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POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act SubRegulatory Guidance: SMD# 13-001, ACA #23
BACKGROUND
CMS expects that states will report on the Health Homes quality measures as well as the state
specific goals and measures. The intent of the two part quality reporting approach is to gain
consistent quality data across states while allowing states to also use existing metrics to measure
Health Home outcomes. The Health Home quality measures will be used to inform the required
independent evaluation for the 2017 report to Congress as well as to assess performance and inform
ongoing quality monitoring of the Health Home program. Health Home providers will be expected to
report to the state Medicaid program, which will report the data in aggregate to CMS at the State Plan
Amendment (SPA) level.
Health Homes Quality Measures Administration is the first screen displayed after a user selects
the “Health Homes Quality Measures” option. The Administration screen lists the 2013 Health
Homes measures, a menu for selecting quality measures for viewing or reporting, and provides
reporting status information for each measure.
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
2013 Health Homes Quality Measures Administration
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with Quality Measures
reporting in a future year?”
o If “Y” is selected, select one of the two options as to the type of assistance.
o If “Specific” is selected, describe the assistance requested in the text box
provided.
o Your request will be flagged in a CMS report to provide the state with future
technical assistance.
Health Homes Reporting Measures
This screen includes the following sections:
Federal Fiscal Year
The federal fiscal year selected on the menu page is displayed, with the option for different
reporting years to be selected.
To select a different reporting year, click on the down arrow to the right of the year and select
from the drop down list.
Chose State Plan Amendment (SPA)
Health Homes quality measures are reported for each Health Homes program operated by the
state. You need to indicate the Health Homes program for which you will be reporting by
selecting the State Plan Amendment (SPA ID number) and name of the Health Homes program
from the list. After this selection is made, all the quality measure reporting will be related to that
program. When you are ready to report on another program, you will return to this field and
select another State Plan Amendment and program name.
Administrative Questions
From this screen, you may click the link to access the Administrative Questions which must be
completed before submitting the quality measures for this Health Homes program to CMS. You
may click the link and answer the questions at any time before sending the completed quality
measures to the State Point of Contact for review.
In this section:
2013 Health Homes Quality Measures Administration
Enter the total annual number of individuals participating in the Health Homes program
you selected previously. The number should correspond to the reporting year.
o Of those, enter the total annual number of adults and the total annual number of
children
Enter the number of Health Homes providers operating under this program during the
reporting year.
Complete the section on Cost Savings Data:
o The calendar year prior to the federal fiscal year of the report will display
o Enter the amount of cost savings for this period
o Describe the methodology you used to calculate the cost savings in the text box
o If you have additional documents which will help to explain the methodology you
used, you may upload them. This is not required.
Core Measures and Utilization Measures Tables
The Core and Utilization Measures Tables display a list of the Health Homes core quality
measures and a list of the Utilization quality measures for the reporting year selected. The status
of each measure is indicated to the right of the measure (more about this when we can see it…)
If not entering data for a measure, you must still select the measure and complete a section
indicating why this measure is not being reported..
Select the measures you plan to complete during a session and assign the sequencing of the
selections (the order by which you intend to access the measures and enter data). If you do not
indicate the sequencing, the default sequencing is the order by which the measures appear in the
quality measures table. The table includes the following:
Core Measures:
o Adult Body Mass Index (BMI) Assessment (ABA)
o Screening for Clinical Depression and Follow-up Plan (CDF)
o Plan All-Cause Readmission Rate (PCR)
o Follow-Up After Hospitalization for Mental Illness (FUH)
o Controlling High Blood Pressure (CBP)
o Care Transition – Timely Transmission of Transition Record (CTR)
2013 Health Homes Quality Measures Administration
o Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
(IET)
o Prevention Quality Indicator (PQI92) : Chronic Condition Composite
Utilization Measures
o Ambulatory Care – Emergency Department Visits (AMB)
o Inpatient Utilization (IU)
o Nursing Facility Utilization (NFU)
Health Homes State-Specific Goals and Measures
To complete the state-specific goals and measures for this Health Homes program, click the link
at “Manage Health Homes State-Specific Goals and Measures here.” See the Implementation
Guide for State-Specific Goals and Measures for further instructions.
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is 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.
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding.
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
NCQA
o If selected, also specify the version of HEDIS used by selecting the year from the
dropdown list
Other
o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for NCQA) or the “Other Performance Measure” section (for Other) will display
further down in the screen.
Data Source
Select one or more of the options listed to indicate the source of data or methodology used to
calculate the measure.
Administrative Data
o If selected, also select one or both of the following sub-options:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
Hybrid (Administrative and Medical Records Data)
o If selected, select one or more of the following sub-options to indicate from where
the administrative data is coming:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
o Next, select only one of the following sub-options to indicate from where the
medical records data is coming:
Electronic Health Record (EHR) Data
Paper
Both (EHR and Paper)
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
If a data source other than “Hybrid” was selected in the “Data Source”
section, specify the total measure eligible population in the text box
provided.
If “Hybrid (Administrative and Medical Records Data)” was selected as
the data source in the “Data Source” section, enter the sample size and the
measure-eligible population in the boxes provided
.
Performance Measure
This section displays only if “NCQA” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
A description of the measure from the Technical Specifications and Resource Manual will
display. Numerator, denominator and rate (N/D/R) fields will also display.
Enter the numerator, denominator and rate for each classification you wish to report.
Enter the total numerator, denominator and rate.
If administrative data was used as the only data source, for each classification for which
you are reporting, enter the numerator and denominator. The system will calculate and
auto-fill the rate.
If a data source other than administrative data or in combination with administrative data
was used, for each classification for which you are reporting, enter the numerator,
denominator and rate.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen. Also, the total must
be entered.
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator).
Other Performance Measure
This section displays only if “Other” is selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
The same number of rate sets (i.e. numerator, denominator, and rate (N/D/R) as specified
in the Technical Specifications and Resource Manual will also display
For each rate you wish to report, enter a description of the rate in the text box provided.
This is followed by fields for the numerator, denominator, and rate.
o Enter the numerator, denominator and rate for each classification you wish to
report.
o If administrative data was used as the only data source, enter the numerator and
denominator. The system will calculate and auto-fill the rate.
o If a data source other than administrative data or in combination with
administrative data was used, enter the numerator, denominator and rate.
Next, select “Y” or “N” to the question “Are there additional/other measures (numerators,
denominators and rates) you want to report?”
o If “Y” is selected, click on the plus (+) button next to “Additional/Other Rate(s)”
to add a rate.
Next, enter a description (e.g., 18-64) of the first or only additional rate
you want to report in the text box provided.
This is followed by fields for the numerator, denominator and rate.
o Enter the numerator, denominator and rate for each classification
you wish to report
o If administrative data was used as the only data source, enter the
numerator and denominator. The system will calculate and auto-fill
the rate.
o If a data source other than administrative data or in combination
with administrative data was used, enter the numerator,
denominator and rate.
o To add more rates, for each rate you want to add, click on the plus (+) button next
to “Additional/Other Rate(s)” and repeat the process.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
Ethnicity
Sex
Primary Spoken Language
Disability Status
Geography
First select the classification being reported. Sub-options will display for each classification
selected, including, with the exception of the “Sex” category, the option to add sub-option(s) not
listed.
