” is defined as the total number of applicants denied for title XXI procedural reasons in FFY 2011 (i.e., incomplete application, missing documentation, missing enrollment fee, etc.).
The “total number of eligibility denials” is defined as the total number of applicants denied for title XXI eligibility reasons in FFY 2011 (i.e., income too high, income too low for title XXI /referred for Medicaid eligibility determination/determined Medicaid eligible , obtained private coverage or if applicable, had access to private coverage during your State’s specified waiting period, etc.)

The total number of applicants that are denied eligibility for title XXI and determined eligible for title XIX

The “total number of applicants denied for other reasons” is defined as any other type of denial that does not fall into 2a or 2b. Please check the box provided if there are no additional categories.

Table 2. Redetermination Status of Children Enrolled in Title XXI

For this table, States may voluntarily report in 2011 and 2012. Reporting is required for 2013.

Is the State reporting this data in the 2011 CARTS?

Yes (complete) State is reporting all measures in the redetermination table.

Yes (but incomplete) Please describe which measures the State did not report on, and why the State did not report on these measures.

Explain: [7500]

No If the State is not reporting any data, please explain why. Explain: [7500]

Please enter the data requested in the table below in the “Number” column, and the template will automatically tabulate the percentages.

	Number	Percent
Total number of children who are eligible to be redetermined	If entered, Must be > 0	100%
Total number of children screened for redetermination			100%
Total number of children retained after the redetermination process
Total number of children disenrolled from title XXI after the redetermination process				100%
Total number of children disenrolled from title XXI for failure to comply with procedures
Total number of children disenrolled from title XXI for failure to meet eligibility criteria					100%
Disenrolled from title XXI because income too high for title XXI (If unable to provide the data, check here )
Disenrolled from title XXI because income too low for title XXI (If unable to provide the data, check here )
Disenrolled from title XXI because application indicated access to private coverage or obtained private coverage (If unable to provide the data or if you have a title XXI Medicaid expansion and this data is not relevant check here )
Disenrolled from title XXI for other eligibility reason(s) Please indicate:_____________________________ (If unable to provide the data check here )
Total number of children disenrolled from title XXI for other reason(s) Please indicate:____________________________________ (Check here if there are no additional categories )

If relevant, please describe any limitations or restrictions on the data entered into this table. Please describe any State policies or procedures that may have impacted the redetermination outcomes data [7500].

_________________________________________________________________________________________________________

Definitions:

The “total number of children who are eligible to be redetermined” is defined as the total number of children due to renew their eligibility in Federal Fiscal Year (FFY) 2011, and did not age out (did not exceed the program’s maximum age requirement) of the program by or before redetermination. This total number may include those children who are eligible to renew prior to their 12 month eligibility redetermination anniversary date. This total number may include children whose eligibility can be renewed through administrative redeterminations, whereby the State sends the family a renewal form that is pre-populated with eligibility information already available through program records and requires the family to report any changes. This total may also include ex parte redeterminations, the process when a State uses information available to it through other databases, such as wage and labor records, to verify ongoing eligibility.
The “total number of children screened for redetermination” is defined as the total number of children that were screened by the State for redetermination in FFY 2011 (i.e., those children whose families have returned redetermination forms to the State, as well as administrative redeterminations and ex parte redeterminations).
The “total number of children retained after the redetermination process” is defined as the total number of children who were found eligible and remained in the program after the redetermination process in FFY 2011.
The “total number of children disenrolled from title XXI after the redetermination process” is defined as the total number of children who are disenrolled from title XXI following the redetermination process in FFY 2011. This includes those children that States may define as “transferred” to Medicaid for title XIX eligibility screening.

The “total number of children disenrolled for failure to comply with procedures” is defined as the total number of children disenrolled from title XXI for failure to successfully complete the redetermination process in FFY 2011 (i.e., families that failed to submit a complete application, failed to provide complete documentation, failed to pay premium or enrollment fee, etc.).
The “total number of children disenrolled for failure to meet eligibility criteria” is defined as the total number of children disenrolled from title XXI for no longer meeting one or more of their State’s CHIP eligibility criteria (i.e., income too low, income too high, obtained private coverage or if applicable, had access to private coverage during your State’s specified waiting period, etc.). If possible, please break out the reasons for failure to meet eligibility criteria in i.-iv.
The “total number of children disenrolled for other reason(s)” is defined as the total number of children disenrolled from title XXI for a reason other than failure to comply with procedures or failure to meet eligibility criteria, and are not already captured in 4.a. or 4.b.

