Form CMS-10398 (#26) CMS-10398 (#26) Reporting of the Core Set of Health Care Quality Measure

OMB Control Number 0938-1148

Expiration date: 10/31/2014

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

BACKGROUND
Section 1139B of the Affordable Care Act required the Secretary of the Department of Health and Human Services (HHS) to identify and publish an initial core set of health quality measures for adult Medicaid enrollees (Medicaid Adult Core Set). The Affordable Care Act also required the Secretary to publish annual changes to the Medicaid Adult Core Set measures beginning in January 2014. One measure (Annual HIV/AIDS Medicaid Visit) was retired from the Medicaid Adult Core Set in 2014 and replaced with HIV Viral Load Suppression. Table 1 lists the Medicaid Adult Core Set measures, their measure stewards, and a general description of each measure. Measure abbreviations were added in 2014.

Additionally, the law required the development of a standardized reporting format for states that volunteer to report on the Medicaid Adult Core Set measures. This CARTS template will be used for standardized reporting on these measures.

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

Table 1: Medicaid Adult Core Set Measures

Measure Abbreviation	Measure	Measure Steward	Measure Description
FVA-AD	Flu Vaccinations for Adults Ages 18 to 64	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 18 to 64 who received an influenza vaccination between July 1 of the measurement year and the date when the CAHPS 5.0H adult survey was completed.
ABA-AD	Adult Body Mass Index Assessment	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 18 to 74 who had an outpatient visit and whose BMI was documented during the measurement year or the year prior to the measurement year.
BCS-AD	Breast Cancer Screening	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid-enrolled women ages 50 to 74 who received a mammogram to screen for breast cancer.
CCS-AD	Cervical Cancer Screening	NCQA/HEDIS (http://www.ncqa.org)	Percentage of women ages 21 to 64 who were screened for cervical cancer using either of the following criteria: Women ages 21 to 64 who had cervical cytology performed every 3 years; or, women ages 30 to 64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.
MCS-AD	Medical Assistance With Smoking and Tobacco Use Cessation	NCQA/HEDIS (http://www.ncqa.org)	A rolling average represents the percentage of Medicaid enrollees age 18 and older who were current smokers or tobacco users and who received medical assistance with smoking and tobacco use cessation during the measurement year.
CDF-AD	Screening for Clinical Depression and Follow-Up Plan	CMS (http://www.usqualitymeasures.org)	Percentage of Medicaid enrollees age 18 and older screened for clinical depression using a standardized depression screening tool and, if positive, a follow-up plan is documented on the date of the positive screen.
PCR-AD	Plan All-Cause Readmission Rate	NCQA/HEDIS (http://www.ncqa.org)	For Medicaid enrollees age 18 and older, the number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following three categories: (1) Count of Index Hospital Stays (IHS), (2) Count of 30-Day Readmissions, and (3) Average Adjusted Probability of Readmission.
PQI01-AD	PQI 01: Diabetes Short-Term Complications Admission Rate	AHRQ (http://www.qualityindicators.ahrq.gov)	Number of discharges for diabetes short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 member months for Medicaid enrollees age 18 and older.
PQI105-AD	PQI 05: Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate	AHRQ (http://www.qualityindicators.ahrq.gov)	Number of discharges for chronic obstructive pulmonary disease (COPD) or asthma per 100,000 member months for Medicaid enrollees age 40 and older.
PQI108-AD	PQI 08: Heart Failure Admission Rate	AHRQ (http://www.qualityindicators.ahrq.gov)	Number of discharges for heart failure per 100,000 member months for Medicaid enrollees age 18 and older.
PQI15-AD	PQI 15: Asthma in Younger Adults Admission Rate	AHRQ (http://www.qualityindicators.ahrq.gov)	Number of discharges for asthma per 100,000 member months for Medicaid enrollees ages 18 to 39 and younger.
CHL-AD	Chlamydia Screening in Women Ages 21 to 24	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid-enrolled women ages 21 to 24 who were identified as sexually active and who had at least one test for Chlamydia during the measurement year.
FUH-AD	Follow-Up After Hospitalization for Mental Illness	NCQA/HEDIS (http://www.ncqa.org)	Percentage of discharges for Medicaid enrollees age 21 and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days of discharge and within 30 days of discharge.
PC01-AD	PC-01 Elective Delivery	The Joint Commission (http://www.jointcommission.org)	Percentage of Medicaid and CHIP enrolled women with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed.
PC03-AD	PC-03 Antenatal Steroids	The Joint Commission (http://www.jointcommission.org)	Percentage of Medicaid and CHIP enrolled women at risk of preterm delivery at >=24 and <32 weeks gestation who received antenatal steroids prior to delivering preterm newborns.
HMV-AD	HIV Viral Load Suppression	Health Resources and Services Administration (www.hrsa.gov/)	Percentage of Medicaid enrollees age 18 and older with a diagnosis of HIV who had a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.
CBP-AD	Controlling High Blood Pressure	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 18 to 85 who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90) during the measurement year.
LDL-AD	Comprehensive Diabetes Care: LDL-C Screening	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 18 to 75 with diabetes (type 1 and type 2) who had a LDL-C screening test.
HA1C-AD	Comprehensive Diabetes Care: Hemoglobin A1c Testing	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 18 to 75 with diabetes (type 1 and type 2) who had a Hemoglobin A1c test.
AMM-AD	Antidepressant Medication Management	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees age 18 and older with a diagnosis of major depression and were treated with antidepressant medication, and who remained on an antidepressant medication treatment for at least 84 days (12 weeks) and for at least 180 days (6 months).
SAA-AD	Adherence to Antipsychotics for Individuals with Schizophrenia	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees ages 19 to 64 with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80 percent of their treatment period.
MPM-AD	Annual Monitoring for Patients on Persistent Medications	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees age 18 and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and who received and who annual monitoring for the therapeutic agent in the measurement year.
CPA-AD	Consumer Assessment of Health Care Providers and Systems (CAHPS) Health Plan Survey 5.0H – Adult Questionnaire	AHRQ NCQA/HEDIS (http://www.ncqa.org)	Survey on adult Medicaid enrollees’ age 18 and older experiences with care.
CTR-AD	Care Transition – Timely Transmission of Transition Record	American Medical Association/Physician Consortium for Performance Improvement (PCPI) (http://www.ama-assn.org)	Percentage of Medicaid enrollees age 18 and older discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge.
IET-AD	Initiation and Engagement of Alcohol and Other Drug Dependence Treatment	NCQA/HEDIS (http://www.ncqa.org)	Percentage of Medicaid enrollees age 18 and older with a new episode of alcohol or other drug (AOD) dependence who: (a) Initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of the diagnosis. (b) Initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.
PPC-AD	Postpartum Care Rate	NCQA/HEDIS (http://www.ncqa.org)	Percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year that had a postpartum visit on or between 21 and 56 days after delivery.