For each sub-option selected, the system will display numerator, denominator and rate
fields for pre-specified classifications (as specified in the Technical Specifications and
Resource Guide), with the option to also select “Additional/Alternative
Classification/Sub-category” in place of, or in addition to the pre-specified
classifications.
If “Additional/Alternative Classification/Sub-category” is selected, describe the
classification in the text box provided.
o For each classification you are reporting, enter the numerator, denominator and
rate.
o If administrative data was used as the only data source, for each classification for
which you are reporting, enter the numerator and denominator. The system will
calculate and auto-fill the rate.
o If a data source other than administrative data or in combination with
administrative data was used, for each classification for which you are reporting,
enter the numerator, denominator and rate.
If reporting an “Additional/Alternative Classification/Sub-category”, click on the plus (+)
button next to “(Additional/Alternative Classification/Sub-category)” and repeat the
process, naming the classification and entering the data.
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
o If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
o Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
2013 ABA-HH: Adult Body Mass Index (BMI) Assessment
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
o Optional Measure Stratification:
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
2013 CDF-HH: Screening for Clinical Depression and Follow-Up Plan
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is the percentage of Health Homes enrollees age 12 and older who were
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.
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
2013 CDF-HH: Screening for Clinical Depression and Follow-Up Plan
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding.
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
2013 CDF-HH: Screening for Clinical Depression and Follow-Up Plan
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
CMS
Other
o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
2013 CDF-HH: Screening for Clinical Depression and Follow-Up Plan
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for CMS) or the “Other Performance Measure” section (for Other) will display
further down in the screen.
Data Source
Select one or more of the following options to indicate the source of data or methodology used to
calculate the measure.
Hybrid (Administrative and Medical Records Data)
o If selected, select one or more of the following sub-options to indicate from where
the administrative data is coming:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
o Next, select only one of the following sub-options to indicate from where the
medical records data is coming:
Electronic Health Record (EHR) Data
Paper
Both (EHR and Paper)
Electronic Health Record (EHR) Data
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
2013 CDF-HH: Screening for Clinical Depression and Follow-Up Plan
Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
If a data source other than “Hybrid” was selected in the “Data Source”
section, specify the total measure eligible population in the text box
provided.
If “Hybrid (Administrative and Medical Records Data)” was selected as
the data source in the “Data Source” section, enter the sample size and the
measure-eligible population in the boxes provided.
.
Performance Measure
This section displays only if “CMS” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
A description of the measure from the Technical Specifications and Resource Manual will
display. Numerator, denominator and rate (N/D/R) fields will also display.
Enter the numerator, denominator and rate for each classification you wish to report.
Enter the total numerator, denominator and rate.
2013 CDF-HH: Screening for Clinical Depression and Follow-Up Plan
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen. Also, the total must
be entered.
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
2013 CDF-HH: Screening for Clinical Depression and Follow-Up Plan
The information may be entered in the text box provided.
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator)
Other Performance Measure
This section displays only if “Other” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
2013 CDF-HH: Screening for Clinical Depression and Follow-Up Plan
The same number of rate sets (i.e. numerator, denominator, and rate (N/D/R) as specified
in the Technical Specifications and Resource Manual will also display
For each rate you wish to report, enter a description of the rate in the text box provided.
This is followed by fields for the numerator, denominator, and rate.
o Enter the numerator, denominator and rate for each classification you wish to
report.
Next, select “Y” or “N” to the question “Are there additional/other measures (numerators,
denominators and rates) you want to report?”
o If “Y” is selected, click on the plus (+) button next to “Additional/Other Rate(s)”
to add a rate.
Next, enter a description (e.g., 18-64) of the first or only additional rate
you want to report in the text box provided.
This is followed by fields for the numerator, denominator and rate.
o Enter the numerator, denominator and rate for each classification
you wish to report.
o To add more rates, for each rate you want to add, click on the plus (+) button next
to “Additional/Other Rate(s)” and repeat the process.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
Ethnicity
Sex
Primary Spoken Language
Disability Status
Geography
First select the classification being reported. Sub-options will display for each classification
selected, including, with the exception of the “Sex” category, the option to add sub-option(s) not
listed.
For each sub-option selected, the system will display numerator, denominator and rate
fields for pre-specified classifications (as specified in the Technical Specifications and
Resource Guide), with the option to also select “Additional/Alternative
2013 CDF-HH: Screening for Clinical Depression and Follow-Up Plan
Classification/Sub-category” in place of, or in addition to the pre-specified
classifications.
If “Additional/Alternative Classification/Sub-category” is selected, describe the
classification in the text box provided.
o For each classification you are reporting, enter the numerator, denominator and
rate.
If reporting an “Additional/Alternative Classification/Sub-category”, click on the plus (+)
button next to “(Additional/Alternative Classification/Sub-category)” and repeat the
process, naming the classification and entering the data.
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
2013 CDF-HH: Screening for Clinical Depression and Follow-Up Plan
Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
Optional Measure Stratification:
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
2013 ABA-HH: Plan All-Cause Readmission Rate
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is, for Medicaid beneficiaries 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)
Observed Readmission (rate)
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
2013 ABA-HH: Plan All-Cause Readmission Rate
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
2013 ABA-HH: Plan All-Cause Readmission Rate
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
NCQA
2013 ABA-HH: Plan All-Cause Readmission Rate
o If selected, also specify the version of HEDIS used by selecting the year from the
dropdown list
Other
o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for NCQA) or the “Other Performance Measure” section (for Other) will display
further down in the screen.
Data Source
Select one or more of the options listed to indicate the source of data or methodology used to
calculate the measure.
Administrative Data
o If selected, also select one or both of the following sub-options:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
2013 ABA-HH: Plan All-Cause Readmission Rate
Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
Specify the total measure eligible population in the text box provided.
Performance Measure
This section displays only if “NCQA” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
A description of the measure from the Technical Specifications and Resource Manual will
display, followed by a table.
For each age group, enter the:
o Count of Index Stays
o Count of 30-Day Readmissions
o Observed Readmissions
Enter the totals for each column
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen.
2013 ABA-HH: Plan All-Cause Readmission Rate
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
2013 ABA-HH: Plan All-Cause Readmission Rate
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator)
Other Performance Measure
This section displays only if “Other” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
Enter a description of the rate (e.g., 18-64) you are reporting in the text box provided.
o Enter the numerator, denominator and rate.
2013 ABA-HH: Plan All-Cause Readmission Rate
If administrative data was used as the only data source enter the numerator
and denominator. The system will calculate and auto-fill the rate.
If a data source other than administrative data or in combination with
administrative data was used, enter the numerator, denominator, and rate.
To add more rates, for each rate you want to add, click on the plus (+) button next to
“Additional/Other Rate(s)” and repeat the process.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
Ethnicity
Sex
Primary Spoken Language
Disability Status
Geography
First select the classification being reported. Sub-options will display for each classification
selected, including, with the exception of the “Sex” category, the option to add sub-option(s) not
listed.