The data entered in 4.a., 4.b., and 4.c. should sum to the total number of children disenrolled from title XXI (line 4).

Table 3. Duration Measure of Selected Children, Ages 0-16, Enrolled in Title XXI, Second Quarter FFY 2012

The purpose of this table is to measure title XXI enrollees’ duration, or continuity, of public coverage (title XIX and title XXI). This information is required by CHIPRA, Section 402(a). Reporting is not required until 2013, but States will need to identify newly enrolled children in the second quarter of FFY 2012 (January, February, and March of 2011). If your eligibility system already has the capability to track a cohort of enrollees over time, an additional “flag” or unique identifier may not be necessary.

Instructions: For this prospective duration measure, please identify newly enrolled children in title XXI in the second quarter of FFY 2012, ages 0 months to 16 years at time of enrollment. Children enrolled in January 2012 must have birthdates after July 1995 (e.g., children must be younger than 16 years and 5 months) to ensure that they will not age out of the program at the 18^th month of coverage. Similarly, children enrolled in February 2012 must have birthdates after August 1995, and children enrolled in March 2012 must have birthdates after September 1995. Each child newly enrolled during this time frame needs a unique identifier or “flag” so that the cohort can be tracked over time. If your eligibility system already has the capability to track a cohort of enrollees over time, an additional “flag” or unique identifier may not be necessary. Please follow the child based on the child’s age category at the time of enrollment (e.g., the child’s age at enrollment creates an age cohort that does not change over the 18 month time span). Please enter the data requested in the table below and the template will tabulate the percentages.

Specify how your “newly enrolled” population is defined:

Not Previously Enrolled in CHIP or Medicaid—“Newly enrolled” is defined as not enrolled in either title XXI or title XIX in the month before enrollment (i.e., for a child enrolled in January 2012, he/she would not be enrolled in either title XXI or title XIX in December 2011, etc.)

Not Previously Enrolled in CHIP—“Newly enrolled” is defined as not enrolled in title XXI in the month before enrollment (i.e., for a child enrolled in January 2012, he/she would not be enrolled in title XXI in December 2011, etc.)

Duration Measure, Title XXI	All Children Ages 0-16		Age Less than 12 months		Ages 1-5		Ages 6-12		Ages 13-16
Duration Measure, Title XXI	Number	Percent	Number	Percent	Number	Percent	Number	Percent	Number	Percent
Total number of children newly enrolled in title XXI in the second quarter of FFY 2012		100%		100%		100%		100%		100%
Enrollment Status 6 months later
Total number of children continuously enrolled in title XXI
Total number of children with a break in title XXI coverage but re-enrolled in title XXI
3.a. Total number of children enrolled in Medicaid (title XIX) during title XXI coverage break (If unable to provide the data, check here )
Total number of children disenrolled from title XXI
4.a. Total number of children enrolled in Medicaid (title XIX) after being disenrolled from title XXI (If unable to provide the data, check here )
Enrollment Status 12 months later
Total number of children continuously enrolled in title XXI
Total number of children with a break in title XXI coverage but re-enrolled in title XXI
6.a. Total number of children enrolled in Medicaid (title XIX) during title XXI coverage break (If unable to provide the data, check here )
Total number of children disenrolled from title XXI
7.a. Total number of children enrolled in Medicaid (title XIX) after being disenrolled from title XXI (If unable to provide the data, check here )
Enrollment Status 18 months later
Total number of children continuously enrolled in title XXI
Total number of children with a break in title XXI coverage but re-enrolled in title XXI
9.a. Total number of children enrolled in Medicaid (title XIX) during title XXI coverage break (If unable to provide the data, check here )
Total number of children disenrolled from title XXI
10.aTotal number of children enrolled in Medicaid (title XIX) after being disenrolled from title XXI (If unable to provide the data, check here )

Definitions:

The “total number of children newly enrolled in title XXI in the second quarter of FFY 2012” is defined as those children either new to public coverage or new to title XXI, in the month before enrollment. Please define your population of “newly enrolled” in the Instructions section.