GUIDANCE FOR REPORTING

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

Did you Report on this Measure?

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

If Data Not Reported, Please Explain Why:

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

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

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

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

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

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

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

The Information for this Measure is Being Provided as Part of the Adult Medicaid Quality Measures Grant:

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

Status of Data Reported:

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

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

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

Measurement Specification:

For each measure, the state should indicate whether a measure adheres to the Medicaid Adult Core Set technical specifications provided by the measure steward (e.g., NCQA, AHRQ) or “Other” measurement specifications. If NCQA is selected, the HEDIS® Version field must be completed. If “Other” measurement specification is selected, an explanation must be provided.

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

• HEDIS® Version:
  Please specify HEDIS® Version (example HEDIS 2014). This field must be completed only when a user selects the NCQA measurement specification.

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

Data Source:

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

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

• Hybrid: A combination of administrative and medical records data. If this box is selected, the user must then indicate whether the administrative data for a measure are coming from the Medicaid Management Information System (MMIS) or another administrative data source. The user must also indicate whether the medical record data for a measure are coming from electronic health records (EHR), paper, or EHR and paper.

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

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

Date Range:

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

Definition of Population Included in the Measure Definition of the Denominator:

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

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

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

Which Delivery Systems are Represented in the Denominator?

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

• Fee-for-Service

• Primary Care Case Management (PCCM)

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

• Integrated Care Models (ICM)

• Other
  
  

Examples:

1. If the measure-eligible population represents all managed care enrollees, enter 100 percent.

2. If fee-for-service enrollees are excluded from the calculation, enter 0 percent.

3. If a portion of the health plans are excluded, enter the proportion of the population represented by the reporting health plans (e.g., 60 percent).