Enter a description of the first or only rate (e.g., 18-64) you are reporting in the text box
provided.
o Enter the numerator, denominator, and rate.
If administrative data was used as the only data source, for each
classification you are reporting, enter the numerator and denominator. The
system will calculate and auto-fill the rate.
If a data source other than administrative data or in combination with
administrative data was used, for each classification you are reporting,
enter the numerator, denominator and rate.
To add more rates, click on the plus (+) button next to text box labeled “Please describe
the additional/alternative classification/sub-category (e.g., 19-64):” and repeat the
process.
2013 ABA-HH: Plan All-Cause Readmission Rate
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
o If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
o Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
2013 ABA-HH: Plan All-Cause Readmission Rate
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
o Optional Measure Stratification:
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
2013 FUH-HH: Follow-Up after Hospitalization for Mental Illness
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is the percentage of discharges for Health Homes enrollees age 6 and older
who were hospitalized for treatment of selected mental health disorders and who had an
outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health
practitioner. Two rates are reported:
The percentage of discharges for which the patient received follow-up within 30 days of
discharge.
The percentage of discharges for which the patient received follow-up within 7 days of
discharge.
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
2013 FUH-HH: Follow-Up after Hospitalization for Mental Illness
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding.
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
2013 FUH-HH: Follow-Up after Hospitalization for Mental Illness
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
NCQA
2013 FUH-HH: Follow-Up after Hospitalization for Mental Illness
o If selected, also specify the version of HEDIS used by selecting the year from the
dropdown list
Other
o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for NCQA) or the “Other Performance Measure” section (for Other) will display
further down in the screen.
Data Source
Select one or more of the options listed to indicate the source of data or methodology used to
calculate the measure.
Administrative Data
o If selected, also select one or both of the following sub-options:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
2013 FUH-HH: Follow-Up after Hospitalization for Mental Illness
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
Specify the total measure eligible population in the text box provided.
Performance Measure
This section displays only if “NCQA” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
A description of the measure from the Technical Specifications and Resource Manual will
display. Numerator, denominator and rate (N/D/R) fields will also display.
Enter the numerator, denominator and rate for each classification you wish to report.
Enter the total numerator, denominator and rate.
If administrative data was used as the only data source, for each classification for which
you are reporting, enter the numerator and denominator. The system will calculate and
auto-fill the rate.
If a data source other than administrative data or in combination with administrative data
was used, for each classification for which you are reporting, enter the numerator,
denominator and rate.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen. Also, the total must
be entered.
2013 FUH-HH: Follow-Up after Hospitalization for Mental Illness
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
2013 FUH-HH: Follow-Up after Hospitalization for Mental Illness
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator).
Other Performance Measure
This section displays only if “Other” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
The same number of rate sets (i.e. numerator, denominator, and rate (N/D/R) as specified
in the Technical Specifications and Resource Manual will also display
2013 FUH-HH: Follow-Up after Hospitalization for Mental Illness
For each rate you wish to report, enter a description of the rate in the text box provided.
This is followed by fields for the numerator, denominator, and rate.
o Enter the numerator, denominator and rate for each classification you wish to
report.
o If administrative data was used as the only data source, enter the numerator and
denominator. The system will calculate and auto-fill the rate.
o If a data source other than administrative data or in combination with
administrative data was used, enter the numerator, denominator and rate.
Next, select “Y” or “N” to the question “Are there additional/other measures (numerators,
denominators and rates) you want to report?”
o If “Y” is selected, click on the plus (+) button next to “Additional/Other Rate(s)”
to add a rate.
Next, enter a description (e.g., 18-64) of the first or only additional rate
you want to report in the text box provided.
This is followed by fields for the numerator, denominator and rate.
o Enter the numerator, denominator and rate for each classification
you wish to report.
o If administrative data was used as the only data source, enter the
numerator and denominator. The system will calculate and auto-fill
the rate.
o If a data source other than administrative data or in combination
with administrative data was used, enter the numerator,
denominator and rate.
o To add more rates, for each rate you want to add, click on the plus (+) button next
to “Additional/Other Rate(s)” and repeat the process.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
Ethnicity
Sex
Primary Spoken Language
Disability Status
Geography
2013 FUH-HH: Follow-Up after Hospitalization for Mental Illness
First select the classification being reported. Sub-options will display for each classification
selected, including, with the exception of the “Sex” category, the option to add sub-option(s) not
listed.
For each sub-option selected, the system will display numerator, denominator and rate
fields for pre-specified classifications (as specified in the Technical Specifications and
Resource Guide), with the option to also select “Additional/Alternative
Classification/Sub-category” in place of, or in addition to the pre-specified
classifications.
If “Additional/Alternative Classification/Sub-category” is selected, describe the
classification in the text box provided.
o For each classification you are reporting, enter the numerator, denominator and
rate.
o If administrative data was used as the only data source, for each classification for
which you are reporting, enter the numerator and denominator. The system will
calculate and auto-fill the rate.
If reporting an “Additional/Alternative Classification/Sub-category”, click on the plus (+)
button next to “(Additional/Alternative Classification/Sub-category)” and repeat the
process, naming the classification and entering the data.
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
2013 FUH-HH: Follow-Up after Hospitalization for Mental Illness
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
o If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
o Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
o Optional Measure Stratification:
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
2013 CBP-HH: Controlling High Blood Pressure
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is the percentage of Health Home 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.
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
2013 CBP-HH: Controlling High Blood Pressure
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding.
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
2013 CBP-HH: Controlling High Blood Pressure
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
NCQA
o If selected, also specify the version of HEDIS used by selecting the year from the
dropdown list
Other
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o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for NCQA) or the “Other Performance Measure” section (for Other) will display
further down in the screen.
Data Source
Select one or more of the following options to indicate the source of data or methodology used to
calculate the measure.
Hybrid (Administrative and Medical Records Data)
o If selected, select one or more of the following sub-options to indicate from where
the administrative data is coming:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
o Next, select only one of the following sub-options to indicate from where the
medical records data is coming:
Electronic Health Record (EHR) Data
Paper
Both (EHR and Paper)
Electronic Health Record (EHR) Data
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
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Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
If a data source other than “Hybrid” was selected in the “Data Source”
section, specify the total measure eligible population in the text box
provided.
If “Hybrid (Administrative and Medical Records Data)” was selected as
the data source in the “Data Source” section, enter the sample size and the
measure-eligible population in the boxes provided.
.
Performance Measure
This section displays only if “NCQA” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
A description of the measure from the Technical Specifications and Resource Manual will
display. Numerator, denominator and rate (N/D/R) fields will also display.
Enter the numerator, denominator and rate for each classification you wish to report.
Enter the total numerator, denominator and rate.
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Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen. Also, the total must
be entered.
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
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The information may be entered in the text box provided.
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator)
Other Performance Measure
This section displays only if “Other” is selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
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The same number of rate sets (i.e. numerator, denominator, and rate (N/D/R) as specified
in the Technical Specifications and Resource Manual will also display
For each rate you wish to report, enter a description of the rate in the text box provided.