The total number of children that were continuously enrolled in title XXI for 6 months is defined as the sum of:

the number of children with birthdates after July 1995, who were newly enrolled in January 2012 and who were continuously enrolled through July 2012

+ the number of children with birthdates after August 1995, who were newly enrolled in February 2012 and who were continuously enrolled through August 2012

+ the number of children with birthdates after September 1995, who were newly enrolled in March 2012 and who were continuously enrolled through September 2012

The total number who had a break in title XXI coverage during 6 months of enrollment (regardless of the number of breaks in coverage) but were re-enrolled in title XXI by the end of the 6 months, is defined as the sum of:

the number of children with birthdates after July 1995, who were newly enrolled in January 2012 and who disenrolled and re-enrolled in title XXI by July 2012

+ the number of children with birthdates after August 1995, who were newly enrolled in February 2012 and who disenrolled and re-enrolled in title XXI by August 2012

+ the number of children with birthdates after September 1995, who were newly enrolled in March 2012 and who disenrolled and re-enrolled in title XXI by September 2012

3.a. From the population in #3, provide the total number of children who were enrolled in title XIX during their break in coverage.

The total number who disenrolled from title XXI, 6 months after their enrollment month is defined as the sum of:

the number of children with birthdates after July 1995, who were newly enrolled in January 2012 and were disenrolled by July 2012

+ the number of children with birthdates after August 1995, who were newly enrolled in February 2012 and were disenrolled by August 2012

+ the number of children with birthdates after September 1995, who were newly enrolled in March 2012 and were disenrolled by September 2012

4.a. From the population in #4, provide the total number of children who were enrolled in title XIX in the month after their disenrollment from title XXI.

The total number of children who were continuously enrolled in title XXI for 12 months is defined as the sum of:

the number of children with birthdates after July 1995, who were newly enrolled in January 2012 and were continuously enrolled through January 2013

+ the number of children with birthdates after August 1995, who were newly enrolled in February 2012 and were continuously enrolled through February 2013

+ the number of children with birthdates after September 1995, who were newly enrolled in March 2012 and were continuously enrolled through March 2013

The total number of children who had a break in title XXI coverage during 12 months of enrollment (regardless of the number of breaks in coverage), but were re-enrolled in title XXI by the end of the 12 months, is defined as the sum of:

the number of children with birthdates after July 1995, who were newly enrolled in January 2012 and who disenrolled and then re-enrolled in title XXI by January 2013

+ the number of children with birthdates after August 1995, who were newly enrolled in February 2012 and who disenrolled and then re-enrolled in title XXI by February 2013

+ the number of children with birthdates after September 1995, who were newly enrolled in March 2012 and who disenrolled and then re-enrolled in title XXI prior to March 2013

6.a. From the population in #6, provide the total number of children who were enrolled in title XIX during their break in coverage.

The total number of children who disenrolled from title XXI 12 months after their enrollment month is defined as the sum of:

the number of children with birthdates after July 1995, who were enrolled in January 2012 and were disenrolled by January 2013

+ the number of children with birthdates after August 1995, who were enrolled in February 2012 and were disenrolled by February 2013

+ the number of children with birthdates after September 1995, who were enrolled in March 2012 and were disenrolled March 2013

7.a. From the population in #7, provide the total number of children, who were enrolled in title XIX in the month after their disenrollment from title XXI.

The total number of children who were continuously enrolled in title XXI for 18 months is defined as the sum of:

the number of children with birthdates after July 1995,who were newly enrolled in January 2012 and were continuously enrolled through July 2013

+ the number of children with birthdates after August 1995, who were newly enrolled in February 2012 and were continuously enrolled through August 2013

+ the number of children with birthdates after September 1995, who were newly enrolled in March 2012 and were continuously enrolled through September 2013

The total number of children who had a break in title XXI coverage during 18 months of enrollment (regardless of the number of breaks in coverage), but were re-enrolled in title XXI by the end of the 18 months, is defined as the sum of:

the number of children with birthdates after July 1995 , who were newly enrolled in January 2012 and who disenrolled and re-enrolled in title XXI by July 2013

+ the number of children with birthdates after August 1995, who were newly enrolled in February 2012 and who disenrolled and re-enrolled in title XXI by August 2013

+ the number of children with birthdates after September 1995, who were newly enrolled in March 2012 and who disenrolled and re-enrolled in title XXI by September 2013

9.a. From the population in #9, provide the total number of children who were enrolled in title XIX during their break in coverage.