Deviation from Measure Specifications:

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

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

The three types (and examples) of deviations are:

• Numerator (e.g., coding issues)

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

• Other (please describe in detail)

Performance Measure:

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

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

Other Performance Measure:

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

Optional Measure Stratification:

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

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

Maternal and Infant Health Initiative Measures:

To determine baseline and assess progress towards the CMS Maternal and Infant Health Initiative goals, states have the option to voluntarily report on 2 measures:

1. Postpartum Care Rate (Measure PPC-AD) from the Medicaid Adult Core Set; and

2. A developmental measure on Contraception Service Utilization.

Postpartum Care Rate and the developmental contraceptive measure can be found as the last two measures in both the CARTS web-based template and this Word template. The technical specifications for the Postpartum Care measure are available in the Technical Specifications and Resource Manual. The technical specifications for the developmental measure are available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Maternal-and-Infant-Health-Care-Quality.html.

Certification

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

Measure FVA-AD: Flu Vaccinations for Adults Ages 18 to 64

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: CAHPS 5.0H Other. Explain:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees ages 18 to 64 who received an influenza vaccination between July 1 of the measurement year and the date when the CAHPS 5.0H adult survey was completed.
	Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure ABA-AD: Adult Body Mass Index Assessment

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information System (MMIS) Other. Specify:       Hybrid (Administrative and Medical Records Data) From where is the Administrative Data coming? Must select one or more: Medicaid Management Information System (MMIS) Other. Specify:       From where is the Medical Records Data coming? Must select one: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees ages 18 to 74 who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.
	Age Range 18-64 Numerator:       Denominator:       Rate:       Age Range 65-74 Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure BCS-AD: Breast Cancer Screening

	FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Select all that apply (Must select at least one): Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information System (MMIS) Other Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid-enrolled women ages 50 to 74 who received a mammogram to screen for breast cancer.
	Age Range: 50-64 Numerator:       Denominator:       Rate:       Age Range: 65-74 Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure CCS-AD: Cervical Cancer Screening

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available. Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information System (MMIS) Other. Specify:       Hybrid (Administrative and Medical Records Data) From where is the Administrative Data coming? Must select one or more: Medicaid Management Information System (MMIS) Other. Specify:       From where is the Medical Records Data coming? Must select one: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of women ages 21 to 64 who were screened for cervical cancer using either of the following criteria: Women ages 21 to 64 who had cervical cytology performed every 3 years Women ages 30 to 64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
	Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure MCS-AD: Medical Assistance with Smoking and Tobacco Use Cessation

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered. Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Select all that apply (Must select at least one): Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of for the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: CAHPS 5.0H Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure A rolling average represents the percentage of Medicaid enrollees age 18 and older who were current smokers or tobacco users and who received medical assistance during the measurement year. The following components of this measure assess different facets of providing medical assistance with smoking and tobacco use cessation and are reported as three separate rolling averages: Advising Smokers and Tobacco Users to Quit – A rolling average represents the percentage of Medicaid enrollees age 18 and older who were current smokers or tobacco users and who received advice to quit during the measurement year Discussing Cessation Medications – A rolling average represents the percentage of Medicaid enrollees age 18 and older who were current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year Discussing Cessation Strategies – A rolling average represents the percentage of Medicaid enrollees age 18 and older who were current smokers or tobacco users and who discussed or were provided cessation methods or strategies during the measurement year
	Advising Smokers and Tobacco Users to Quit: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Discussing Cessation Medications: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Discussing Cessation Strategies: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Percentage of Current Smokers and Tobacco Users – Supplemental Calculation: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure CDF-AD: Screening for Clinical Depression and Follow-Up Plan

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: CMS Other. Explain:      
	Data Source: Hybrid (Administrative and Medical Records Data) From where is the Administrative Data coming? Must select one or more: Medicaid Management Information System (MMIS) Other. Specify:       From where is the Medical Records Data coming? Must select one: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees age 18 and older screened for clinical depression using a standardized depression screening tool, and if positive, a follow-up plan is documented on the date of the positive screen.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure PCR-AD: Plan All-Cause Readmission Rate

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure For Medicaid enrollees 18 years and older, the number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories: Count of Index Hospital Stays (IHS) (denominator) Count of 30-Day Readmissions (numerator) Average Adjusted Probability of Readmission (rate)
	Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Table 1. Plan All-Cause Readmission Rates by Age, Gender, and Risk Assessment: Age 18-64

Age	Sex	Count of Index Stays (Den)	Count of 30-Day Readmissions (Num)	Observed Readmission (Num/Den)
18-44	Male
	Female
	Total
45-54	Male
	Female
	Total
55-64	Male
	Female
	Total
Total 18-64	Male
	Female
	Total

Table 2. Plan All-Cause Readmission Rates by Age, Gender, and Risk Assessment: Age 65+