This is followed by fields for the numerator, denominator, and rate.
o Enter the numerator, denominator and rate for each classification you wish to
report.
Next, select “Y” or “N” to the question “Are there additional/other measures (numerators,
denominators and rates) you want to report?”
o If “Y” is selected, click on the plus (+) button next to “Additional/Other Rate(s)”
to add a rate.
Next, enter a description (e.g., 18-64) of the first or only additional rate
you want to report in the text box provided.
This is followed by fields for the numerator, denominator and rate.
Enter the numerator, denominator and rate for each classification
you wish to report.
To add more rates, for each rate you want to add, click on the plus (+)
button next to “Additional/Other Rate(s)” and repeat the process.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
Ethnicity
Sex
Primary Spoken Language
Disability Status
Geography
First select the classification being reported. Sub-options will display for each classification
selected, including, with the exception of the “Sex” category, the option to add sub-option(s) not
listed.
For each sub-option selected, the system will display numerator, denominator and rate
fields for pre-specified classifications (as specified in the Technical Specifications and
Resource Guide), with the option to also select “Additional/Alternative
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Classification/Sub-category” in place of, or in addition to the pre-specified
classifications.
If “Additional/Alternative Classification/Sub-category” is selected, describe the
classification in the text box provided.
o For each classification you are reporting, enter the numerator, denominator and
rate.
If reporting an “Additional/Alternative Classification/Sub-category”, click on the plus (+)
button next to “(Additional/Alternative Classification/Sub-category)” and repeat the
process, naming the classification and entering the data.
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
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Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
Optional Measure Stratification:
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
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POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is the percentage of Health Home enrollees of all ages 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, Health Home provider or primary physician or other health care professional designated
for follow-up care, within 24 hours of discharge.
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
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Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding.
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
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o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
AMA/PCPI
Other
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o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for AMA/PCPI) or the “Other Performance Measure” section (for Other) will
display further down in the screen.
Data Source
Select one or more of the following options to indicate the source of data or methodology used to
calculate the measure.
Hybrid (Administrative and Medical Records Data)
o If selected, select one or more of the following sub-options to indicate from where
the administrative data is coming:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
o Next, select only one of the following sub-options to indicate from where the
medical records data is coming:
Electronic Health Record (EHR) Data
Paper
Both (EHR and Paper)
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
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Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
If a data source other than “Hybrid” was selected in the “Data Source”
section, specify the total measure eligible population in the text box
provided.
If “Hybrid (Administrative and Medical Records Data)” was selected as
the data source in the “Data Source” section, enter the sample size and the
measure-eligible population in the boxes provided.
.
Performance Measure
This section displays only if “AMA/PCPI” was selected in the “Measurement Specification”
section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
A description of the measure from the Technical Specifications and Resource Manual will
display. Numerator, denominator and rate (N/D/R) fields will also display.
Enter the numerator, denominator and rate for each classification you wish to report.
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Enter the total numerator, denominator and rate.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen. Also, the total must
be entered.
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
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If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator)
Other Performance Measure
This section displays only if “Other” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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
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rate in the “Rate” field, and when possible, include individual reporting unit numerators,
denominators, and rates in the field labeled “Additional Notes/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
The same number of rate sets (i.e. numerator, denominator, and rate (N/D/R) as specified
in the Technical Specifications and Resource Manual will also display
For each rate you wish to report, enter a description of the rate in the text box provided.
This is followed by fields for the numerator, denominator, and rate.
o Enter the numerator, denominator and rate for each classification you wish to
report.
Next, select “Y” or “N” to the question “Are there additional/other measures (numerators,
denominators and rates) you want to report?”
o If “Y” is selected, click on the plus (+) button next to “Additional/Other Rate(s)”
to add a rate.
Next, enter a description (e.g., 18-64) of the first or only additional rate
you want to report in the text box provided.
This is followed by fields for the numerator, denominator and rate.
o Enter the numerator, denominator and rate for each classification
you wish to report.
o To add more rates, for each rate you want to add, click on the plus (+) button next
to “Additional/Other Rate(s)” and repeat the process.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
Ethnicity
Sex
Primary Spoken Language
Disability Status
Geography
2013 CTR-HH: Care Transition – Timely Transmission of Transitional
Record
First select the classification being reported. Sub-options will display for each classification
selected, including, with the exception of the “Sex” category, the option to add sub-option(s) not
listed.
For each sub-option selected, the system will display numerator, denominator and rate
fields for pre-specified classifications (as specified in the Technical Specifications and
Resource Guide), with the option to also select “Additional/Alternative
Classification/Sub-category” in place of, or in addition to the pre-specified
classifications.
If “Additional/Alternative Classification/Sub-category” is selected, describe the
classification in the text box provided.
o For each classification you are reporting, enter the numerator, denominator and
rate.
If reporting an “Additional/Alternative Classification/Sub-category”, click on the plus (+)
button next to “(Additional/Alternative Classification/Sub-category)” and repeat the
process, naming the classification and entering the data.
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
2013 CTR-HH: Care Transition – Timely Transmission of Transitional
Record
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
Optional Measure Stratification:
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is the percentage of Health Home enrollees age 13 and older with a new
episode of alcohol or other drug (AOD) dependence who received the following:
Initiation of AOD Treatment. The percentage of Health Home enrollees who initiated
treatment through an inpatient AOD admission, outpatient visit, intensive outpatient
encounter, or partial hospitalization within 14 days of the diagnosis.
Engagement of AOD Treatment. The percentage of Health Home enrollees who initiated
treatment and who had two or more additional services with a diagnosis of AOD within
30 days of the initiation visit
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding.
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
NCQA
o If selected, also specify the version of HEDIS used by selecting the year from the
dropdown list
Other
o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for NCQA) or the “Other Performance Measure” section (for Other) will display
further down in the screen.
Data Source
Select one or more of the options listed to indicate the source of data or methodology used to
calculate the measure.
Administrative Data
o If selected, also select one or both of the following sub-options:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
Electronic Health Record (EHR) Data
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
Specify the total measure eligible population in the text box provided.
Performance Measure
This section displays only if “NCQA” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
A description of the measure from the Technical Specifications and Resource Manual will
display. Numerator, denominator and rate (N/D/R) fields will also display.
Enter the numerator, denominator and rate for each classification you wish to report.
Enter the total numerator, denominator and rate.
If administrative data was used as the only data source, for each classification for which
you are reporting, enter the numerator and denominator. The system will calculate and
auto-fill the rate.
If a data source other than administrative data or in combination with administrative data
was used, for each classification for which you are reporting, enter the numerator,
denominator and rate.
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen. Also, the total must
be entered.
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator)
Other Performance Measure
This section displays only if “Other” is selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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,
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
denominators, and rates in the field labeled “Additional Notes/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
The same number of rate sets (i.e. numerator, denominator, and rate (N/D/R) as specified
in the Technical Specifications and Resource Manual will also display
For each rate you wish to report, enter a description of the rate in the text box provided.
This is followed by fields for the numerator, denominator, and rate.
o Enter the numerator, denominator and rate for each classification you wish to
report.
o If administrative data was used as the only data source, enter the numerator and
denominator. The system will calculate and auto-fill the rate.
o If a data source other than administrative data or in combination with
administrative data was used, enter the numerator, denominator and rate.