The total number of children who were disenrolled from title XXI 18 months after their enrollment month is defined as the sum of:

the number of children with birthdates after July 1995, who were newly enrolled in January 2012 and disenrolled by July 2013

+ the number of children with birthdates after August 1995, who were newly enrolled in February 2012 and disenrolled by August 2013

+ the number of children with birthdates after September 1995, who were newly enrolled in March 2012 and disenrolled by September 2013

D. Cost Sharing

Describe how the State tracks cost sharing to ensure enrollees do not pay more than 5 percent aggregate maximum in the year?

a. Cost sharing is tracked by:

Enrollees (shoebox method)

Health Plan(s)

State

Third Party Administrator

N/A (No cost sharing required)

Other, please explain. [7500]

If the State uses the shoebox method, please describe informational tools provided to enrollees to track cost sharing. [7500]

When the family reaches the 5% cap, are premiums, copayments and other cost sharing ceased? Yes No
Please describe how providers are notified that no cost sharing should be charged to enrollees exceeding the 5% cap. [7500]
Please provide an estimate of the number of children that exceeded the 5 percent cap in the State’s CHIP program during the Federal fiscal year. [500]
Has your State undertaken any assessment of the effects of premiums/enrollment fees on participation in CHIP?

Yes No If so, what have you found? [7500]

Has your State undertaken any assessment of the effects of cost sharing on utilization of health services in CHIP?

Yes No If so, what have you found? [7500]

If your State has increased or decreased cost sharing in the past Federal Fiscal year, how is the State monitoring the impact of these changes on application, enrollment, disenrollment, and utilization of children’s health services in CHIP. If so, what have you found? [7500]

Employer sponsored insurance Program (including Premium Assistance Program(s)) under the CHIP State Plan or a Section 1115 title XXI demonstration

Does your State offer an employer sponsored insurance program (including a premium assistance program) for children and/or adults using Title XXI funds?

Yes, please answer questions below.

No, skip to Program Integrity subsection.

Children

		Yes, Check all that apply and complete each question for each authority.

			Purchase of Family Coverage under the CHIP State Plan (2105(c)(3))
			Additional Premium Assistance Option under CHIP State Plan (2105(c)(10))
			Section 1115 Demonstration (Title XXI)
			Premium Assistance Option (applicable to Medicaid expansion) children (1906)
			Premium Assistance Option (applicable to Medicaid expansion) children (1906A)

Adults

		Yes, Check all that apply and complete each question for each authority.

			Purchase of Family Coverage under the CHIP State Plan (2105(c)(10)
			Additional Premium Assistance Option under the CHIP State Plan (2105(c)(3)
			Section 1115 Demonstration (Title XXI)
			Premium Assistance option under the Medicaid State Plan (1906)
			Premium Assistance option under the Medicaid State Plan (1906A)

2. Please indicate which adults your State covers with premium assistance. (Check all that apply.)

	Parents and Caretaker Relatives
	Childless Adults
	Pregnant Women

3. Briefly describe how your program operates (e.g., is your program an employer sponsored insurance program or a premium assistance program., how do you coordinate assistance between the state and/or employer, who receives the subsidy if a subsidy is provided, etc.) [7500]

4. What benefit package does the ESI program use? [7500]

5. Are there any minimum coverage requirements for the benefit package?

Yes No

6. Does the program provide wrap-around coverage for benefits?

Yes No ?

7. Are there limits on cost sharing for children in your ESI program?

Yes No

Are there any limits on cost sharing for adults in your ESI program?

Yes No

Are there protections on cost sharing for children (e.g., the 5 percent out-of-pocket maximum) in your premium assistance program?

Yes No If yes, how is the cost sharing tracked to ensure it remains within the 5 percent yearly aggregate maximum [7500]?

Identify the total number of children and adults enrolled in the ESI program for whom Title XXI funds are used during the reporting period (provide the number of adults enrolled in this program even if they were covered incidentally, i.e., not explicitly covered through a demonstration).

		Number of childless adults ever-enrolled during the reporting period
		Number of adults ever-enrolled during the reporting period
		Number of children ever-enrolled during the reporting period

Provide the average monthly enrollment of children and parents ever enrolled in the premium assistance program during FFY 2011.