Age	Sex	Count of Index Stays (Den)	Count of 30-Day Readmissions (Num)	Observed Readmission (Num/Den)
65-74	Male
	Female
	Total
75-84	Male
	Female
	Total
85+	Male
	Female
	Total
Total 65+	Male
	Female
	Total

Measure PQI 01-AD: Diabetes Short-term Complications Admission Rate

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: AHRQ Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The number of discharges for diabetes short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 member months for Medicaid enrollees ages 18 and older.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure PQI 05-AD: Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Select all that apply (Must select at least one): Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: AHRQ Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information System (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure Number of discharges for chronic obstructive pulmonary disease (COPD) or asthma per 100,000 member months for Medicaid enrollees age 40 and older.
	Age Range: 40-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

PQI 08: Heart Failure Admission Rate

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Select all that apply (Must select at least one): Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: AHRQ Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information System (MMIS) Other. Specify:       Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure Number of discharges for heart failure per 100,000 member months for Medicaid enrollees age 18 and older.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure PQI 15-AD: Asthma in Younger Adults Admission Rate

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30). Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: AHRQ Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure Number of discharges for asthma per 100,000 member months for Medicaid enrollees ages 18 to39.
	Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure CHL-AD: Chlamydia Screening in Women Ages 21 to 24

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid-enrolled women ages 21 to 24 years who were identified as sexually active and who had at least one test for Chlamydia during the measurement year.
	Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure FUH-AD: Follow-Up After Hospitalization for Mental Illness

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of discharges for Medicaid enrollees age 21 years and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner. Two rates are reported: Percentage of discharges for which the enrollee received follow-up within 30 days of discharge. Percentage of discharges for which the enrollee received follow-up within 7 days of discharge.
	Follow-up within 7 days of discharge: Age Range: 21-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Follow-up within 30 days of discharge: Age Range: 21-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).

	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure PC01-AD: Elective Delivery

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: The Joint Commission Other. Explain:      
	Data Source: Hybrid (Administrative and Medical Records Data) From where is the Administrative Data coming? Must select one or more: Medicaid Management Information System (MMIS) Vital Records Other. Specify:       From where is the Medical Records Data coming? Must select one: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid and CHIP enrolled women with elective vaginal deliveries or elective cesarean sections at ≥ 37 and < 39 weeks of gestation completed.
	Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range.”)
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure PC03-AD: Antenatal Steroids

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: The Joint Commission Other. Explain:      
	Data Source: Hybrid (Administrative and Medical Records Data) From where is the Administrative Data coming? Must select one or more: Medicaid Management Information System (MMIS) Vital Records Other. Specify:       From where is the Medical Records Data coming? Must select one: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid and CHIP enrolled women at risk of preterm delivery at ≥24 and <32 weeks gestation who received antenatal steroids prior to delivering preterm newborns.
	Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure HMV-AD: HIV Viral Load Suppression

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: HRSA Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees age 18 and older with a diagnosis of HIV who had a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure CBP-AD: Controlling High Blood Pressure

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Hybrid (Administrative and Medical Records Data) From where is the Administrative Data coming? Must select one or more: Medicaid Management Information System (MMIS) Other. Specify:       From where is the Medical Records Data coming? Must select one: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees ages 18 to 85 who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year. Use the Hybrid Method for this measure.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65-85 Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure LDL-AD: Comprehensive Diabetes Care: LDL-C Screening

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Hybrid (Administrative and Medical Records Data) From where is the Administrative Data coming? Must select one or more: Medicaid Management Information System (MMIS) Other. Specify:       From where is the Medical Records Data coming? Must select one: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees ages 18 to75 with diabetes (type 1 and type 2) who had a LDL-C screening test.
	Age Range 18-64 Numerator:       Denominator:       Rate:       Age Range 65-75 Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure HA1C-AD: Comprehensive Diabetes Care: Hemoglobin A1c Testing

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Hybrid (Administrative and Medical Records Data) From where is the Administrative Data coming? Must select one or more: Medicaid Management Information System (MMIS) Other. Specify:       From where is the Medical Records Data coming? Must select one: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees ages 18 to 75 with diabetes (type 1 and type 2) who had a hemoglobin A1c (HbA1c) test.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65-75 Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure AMM-AD: Antidepressant Medication Management