Next, select “Y” or “N” to the question “Are there additional/other measures (numerators,
denominators and rates) you want to report?”
o If “Y” is selected, click on the plus (+) button next to “Additional/Other Rate(s)”
to add a rate.
Next, enter a description (e.g., 18-64) of the first or only additional rate
you want to report in the text box provided.
This is followed by fields for the numerator, denominator and rate.
If administrative data was used as the only data source, enter the
numerator and denominator. The system will calculate and auto-fill
the rate.
If a data source other than administrative data or in combination
with administrative data was used, enter the numerator,
denominator and rate.
To add more rates, for each rate you want to add, click on the plus (+)
button next to “Additional/Other Rate(s)” and repeat the process.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
Ethnicity
Sex
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
Primary Spoken Language
Disability Status
Geography
First select the classification being reported. Sub-options will display for each classification
selected, including, with the exception of the “Sex” category, the option to add sub-option(s) not
listed.
For each sub-option selected, the system will display numerator, denominator and rate
fields for pre-specified classifications (as specified in the Technical Specifications and
Resource Guide), with the option to also select “Additional/Alternative
Classification/Sub-category” in place of, or in addition to the pre-specified
classifications.
If “Additional/Alternative Classification/Sub-category” is selected, describe the
classification in the text box provided.
o For each classification you are reporting, enter the numerator, denominator and
rate.
o If administrative data was used as the only data source, for each classification for
which you are reporting, enter the numerator and denominator. The system will
calculate and auto-fill the rate.
o If a data source other than administrative data or in combination with
administrative data was used, for each classification for which you are reporting,
enter the numerator, denominator and rate.
If reporting an “Additional/Alternative Classification/Sub-category”, click on the plus (+)
button next to “(Additional/Alternative Classification/Sub-category)” and repeat the
process, naming the classification and entering the data.
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
o If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
o Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
o Optional Measure Stratification:
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
2013 IET- HH Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
2013 PQ192-HH: Prevention Quality Indicator (PQI) 92: Chronic Condition
Composite
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is the total number of hospital admissions for ambulatory care sensitive
chronic conditions per 100,000 Health Home enrollees age 18 and older. This measure includes
adult hospital admissions for diabetes with short-term complications; diabetes with long-term
complications; uncontrolled diabetes without complications; diabetes with lower-extremity
amputation; chronic obstructive pulmonary disease; asthma; hypertension; heart failure; or
angina without a cardiac procedure.
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
2013 PQ192-HH: Prevention Quality Indicator (PQI) 92: Chronic Condition
Composite
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding.
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
2013 PQ192-HH: Prevention Quality Indicator (PQI) 92: Chronic Condition
Composite
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
2013 PQ192-HH: Prevention Quality Indicator (PQI) 92: Chronic Condition
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AHRQ
Other
o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for AHRQ) or the “Other Performance Measure” section (for Other) will display
further down in the screen.
Data Source
Select one or more of the options listed to indicate the source of data or methodology used to
calculate the measure.
Administrative Data
o If selected, also select one or both of the following sub-options:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
2013 PQ192-HH: Prevention Quality Indicator (PQI) 92: Chronic Condition
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Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
Specify the total measure eligible population in the text box provided.
Performance Measure
This section displays only if “AHRQ” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
A description of the measure from the Technical Specifications and Resource Manual will
display. Numerator, denominator and rate (N/D/R) fields will also display.
Enter the numerator, denominator and rate for each classification you wish to report.
Enter the total numerator, denominator and rate.
If administrative data was used as the only data source, for each classification for which
you are reporting, enter the numerator and denominator. The system will calculate and
auto-fill the rate.
If a data source other than administrative data or in combination with administrative data
was used, for each classification for which you are reporting, enter the numerator,
denominator and rate.
2013 PQ192-HH: Prevention Quality Indicator (PQI) 92: Chronic Condition
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Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen. Also, the total must
be entered.
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
2013 PQ192-HH: Prevention Quality Indicator (PQI) 92: Chronic Condition
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If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator)
Other Performance Measure
This section displays only if “Other” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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,
2013 PQ192-HH: Prevention Quality Indicator (PQI) 92: Chronic Condition
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denominators, and rates in the field labeled “Additional Notes/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
The same number of rate sets (i.e. numerator, denominator, and rate (N/D/R) as specified
in the Technical Specifications and Resource Manual will also display
For each rate you wish to report, enter a description of the rate in the text box provided.
This is followed by fields for the numerator, denominator, and rate.
o Enter the numerator, denominator and rate for each classification you wish to
report.
o If administrative data was used as the only data source, enter the numerator and
denominator. The system will calculate and auto-fill the rate.
o If a data source other than administrative data or in combination with
administrative data was used, enter the numerator, denominator and rate.
Next, select “Y” or “N” to the question “Are there additional/other measures (numerators,
denominators and rates) you want to report?”
o If “Y” is selected, click on the plus (+) button next to “Additional/Other Rate(s)”
to add a rate.
Next, enter a description (e.g., 18-64) of the first or only additional rate
you want to report in the text box provided.
This is followed by fields for the numerator, denominator and rate.
Enter the numerator, denominator and rate for each classification
you wish to report.
If administrative data was used as the only data source, enter the
numerator and denominator. The system will calculate and auto-fill
the rate.
If a data source other than administrative data or in combination
with administrative data was used, enter the numerator,
denominator and rate.
o To add more rates, for each rate you want to add, click on the plus (+) button next
to “Additional/Other Rate(s)” and repeat the process.
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
2013 PQ192-HH: Prevention Quality Indicator (PQI) 92: Chronic Condition
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Ethnicity
Sex
Primary Spoken Language
Disability Status
Geography
First select the classification being reported. Sub-options will display for each classification
selected, including, with the exception of the “Sex” category, the option to add sub-option(s) not
listed.
For each sub-option selected, the system will display numerator, denominator and rate
fields for pre-specified classifications (as specified in the Technical Specifications and
Resource Guide), with the option to also select “Additional/Alternative
Classification/Sub-category” in place of, or in addition to the pre-specified
classifications.
If “Additional/Alternative Classification/Sub-category” is selected, describe the
classification in the text box provided.
o For each classification you are reporting, enter the numerator, denominator and
rate.
o If administrative data was used as the only data source, for each classification for
which you are reporting, enter the numerator and denominator. The system will
calculate and auto-fill the rate.
If reporting an “Additional/Alternative Classification/Sub-category”, click on the plus (+)
button next to “(Additional/Alternative Classification/Sub-category)” and repeat the
process, naming the classification and entering the data.
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
2013 PQ192-HH: Prevention Quality Indicator (PQI) 92: Chronic Condition
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If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
o If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
o Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
o Optional Measure Stratification:
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
2013 AMB-HH: Ambulatory Care – Emergency Department Visits
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is the rate of emergency department (ED) visits per 1,000 enrollee months
among Health Home enrollees.
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
2013 AMB-HH: Ambulatory Care – Emergency Department Visits
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding.