Children ______ Parents_______

During the reporting period, what has been the greatest challenge your ESI program has experienced? [7500]
During the reporting period, what accomplishments have been achieved in your ESI program? [7500]

What changes have you made or are planning to make in your ESI program during the next fiscal year? Please comment on why the changes are planned. [7500]
What do you estimate is the impact of your ESI program (including premium assistance) on enrollment and retention of children? How was this measured? [7500]
Identify the total state expenditures for providing coverage under your ESI program during the reporting period. [7500]

Provide the average amount each entity pays towards coverage of the dependent child/parent under your ESI program:

Child Parent

State: ________ State: ________

Employer: ________ Employer: ________

Employee: ________ Employee: ________

Indicate the range in the average monthly dollar amount of premium assistance provided by the state on behalf of a child or parent.

Children Low______ High ______

Parent Low______ High ______

If you offer a premium assistance program, what, if any, is the minimum employer contribution? [500]

Do you have a cost effectiveness test that you apply in determining whether an applicant can receive coverage (e.g., the state’s share of a premium assistance payment must be less than or equal to the cost of covering the applicant under SCHIP or Medicaid)?

Yes No

Please provide the income levels of the children or families provided premium assistance.

From To

Income level of Children: _______ % of FPL [5] __________% of FPL [5]

Income level of Parents: _______ % of FPL [5] __________% of FPL [5]

Is there a required period of uninsurance before enrolling in premium assistance?

Yes No

If yes, what is the period of uninsurance? [500]

Do you have a waiting list for your program? Yes No

Can you cap enrollment for your program? Yes No
What strategies has the State found to be effective in reducing administrative barriers to the provision of premium assistance in ESI? [7500]

Enter any Narrative text below. [7500]

F. Program Integrity (COMPLETE ONLY WITH REGARD TO SEPARATE CHIP PROGRAMS, I.E., THOSE THAT ARE NOT MEDICAID EXPANSIONS)

Does your state have a written plan that has safeguards and establishes methods and procedures for:

(1) prevention: Yes No

(2) investigation;: Yes No

(3) referral of cases of fraud and abuse? Yes No

Please explain: [7500]

Do managed health care plans with which your program contracts have written plans? Please Explain: [500]

For the reporting period, please report the

  Number of fair hearing appeals of eligibility denials

  Number of cases found in favor of beneficiary

For the reporting period, please indicate the number of cases investigated, and cases referred, regarding fraud and abuse in the following areas:

Provider Credentialing

  Number of cases investigated

  Number of cases referred to appropriate law enforcement officials

Provider Billing

  Number of cases investigated

  Number of cases referred to appropriate law enforcement officials

Beneficiary Eligibility

  Number of cases investigated

  Number of cases referred to appropriate law enforcement officials

Are these cases for:

CHIP

Medicaid and CHIP Combined

4. Does your state rely on contractors to perform the above functions?

Yes, please answer question below.

5. If your state relies on contractors to perform the above functions, how does your state provide oversight of those contractors? Please explain: [7500]

6. Do you contract with managed care health plans and/or a third party contractor to provide this oversight?

Yes

Please Explain: [500]

G. Dental Benefits - Reporting is required in 2010 CARTS

Is the State reporting this data in the 2011 CARTS?

Yes If yes, then please complete G1 and G2.

No If the State is not reporting data, please explain why.

Explain: [7500]

1. Information on Dental Care for CHIP Children (Include all delivery types, i.e. MCO, PCCM, FFS).

Data for this table are based from the definitions provided on the Early and Periodic Screening,

Diagnostic, and Treatment (EPSDT) Report (Form CMS-416)

a. Annual Dental Participation Table for CHIP Enrolled Children (Include children receiving full CHIP benefits and supplemental benefits) .

Please check which populations of CHIP children are included in the following table:

Medicaid Expansion

Separate CHIP

Both Medicaid Expansion and Separate CHIP

State__________ FFY__________	Age Groups
State__________ FFY__________	Total	<1	1 – 2*	3 – 5	6 – 9	10–14	15–18
Total Enrollees Receiving Any Dental Services¹ [7]
Total Enrollees Receiving Preventive Dental Services² [7]
Total Enrollees Receiving Dental Treatment Services³ [7]

*Includes 12-month visit

¹Total Eligibles Receiving Any Dental Services - Enter the unduplicated number of children enrolled in CHIP for at least 90 continuous days and receiving at least one dental service by or under the supervision of a dentist as defined by HCPCS codes D0100 - D9999 (CDT codes D0100 - D9999).