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees age 18 and older with a diagnosis of major depression and were treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported: Effective Acute Phase Treatment. The percentage of newly diagnosed and treated Medicaid enrollees who remained on an antidepressant medication for at least 84 days (12 weeks). Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated Medicaid enrollees who remained on an antidepressant medication for at least 180 days (6 months).
	Effective Acute Phase Treatment: Remained on medication for at least 84 days (12 weeks): Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Effective Continuation Phase Treatment: Remained on medication for at least 180 days (6 months): Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure SAA-AD: Adherence to Antipsychotics for Individuals with Schizophrenia

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all that delivery systems apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees ages 19 to64 with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80 percent of their treatment period.
	Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure MPM-AD: Annual Monitoring for Patients on Persistent Medications

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees age 18 and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and who received annual monitoring for the therapeutic agent in the measurement year. Report each of the four rates separately and a total rate. Annual monitoring for enrollees on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). Annual monitoring for members on digoxin. Annual monitoring for members on diuretic. Annual monitoring for members on anticonvulsants. Total rate (the sum of the four numerators divided by the sum of the four denominators).
	Annual Monitoring for Members on ACE Inhibitors or ARBs: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Annual Monitoring for Members on Digoxin (ages 18-64) Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Annual Monitoring for Members on Diuretic: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Annual Monitoring for Members on Anti-convulsants: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Total Rate (sum of the four rates) Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure CPA-AD: Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey 5.0H – Adult Questionnaire

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Measurement Specification: AHRQ & NCQA Other. Explain:      
	Data Source: CAHPS 5.0H Other Which Supplemental Item Sets were Included in the Survey? No supplemental item sets were included Supplemental items for Adult Survey 5.0H Other CAHPS item set Explain:       Which Administrative Protocol was Used to Administer the Survey? NCQA HEDIS CAHPS 5.0H administrative protocol AHRQ CAHPS administrative protocol Other administrative protocol Explain:      
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:      
Please submit a CAHPS summary report to CMS using the CARTS attachment facility (Note: do NOT submit raw CAHPS data to CMS). States should calculate survey results for two age groups (as applicable): ages 18 to 64 and ages 65 and older.

Measure CTR-AD: Care Transition – Timely Transmission of Transition Record

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: AMA/PCPI Other. Explain:      
	Data Source: Hybrid (Administrative and Medical Records Data) From where is the Administrative Data coming? Must select one or more: Medicaid Management Information System (MMIS) Other. Specify:       From where is the Medical Records Data coming? Must select one: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees age 18 years and older discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge.
	Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 64 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure IET-AD: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of Medicaid enrollees age 18 and older with a new episode of alcohol or other drug (AOD) dependence who: Initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis (initiation of AOD treatment). Initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit (engagement of AOD treatment).
	Initiation of AOD Treatment: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Engagement of AOD Treatment: Age Range: 18-64 Numerator:       Denominator:       Rate:       Age Range: 65 and older Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Sex
Male Numerator:       Denominator:       Rate:      		Female Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Measure PPC-AD: Postpartum Care Rate

FFY 2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	The information for this measure is being provided as part of the Adult Medicaid Quality Measures Grant: Yes (as part of the grant) No (this information is for voluntary core set reporting) Both (as part of the grant and voluntary core set reporting)
	Status of Data Reported: Provisional Final
	Measurement Specification: NCQA Specify version of HEDIS used:       Other. Explain:      
	Data Source: Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Hybrid (Administrative and Medical Record Data) From where is the Administrative Data coming? Must select one or more: Medicaid Management Information System (MMIS) Other. Specify:       From where is the Medical Records Data coming? Must select one: Electronic Health Record (EHR) Data Paper Both (EHR and paper) Other. Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women) Denominator includes Medicare and Medicaid Dually-Eligible population Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year that had a postpartum visit on or between 21 and 56 days after delivery.
	Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range”).
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

Maternal and Infant Health Initiative Developmental Measure: Contraceptive Effectiveness