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
2013 AMB-HH: Ambulatory Care – Emergency Department Visits
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
NCQA
o If selected, also specify the version of HEDIS used by selecting the year from the
dropdown list
Other
o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
2013 AMB-HH: Ambulatory Care – Emergency Department Visits
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for NCQA) or the “Other Performance Measure” section (for Other) will display
further down in the screen.
Data Source
Select one or more of the options listed to indicate the source of data or methodology used to
calculate the measure.
Administrative Data
o If selected, also select one or both of the following sub-options:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
2013 AMB-HH: Ambulatory Care – Emergency Department Visits
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
Specify the total measure eligible population in the text box provided.
Performance Measure
This section displays only if “NCQA” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
A description of the measure from the Technical Specifications and Resource Manual will
display, followed by a table.
For each age group, enter the number of ED Visits (numerator), Enrollee Months
(denominator) and Visits per 1,000 Enrollee Months (rate).
Enter the totals
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen. The total must also
be entered.
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
2013 AMB-HH: Ambulatory Care – Emergency Department Visits
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
2013 AMB-HH: Ambulatory Care – Emergency Department Visits
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator)
Other Performance Measure
This section displays only if “Other” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
Enter a description of the rate (e.g., 18-64) you are reporting in the text box provided.
o Enter the numerator, denominator and rate.
If administrative data was used as the only data source enter the numerator
and denominator. The system will calculate and auto-fill the rate.
If a data source other than administrative data or in combination with
administrative data was used, enter the numerator, denominator, and rate.
To add more rates, click on the plus (+) button next to text box labeled “Please describe
the rate (e.g., 18-64):” and repeat the process.
2013 AMB-HH: Ambulatory Care – Emergency Department Visits
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
Ethnicity
Sex
Primary Spoken Language
Disability Status
Geography
Enter a description of the first or only rate (e.g., 18-64) you are reporting in the text box
provided.
o Enter the numerator, denominator, and rate.
o If administrative data was used as the only data source, for each classification you
are reporting, enter the numerator and denominator. The system will calculate and
auto-fill the rate.
o If a data source other than administrative data or in combination with
administrative data was used, for each classification you are reporting, enter the
numerator, denominator and rate.
To add more rates, click on the plus (+) button next to text box labeled “Please describe
the additional/alternative classification/sub-category (e.g., 19-64):” and repeat the
process.
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
2013 AMB-HH: Ambulatory Care – Emergency Department Visits
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
o If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
o Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
o Optional Measure Stratification:
2013 AMB-HH: Ambulatory Care – Emergency Department Visits
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
2013 IU-HH: Inpatient Utilization
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is the rate of acute inpatient care and services (total, maternity, mental
health, surgery, and medicine) per 1,000 enrollee months among Health Homes enrollees.
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
2013 IU-HH: Inpatient Utilization
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding.
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
2013 IU-HH: Inpatient Utilization
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
CMS
Other
o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
2013 IU-HH: Inpatient Utilization
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for CMS) or the “Other Performance Measure” section (for Other) will display
further down in the screen.
Data Source
Select one or more of the options listed to indicate the source of data or methodology used to
calculate the measure.
Administrative Data
o If selected, also select one or both of the following sub-options:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
o Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
2013 IU-HH: Inpatient Utilization
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
Specify the total measure eligible population in the text box provided.
Performance Measure
This section displays only if “CMS” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
A description of the measure from the Technical Specifications and Resource Manual will
display, followed by two tables.
In the first table, enter the number of Enrollee Months (denominator) for each age group.
In the second table:
o Enter for each age group, by category (provided you have the data):
The Number of Discharges from acute inpatient care (numerator)
The Discharges/1000 Enrollee Months (rate)
The Number of Days of acute inpatient care (numerator)
The Days/1000 Enrollee Months (rate)
The Average Length of Stay
o Enter the totals for each category
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen. The totals must also
be entered.
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
2013 IU-HH: Inpatient Utilization
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
2013 IU-HH: Inpatient Utilization
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator)
Other Performance Measure
This section displays only if “Other” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
Enter a description of the rate (e.g., 18-64) you are reporting in the text box provided.
o Enter the numerator, denominator and rate.
If administrative data was used as the only data source enter the numerator
and denominator. The system will calculate and auto-fill the rate.
If a data source other than administrative data or in combination with
administrative data was used, enter the numerator, denominator, and rate.
To add more rates, click on the plus (+) button next to text box labeled “Please describe
the rate (e.g., 18-64):” and repeat the process.
2013 IU-HH: Inpatient Utilization
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
Ethnicity
Sex
Primary Spoken Language
Disability Status
Geography
Enter a description of the first or only rate (e.g., 18-64) you are reporting in the text box
provided.
o Enter the numerator, denominator, and rate.
o If administrative data was used as the only data source, for each classification you
are reporting, enter the numerator and denominator. The system will calculate and
auto-fill the rate.
o If a data source other than administrative data or in combination with
administrative data was used, for each classification you are reporting, enter the
numerator, denominator and rate.
To add more rates, click on the plus (+) button next to text box labeled “Please describe
the additional/alternative classification/sub-category (e.g., 19-64):” and repeat the
process.
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
2013 IU-HH: Inpatient Utilization
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
o If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
o Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
o Optional Measure Stratification:
2013 IU-HH: Inpatient Utilization
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
2013 NF-HH: Nursing Facility Utilization
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
This quality measure is the number of admissions to a nursing facility from the community that
result in a short-term (less than 101 days) or long-term stay (greater than or equal to 101 days)
during the measurement year per 1,000 enrollee months.
Please refer to the latest Technical Specifications and Resource Manual at the following
hyperlink for information on Health Homes Quality Measures reporting:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes-technical-assistance/downloads/health-home-core-set-manual.pdf
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
2013 NF-HH: Nursing Facility Utilization
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
Reporting on Measure Question
The response to the first question “Are you reporting on this measure?” determines which
sections will display for completion by the state.
Note: 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 the measure. Your selection of a reason for
not reporting and/or provision of an “Other” reason for not reporting will assist CMS in
that understanding.
If “N,” is selected, the “Not Reporting on Measure” section displays. See the “Not Reporting on
Measure” section, below, for instructions on completing this section.
If “Y” is selected for “Are you reporting on this measure?” the following sections display:
Measurement Specification
Data Source
Date Range
Definition of Population Included in the Measure
Performance Measure, if applicable
Deviations from Measure Specifications, if applicable
Other Performance Measure, if applicable
Optional Measure Stratification
Final Comments
Upload Functionality
For instructions on completing each section, see below, by section name.
Unless noted as optional, the state must provide the information requested in each section
displayed.
Not Reporting on Measure
From the list displayed on the screen, select all applicable reasons why you are not reporting on
the measure. At least one option must be selected from the following options:
Service Not Covered: Select this option if your program does not cover this service.
Population Not Covered: Select this option if your program does not cover the population
included in the measure. If this option is selected, also , select one of the following two
sub-options to indicate whether the entire population or partial population was not
covered under its program.
o Entire population not covered
o Partial population not covered: If selected, also enter a detailed explanation of the
partial population not covered in the text box provided.