²Total Eligibles Receiving Preventive Dental Services - Enter the unduplicated number of children enrolled in CHIP for at least 90 continuous days and receiving at least one preventive dental service by or under the supervision of a dentist as defined by HCPCS codes D1000 - D1999 -(CDT codes D1000 - D1999).

³Total Eligibles Receiving Dental Treatment Services - Enter the unduplicated number of children enrolled in CHIP for at least 90 continuous days and receiving at least one treatment service by or under the supervision of a dentist, as defined by HCPCS codes D2000 - D9999 (CDT codes D2000 - 09999).

b. For the age grouping that includes children 8 years of age, what is the number of such children who have received a protective sealant on at least one permanent molar tooth⁴? [7]

⁴Receiving a Sealant on a Permanent Molar Tooth -- Enter the unduplicated number of children enrolled in CHIP for 90 continuous days and in the age category of 6-9 who received a sealant on a permanent molar tooth regardless of whether the sealant was provided by a dentist or a non-dentist, as defined by HCPCS code D1351 (CDT code D1351).

2. Does the State provide supplemental dental coverage? Yes No

If yes, how many children are enrolled? ______[7]

What percent of the total amount of children have supplemental dental coverage? _____[5]

Section IV: Program financing for State Plan

1. Please complete the following table to provide budget information. Describe in narrative any details of your planned use of funds below, including the assumptions on which this budget was based (per member/per month rate, estimated enrollment and source of non-Federal funds). (Note: This reporting period equals Federal Fiscal Year 2011. If you have a combination program you need only submit one budget; programs do not need to be reported separately.)

COST OF APPROVED CHIP PLAN


Benefit Costs	2011	2012	2013
Insurance payments
Managed Care
Fee for Service
Total Benefit Costs
(Offsetting beneficiary cost sharing payments)
Net Benefit Costs

Administration Costs
Personnel
General Administration
Contractors/Brokers (e.g., enrollment contractors)
Claims Processing
Outreach/Marketing costs
Other (e.g., indirect costs)
Health Services Initiatives
Total Administration Costs
10% Administrative Cap (net benefit costs  9)

Federal Title XXI Share
State Share

TOTAL COSTS OF APPROVED CHIP PLAN

2. What were the sources of non-Federal funding used for State match during the reporting period?

	State appropriations
	County/local funds
	Employer contributions
	Foundation grants
	Private donations
	Tobacco settlement
	Other (specify) [500]

3. Did you experience a short fall in CHIP funds this year? If so, what is your analysis for why there were not enough Federal CHIP funds for your program? [1500]

4. In the table below, enter 1) number of eligibles used to determine per member per month costs for the current year and estimates for the next two years; and, 2) per member per month cost rounded to a whole number. If you have CHIP enrollees in a fee for service program, per member per month cost will be the average cost per month to provide services to these enrollees.

	2011		2012		2013
	# of eligibles	$ PMPM	# of eligibles	$ PMPM	# of eligibles	$ PMPM
Managed Care		$		$		$
Fee for Service		$		$		$

Enter any Narrative text below. [1500]

Section V: 1115 Demonstration Waivers (financed by CHIP)

Please reference and summarize attachments that are relevant to specific questions.

If you do not have a Demonstration Waiver financed with CHIP funds skip to Section VI. If you do, please complete the following table showing whom you provide coverage to.

CHIP Non-HIFA Demonstration Eligibility				HIFA Waiver Demonstration Eligibility
* Upper % of FPL are defined as Up to and Including
Children	From	% of FPL to	% of FPL*		From	% of FPL to	% of FPL*
Parents	From	% of FPL to	% of FPL*		From	% of FPL to	% of FPL*
Childless Adults	From	% of FPL to	% of FPL*		From	% of FPL to	% of FPL
Pregnant Women	From	% of FPL to	% of FPL*		From	% of FPL to	% of FPL*

2. Identify the total number of children and adults ever enrolled (an unduplicated enrollment count) in your CHIP demonstration during the reporting period.