	2014
	Did you Report on this Measure? Yes No If Data Not Reported, Please Explain Why: Select all that apply (Must select at least one): Service not covered Population not covered Entire population not covered Partial population not covered Explain the partial population not covered:                      Data not available Explain why data not available Budget constraints Staff constraints Data inconsistencies/accuracy Please explain:                      Data source not easily accessible Select all that apply: Requires medical record review Requires data linkage which does not currently exist Other:                      Information not collected Select all that apply: Not collected by provider (hospital/health plan) Other:                      Other:                      Small sample size (less than 30) Enter specific sample size:       Other. Explain:      
	Status of Data Reported: Provisional Final
	Measurement Specification: Rate 1: The most effective or moderately effective contraception and received services CDC Other. Explain:       Rate 2: Long-acting reversible contraception and received services CDC Other. Explain:       Rate 3: The most effective or moderately effective contraception at risk CDC Other. Explain:       Rate 4: Long-acting reversible contraception at risk CDC Other. Explain:      
	Data Source: Rate 1: The most effective or moderately effective contraception received services Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other: Specify:       Rate 2: Long-acting reversible contraception and received services Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other: Specify:       Rate 3: The most effective or moderately effective contraception at risk Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other: Specify:       Rate 4: Long-acting reversible contraception at risk Administrative Data Only From where is the Administrative Data coming? Must select one or more if Administrative Data is selected: Medicaid Management Information Systems (MMIS) Other. Specify:       Other: Specify:      
	Date Range: Start Date: (mm/yyyy) End Date: (mm/yyyy)
	Definition of Population Included in the Measure: Definition of denominator: Select all that apply: Denominator includes Medicaid population Denominator includes CHIP population (e.g. pregnant women). Denominator includes Medicare and Medicaid Dually-Eligible population. Other. Specify:       Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? Yes No Which delivery systems are represented in the denominator? Select all delivery systems that apply in your state (Must select at least one); for each delivery system, enter the percentage of the total state population represented in the measure. For example, if the measure-eligible population represents all managed care enrollees, enter 100 percent. Fee-for-Service Percentage of total state FFS population represented:       Primary Care Case Management (PCCM) Percentage of total state PCCM population represented:       Managed Care Organization/Prepaid Inpatient Health Plan (MCO/PIHP) Number of health plans:       Percentage of total state MCO/PIHP population represented:       Integrated Care Models (ICM) Percentage of total state ICM population represented:       Other Describe:       Percentage of total other population represented:       If applicable, number of health plans represented:      
	Deviations from Measure Specifications: Did your calculation of this measure deviate from the measure specifications in any way? Yes No If yes, select all that apply: Numerator. Explain:       Denominator. Explain:       Other. Explain:      
	Performance Measure Proportion of female users aged 15-44 years who received contraceptive services in the past 12 months that adopt or continue use of: The most effective (i.e., male or female sterilization, implants, intrauterine devices or systems [IUD/IUS]) or moderately effective (i.e., injectables, oral pills, patch, ring, or diaphragm) FDA-approved methods of contraception. An FDA-approved, long-acting reversible method of contraception (i.e., implants, intrauterine devices or systems [IUD/IUS]).
	The most effective or moderately effective contraception received services Numerator:       Denominator:       Rate: Long-acting reversible contraception and received services Numerator:       Denominator:       Rate: The most effective or moderately effective contraception at risk Numerator:       Denominator:       Rate: Long-acting reversible contraception at risk Numerator:       Denominator:       Rate:       Were data combined across multiple reporting units (e.g. health plans, delivery systems) to create a state-level rate? Yes No If yes, were the data weighted to reflect the measure eligible population of each reporting unit? Yes No
	Additional notes/comments on measure:      
	Other Performance Measure: If reporting with another methodology, please describe:                      Numerator:       Denominator:       Rate:       If reporting with another methodology, and there are additional numerators, denominators and rates you want to report, please upload the information to the attachment facility, along with a brief description of the measure (e.g. “data reported for individuals in the 18-64 age range.”)
	Optional Measure Stratification If there are other or additional racial, ethnic, sex, language, disability status, or geographic stratifications you want to report, or if stratified data for measures with multiple rates are being provided, please upload the numerator(s), denominator(s), and rate(s), along with a brief description of the stratification, to the attachment facility.
	Race (non-Hispanic)
White Numerator:       Denominator:       Rate:       American Indian or Alaska Native Numerator:       Denominator:       Rate:       Native Hawaiian or Other Pacific Islander Numerator:       Denominator:       Rate:      		Black or African American Numerator:       Denominator:       Rate:       Asian Numerator:       Denominator:       Rate:      
	Ethnicity
Hispanic or Latino Numerator:       Denominator:       Rate:      		Not Hispanic or Latino Numerator:       Denominator:       Rate:      
	Primary Spoken Language
English Numerator:       Denominator:       Rate:      		Spanish Numerator:       Denominator:       Rate:      
	Disability Status
SSI Numerator:       Denominator:       Rate:      		Non-SSI Numerator:       Denominator:       Rate:      
	Geography
Urban Numerator:       Denominator:       Rate:      		Rural Numerator:       Denominator:       Rate:      

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. 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 comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

FFY 2014 Medicaid Adult Quality Measures Template