Data Not Available: Select this option if data are not available for this measure in your
state. If this option is selected, users will need to explain why data are not available for
reporting by selecting one or more of the following options:
2013 NF-HH: Nursing Facility Utilization
o Budget Constraints
o Staff Constraints
o Data Inconsistencies/Accuracy: If selected, provide an explanation in the text box
provided.
o Data Source Not Easily Accessible: If selected, also select one or more of the
following sub-options:
Requires Medical Record Review
Requires Data Linkage which does not
Other: if selected, provide an explanation in the text box provided.
o Information Not Collected: If selected, also select one or both of the following
sub-options:
Not Collected by Provider (Hospital/Health Plan)
Other: If selected, provide an explanation in the text box provided.
o Other: If selected, provide an explanation in the text box provided.
Small Sample Size: Select this option 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
box provided.
Continuous enrollment requirement not met due to start date of SPA
Other: If selected, please specify if there is another reason why your state cannot report
the measure. If this option is selected, provide an explanation of the other reason why
data are reported in the text box provided.
Measurement Specification
The template provides two sections for entering the data (i.e. numerators, denominators, and
rates for each measure or component), depending on whether you are reporting using the
technical specifications provided by the measure steward 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/Comments on Measure” section, below. “Additional Notes/Comments on
Measure” may be entered but is not required. Please note that some measures require reporting of
multiple rates.
Select one of the following options to indicate the measure specifications used for this measure.
CMS
Other
o If selected, explain what other measurement specifications were used. If the
specifications of a different measure steward were used, include the name of the
measure steward and version of the specifications used.
2013 NF-HH: Nursing Facility Utilization
Note: Depending on the measurement specification selected, either the “Performance Measure”
section (for CMS) or the “Other Performance Measure” section (for Other) will display
further down in the screen.
Data Source
Select one or more of the options listed to indicate the source of data or methodology used to
calculate the measure.
Administrative Data
o If selected, also select one or both of the following sub-options:
Medicaid Management Information System (MMIS)
Other
If selected, specify the other source of administrative data used in
the text box provided.
Other
o If selected, specify the other data source in the text box provided.
Date Range
Define the date range for the reporting period:
First enter the “Start Date” of the reporting period.
Next, enter the “End Date” of the reporting period.
Note: The “Start Date” should be the month and year that corresponds to the beginning period in
which utilization took place. The “End Date” should be 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, as this may be different from the period
corresponding to utilization of services.
If the measure includes utilization of services during the measurement year and prior
year(s) (the “look-back period”), the full measurement period for utilization should be
reported. That is the “Start Date” should be month and year that corresponds to the
beginning of the “look-back period.”
Definition of Population Included in the Measure
Indicate the definition of the population included in the denominator for this measure by
checking one or more of the following population options:
o Denominator includes Medicaid population
o Denominator includes Medicare and Medicaid Dually-Eligible population
o Other – if selected, specify what other population was included in the text box
provided.
o Next, select “Y” or “N” as to whether the denominator represents the total measure
eligible population as defined by the technical specifications for this measure.
2013 NF-HH: Nursing Facility Utilization
o If “N” is selected, first explain which populations are excluded and the reason
they are excluded in the text box provided
Specify the total measure eligible population in the text box provided.
Performance Measure
This section displays only if “CMS” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
A description of the measure from the Technical Specifications and Resource Manual will
display, followed by two tables.
In the first table, enter the number of Enrollee Months (denominator) for each age group.
In the second table:
o Enter for each age group (provided you have the data):
The Number of Short Term Admissions (numerator)
The Short Term Admissions/1000 Enrollees Months (rate)
The Number of Long Term Admissions (numerator)
The Long Term Admissions/1000 Enrollee Months (rate)
o Enter the total for each column
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one of the N/D/R sets displayed on the screen. The total must also
be entered.
If any of the N/D/R sets are left blank, for each classification (N/D/R set) left blank, enter an
explanation as to why data was not entered in the text box provided.
2013 NF-HH: Nursing Facility Utilization
Reporting on Ages 65 and Older
If data (N/D/R) is reported by the state for ages 65 and older and "Denominator includes
Medicare and Medicaid Dually-Eligible population" was not selected in "Definition of
Population Included in the Measure", the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was not
selected in the "Definition of Population Included in the Measure". Is the Medicare and
Medicaid Dually-Eligible population included in this denominator?”
If “Y” is selected, you must return to the "Definition of Population Included in the
Measure" and select "Denominator includes Medicare and Medicaid Dually-Eligible
population".
If “N” is selected, enter an explanation why "Denominator includes Medicare and
Medicaid Dually-Eligible population" was not selected (i.e. was not included in the
population) in the text box provided
If "Denominator includes Medicare and Medicaid Dually-Eligible population" was selected in
"Definition of Population Included in the Measure", but no data (N/D/R) for ages 65 and older
was entered, the following question will display:
“The option "Denominator includes Medicare and Medicaid Dually-Eligible population" was
selected in the "Definition of Population Included in the Measure" section, however no data were
reported for the population age 65 and older. Are data available for population age 65 and over?”
If “Y” is selected, you must either:
1. Enter a N/D/R for this age group;
2. Explain why data were not reported for age 65 and older (for example if the 65
and older age group were combined with the 18-64 age group) in the text box
provided; or
3. Return to the "Definition of Population Included in the Measure" to re-visit the
selections.
If “N” is selected, either return to the "Definition of Population Included in the Measure"
section and de-select the option "Denominator includes Medicare and Medicaid DuallyEligible population" or provide an explanation in the text box provided.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Deviation from Measure Specifications
This section displays only when the measure is being reported in adherence to the Medicaid
Health Homes Core Set technical specifications provided by the measure steward (e.g., NCQA,
AHRQ, CMS) in the “Measurement Specification” section.
2013 NF-HH: Nursing Facility Utilization
Select “Y” or “N” to the question, “Did your calculation of the measure deviate from the
measure specification in any way?”
If “Y” is selected, for each rate reported in the “Performance Measure” section, the name
of the rate reported (e.g. Age Range: 18-64) will display, with the following options
displayed under each:
o Numerator
o Denominator
o Other
Select one or more of the options. At least one option must be selected.
o For each option selected, provide an explanation of the deviation in the text box
provided.
Note: Examples of deviations include: coding issues (numerator); different age groups,
definition of continuous enrollment (denominator)
Other Performance Measure
This section displays only if “Other” was selected in the “Measurement Specification” section.
Note: The reporting unit for each measure is the state Health Home program as a whole. States
reporting the Health Home Core Set measures should collect data across all Health Home
providers within a specific Health Home program, as defined by the approved SPA
applicable to the program. States should aggregate data from all Health Home providers
into one Health Home program-level rate before reporting data to CMS. States with more
than one SPA should report separately for each Health Home program, as defined in their
SPA.
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/Comments on Measure,
below.”
First, provide a description of the other methodology used in the text box provided.
Enter a description of the rate (e.g., 18-64) you are reporting in the text box provided.
o Enter the numerator, denominator and rate.
If administrative data was used as the only data source enter the numerator
and denominator. The system will calculate and auto-fill the rate.