		Number of children ever enrolled during the reporting period in the demonstration
		Number of parents ever enrolled during the reporting period in the demonstration
		Number of pregnant women ever enrolled during the reporting period in the demonstration
		Number of childless adults ever enrolled during the reporting period in the demonstration (*Only report for 1^st Quarter of the FFY)

What have you found about the impact of covering adults on enrollment, retention, and access to care of children? You are required to evaluate the effectiveness of your demonstration project, so report here on any progress made in this evaluation, specifically as it relates to enrollment, retention, and access to care for children. [1000]

Please provide budget information in the following table for the years in which the demonstration is approved. Note: This reporting period (Federal Fiscal Year 2011 starts 10/1/2010 and ends 9/30/2011).

COST PROJECTIONS OF DEMONSTRATION (SECTION 1115 or HIFA)	2011	2012	2013	2014	2015
Benefit Costs for Demonstration Population #1 (e.g., children)
Insurance Payments
Managed care
per member/per month rate for managed care
Fee for Service
Average cost per enrollee in fee for service
Total Benefit Costs for Waiver Population #1

Benefit Costs for Demonstration Population #2 (e.g., parents)
Insurance Payments
Managed care
per member/per month rate for managed care
Fee for Service
Average cost per enrollee in fee for service
Total Benefit Costs for Waiver Population #2

Benefit Costs for Demonstration Population #3 (e.g., pregnant women)
Insurance Payments
Managed care
per member/per month rate for managed care
Fee for Service
Average cost per enrollee in fee for service
Total Benefit Costs for Waiver Population #3

Benefit Costs for Demonstration Population #4 (e.g., childless adults)
Insurance Payments
Managed care
per member/per month rate for managed care
Fee for Service
Average cost per enrollee in fee for service
Total Benefit Costs for Waiver Population #3

Total Benefit Costs
(Offsetting Beneficiary Cost Sharing Payments)
Net Benefit Costs (Total Benefit Costs - Offsetting Beneficiary Cost Sharing Payments)

Administration Costs
Personnel
General Administration
Contractors/Brokers (e.g., enrollment contractors)
Claims Processing
Outreach/Marketing costs
Other (specify)
Total Administration Costs
10% Administrative Cap (net benefit costs  9)

Federal Title XXI Share
State Share

TOTAL COSTS OF DEMONSTRATION

When was your budget last updated (please include month, day and year)? [500]

Please provide a description of any assumptions that are included in your calculations. [7500]

Other notes relevant to the budget: [7500]

Section VI: Program Challenges and Accomplishments

For the reporting period, please provide an overview of your state’s political and fiscal environment as it relates to health care for low income, uninsured children and families, and how this environment impacted CHIP. [7500]

During the reporting period, what has been the greatest challenge your program has experienced? [7500]

During the reporting period, what accomplishments have been achieved in your program? [7500]

What changes have you made or are planning to make in your CHIP program during the next fiscal year? Please comment on why the changes are planned. [7500]

Enter any Narrative text below. [7500]

1 P.L. 111-3, §402(a)(2)(e)

CHIP Annual Report Template – FFY 2011 Version 12.01.2011 2

File Type	application/msword
File Title	Section I Snapshot of SCHIP Program
Author	MBES
Last Modified By	Mitch Bryman
File Modified	2014-12-15
File Created	2014-12-15

Form CMS-10398 (#1) CMS-10398 (#1) FRAMEWORK FOR THE ANNUAL REPORT

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

#1 - CARTS Template [rev 12-15-2014]

#1: CHIP Annual Report Template System (CARTs)

OMB: 0938-1148

Outreach

Substitution of Coverage (Crowd-out)

All states should answer the following questions. Please include percent calculations in your responses when applicable and requested.

All States must complete the following questions

C. Eligibility

(This subsection should be completed by all States. Medicaid Expansion states should complete applicable responses and indicate those questions that are non-applicable with N/A.

Section IIIC: Subpart C: Eligibility Renewal and Retention

D. Cost Sharing

Employer sponsored insurance Program (including Premium Assistance Program(s)) under the CHIP State Plan or a Section 1115 title XXI demonstration

Children

Adults

F. Program Integrity (COMPLETE ONLY WITH REGARD TO SEPARATE CHIP PROGRAMS, I.E., THOSE THAT ARE NOT MEDICAID EXPANSIONS)

G. Dental Benefits - Reporting is required in 2010 CARTS

COST OF APPROVED CHIP PLAN