If a data source other than administrative data or in combination with
administrative data was used, enter the numerator, denominator, and rate.
To add more rates, click on the plus (+) button next to text box labeled “Please describe
the rate (e.g., 18-64):” and repeat the process.
2013 NF-HH: Nursing Facility Utilization
Note: At least one rate must be provided, i.e. numerator, denominator and rate information must
be entered for at least one N/D/R set. Also, the total must be entered.
If the form fields do not provide enough space to fully report on the measure, the state may, at its
option, use this section to provide additional information.
The information may be entered in the text box provided.
Optional Measure Stratification
At its option, the state may report stratified data for this measure if available, according to the
following additional classifications/sub-categories:
Race (Non-Hispanic)
Ethnicity
Sex
Primary Spoken Language
Disability Status
Geography
Enter a description of the first or only rate (e.g., 18-64) you are reporting in the text box
provided.
o Enter the numerator, denominator, and rate.
o If administrative data was used as the only data source, for each classification you
are reporting, enter the numerator and denominator. The system will calculate and
auto-fill the rate.
o If a data source other than administrative data or in combination with
administrative data was used, for each classification you are reporting, enter the
numerator, denominator and rate.
To add more rates, click on the plus (+) button next to text box labeled “Please describe
the additional/alternative classification/sub-category (e.g., 19-64):” and repeat the
process.
Final Comments (Optional)
At its option, the state may enter any additional summary comments to more fully describe the
reporting for this measure.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
2013 NF-HH: Nursing Facility Utilization
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If a selection is not made for Yes/No questions, an error message will display.
If any of the requested/required data is not entered, an error message will display.
When presented with options for selection, if at least one option is not selected, an error
message will display.
If information is not entered for non-optional text boxes (e.g. explanation of “Other”) an
error message will display.
Not Reporting on Measure: If the number entered for “Small Sample Size” is not less
than (<) 30, an error message will display.
Technical Assistance: If requesting technical assistance for the current from the
administrative screen, if information is not entered in the “Subject” and “Message”
fields, an error message will display and the email cannot be sent.
Date Range:
o If the “End Date” is not later than the “Start Date”, an error message will display.
o If both the “End Date” and the “Start Date” are not in the past, an error message
will display.
Performance Measure/Other Performance Measure:
o If completion of at least one set of Numerator/Denominator/Rate (numeric entry,
other than zero, in all three fields) is not entered, an error message will display.
o If the total N/D/R set is not completed, an error message will display.
o If partial completion of Numerator/Denominator/Rate (i.e. only one or two fields
have a numeric entry other than zero), an error message will display.
o Performance Measure/Other Performance Measure/Optional Measure Stratification:
o If the number entered for the numerator is larger than the number entered for the
denominator for completed N/D/R sets, an error message will display.
o The system will not allow a number entry for the rate that includes more than one
decimal place.
o The system will not allow the number entered for the rate to be a number other
than a number between 0.0 and 100.0.
o The user will not be permitted to enter non-numeric values in the N/D/R fields.
o For all data sources, the system will not allow entry of numerator and
denominator that is not a whole number.
o Optional Measure Stratification:
2013 NF-HH: Nursing Facility Utilization
o For each selected category (classification), if completion of at least one set of
Numerator/Denominator/Rate (numeric entry, other than zero, in all three fields)
is not entered, an error message will display.
o For each selected category (classification), if partial completion of
Numerator/Denominator/Rate (i.e. only one or two fields have a numeric entry
other than zero), an error message will display.
(
2013 Health Homes State-Specific Measures
POLICY CITATION
Statute: Section 1945 of the Social Security Act, Section 2703 of the Affordable Care Act
BACKGROUND
In addition to reporting on the Health Homes core and utilization measures, CMS expects that
states will report on Health Homes state-specific goals and measures identified by individual
states. The intent of the state-specific goals and measures is to allow states to use existing quality
metrics to measure Health Homes outcomes. These goals and measures should relate
specifically to the Health Homes program and can be used to measure the success of the
particular program’s design. All of the quality data will be utilized by CMS to work with states
and other stakeholders to continually improve Health Homes.
TECHNICAL GUIDANCE
Technical Assistance
Technical assistance from the Technical Assistance and Analytic Support mailbox is available
from the administrative screen as well as from each individual quality measure screen. Technical
assistance can be requested at any point in time by clicking on the “Request Technical
Assistance” link on the top right hand corner of the screen.
When accessing Technical Assistance from the administrative screen:
First, respond to the question “Do you have a Technical Assistance request for the
Technical Assistance and Analytic Support mailbox in the current year?”
o If “Y” is selected, the system will pre-populate the name and email address in the
“From” field from the State Profile information provided by the state.
o Enter an email address in the “cc” field at your option.
o Enter a topic name in the “Subject” field.
o Enter the reason for the assistance request in the “Message” field.
o After all the information is entered and you are ready to send the email, click on
the “Send Email” button.
Next, respond to the question “Do you want Technical Assistance with reporting this
measure in a future year?”
o If “Y” is selected, this quality measure will be flagged in a CMS report to provide
the state with future technical assistance.
2013 Health Homes State-Specific Measures
Health Homes State-Specific Goals and Measures
In this section, enter the goal(s) for the Health Homes program on which you are reporting. You
must enter at least one goal for the program, and may enter more than one goal, up to five.
Name the goal and enter a more detailed description. After you have entered the first goal, enter
the measure(s) corresponding to that goal. Name the measure and enter a more detailed
description. The measure description should include the description of the population (ex. age
ranges) included in the measure as well as data source(s). You must enter at least one measure
related to the goal, and may enter more than one, up to five. For each measure that you enter,
complete the Performance Measure section, below. Continue to enter goals, if you have more
than one, and after each goal, enter its corresponding measure(s) and the Performance Measure
section.
Performance Measure
This section must be entered for each measure you have described above. You must complete at
least one numerator, denominator and rate (N/D/R) set for each measure. You may complete as
many N/D/R sets for each measure as you need. For each N/D/R set, enter text to describe the
numerator and denominator.
Upload
This section provides an option to upload supporting documentation for the measure by clicking
on the “Upload” button. For each document uploaded, provide a description of the document
(e.g. document name) in the text box provided.
Validations
The following describes validations applicable to this measure. To trigger the validation, click on
the Validation button at the bottom of the screen. If anything is missing or incorrect (based on
the programmed edits), an error message will appear. Make sure to fix any problems and
continue to click the Validation button until there are no error messages. This will cause the
status of the quality measure to change to “Complete.” All quality measures must be in
Complete status in order for the report to be sent on.
If no goal is entered, an error message will display.
If the user attempts to enter a sixth goal, an error message will display.
If no measure is entered for a goal, an error message will display.
If the user attempts to enter a sixth measure for one goal, an error message will display.
If the user does not enter at least one complete N/D/R set for a measure, an error message
will display.
The user will not be permitted to enter non-numeric values in the N/D/R fields.
| File Type | application/pdf |
| Author | Nancy Blickenstaff |
| File Modified | 2016-06-20 |
| File Created | 2015-07-24 |