Memo - Updated Requirements for Reporting of 2013 Measures

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850

CENTER FOR MEDICARE
DATE:

August 3, 2012

TO:

Medicare Advantage and 1876 Cost Contracts Quality Contacts and Medicare
Compliance Officers

FROM:

Cynthia G. Tudor, Ph.D., Director, Medicare Drug Benefit and C & D Data Group
Danielle R. Moon, J.D., M.P.A., Director, Medicare Drug & Health Plan Contract
Administration Group

SUBJECT:

Updated Requirements for Reporting of 2013 HEDIS®, HOS and CAHPS® Measures

Overview
This memorandum contains the Healthcare Effectiveness Data Information Set (HEDIS) measures
required to be reported by all Medicare Advantage Organizations (MA organizations or MAOs) and
other organization types in 2013. It also includes information about which contracts are required to
participate in the Medicare Health Outcomes Survey (HOS) and Consumer Assessment of
Healthcare Providers and Systems (CAHPS) Survey. Sections 422.152 and 422.516 of Volume 42
of the Code of Federal Regulations (CFR) state that Medicare Advantage (MA) contracts must
submit performance measures as specified by the Department of Health & Human Services (DHHS)
Secretary and the Centers for Medicare & Medicaid Services (CMS). HOS requirements are
updated in this version and can be found in the HOS section in italics.
HEDIS 2013 Requirements
In 2013 (the reporting year), the National Committee for Quality Assurance (NCQA) will collect
data for services covered in 2012 (the measurement year). NCQA publishes detailed specifications
for HEDIS measures in HEDIS® 2013, Volume 2, Technical Specifications for Health Plans.
All HEDIS 2013 measures must be submitted to NCQA by 11:59 p.m. Eastern Time on June 17,
2013. Please note that late submissions will not be accepted. If an organization (contract/plan) does
not submit HEDIS data by June 17, 2013, they will automatically receive a rating of one star for
each HEDIS measure used to populate the Plan Ratings in Medicare Plan Finder (in the fall of
2013). MA ratings affect MA Quality Bonus Payments.

For the reporting year of 2013, MAOs and other organization types listed in Table 1 must submit
audited, summary-level HEDIS data to NCQA. Table 1 also indicates which organization types
need to report CAHPS and HOS data.
Table 1: 2013 Performance Measure Reporting Requirements
2013 Performance Measure Reporting Requirements
Organization Type
CAHPS HEDIS HOS HOS-M
1876 Cost




Chronic Care (not Demonstration)




Employer/Union Only Direct Contract PFFS




HCPP-1833 Cost




Local Coordinated Care Plans (CCP)




MSA




National PACE




PFFS




Regional CCP




RFB PFFS




RFB Local CCP




 = Not required to report
 = Required to report
All contracts marked as required to report in Table 1, and whose contract effective date is January 1,
2012 or earlier are required to collect and submit HEDIS summary data to CMS. The minimum
enrollment requirement from previous HEDIS data collections has been eliminated so quality data
are available for all contracts.
If your Health Plan Management System (HPMS) contract status is listed as a consolidation, a
merger, or a novation during the measurement year, the surviving contract must report HEDIS data
for all members of all contracts involved. If a contract status is listed as a conversion in the
measurement year, the contract must report if their new organization type is required to report.
All 1876 Cost contracts are required to report HEDIS regardless of their enrollment closure status.
All contracts are also required to submit Patient-Level Detail (PLD) files to the designated CMS
contractor. CMS expects these files to contain the details of the data used for the contracts’
summary data submission. More details about the patient-level data submission will be forthcoming
in a separate memorandum.
In 2013, CMS will continue collecting audited data from each Plan Benefit Package (PBP)
designated as a Special Needs Plan (SNP). The SNP must have had 30 or more members enrolled as
listed in the February 2012 SNP Comprehensive Report (the report can be found at this link:
http://www.cms.hhs.gov/MCRAdvPartDEnrolData/SNP/list.asp#TopOfPage). SNP PBPs which
meet the enrollment criteria must also exist in both the measurement year and reporting years. PBPs
which end as of December 31, 2012 are not required to report, but may still do so voluntarily.
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Contracts with SNP PBPs do not have to report any additional PLD files. The PLD for the contract
level data includes the data about the SNP PBPs.
MAOs that are new to HEDIS must become familiar with the requirements for data submission to
NCQA, and make the necessary arrangements as soon as possible. All information about the HEDIS
audit compliance program is available at http://www.ncqa.org/tabid/204/Default.aspx.
Please note that MAOs should refer to this memorandum for CMS Medicare HEDIS reporting
requirements, rather than to the NCQA website or any other third-party source. The measures to be
reported in HEDIS 2013 are summarized in Table 2.
Please address all questions on the measures, reporting or submission requirements to the CMS
mailbox at: [email protected].
Table 2: HEDIS 2013 Measures for Reporting by Organization Types

HEDIS 2013 Measures for Reporting

ABA
BCS
COL
GSO
COA
SPR
PCE
CMC
CBP
PBH
CDC
ART
OMW
AMM
FUH

Effectiveness of Care
Adult BMI Assessment
Breast Cancer Screening
Colorectal Cancer Screening
Glaucoma Screening in Older Adults
Care for Older Adults (SNP-only measure)
Use of Spirometry Testing in the Assessment and
Diagnosis of Chronic Obstructive Pulmonary Disease
(COPD)
Pharmacotherapy Management of COPD
Exacerbation
Cholesterol Management for Patients With
Cardiovascular Conditions
Controlling High Blood Pressure
Persistence of Beta-Blocker Treatment After a Heart
Attack
Comprehensive Diabetes Care 1
Disease Modifying Anti-Rheumatic Drug Therapy in
Rheumatoid Arthritis
Osteoporosis Management in Women Who Had a
Fracture
Antidepressant Medication Management
Follow-up After Hospitalization for Mental Illness

3

MA HMO,
§1876
MSA, PFFS,
Cost
E-PFFS & PPO Contracts
Contracts

SNP*
PBPs

X
X
X
X

X
X
X
X

X
X
X

X

X

X

X

X

X

X

X

-

X

X

X

X

X

X

X

X

-

X

X

-

X

X

X

X
X

X
X

X
X

Table 2: HEDIS 2013 Measures for Reporting by Organization Types

HEDIS 2013 Measures for Reporting

MPM
MRP
DDE
DAE
HOS
FRM
MUI
OTO
PAO
FSO
MSC
PNU

AAP
IET
CAT

Annual Monitoring for Patients on Persistent
Medications
Medication Reconciliation Post-Discharge (SNP-only
measure)
Potentially Harmful Drug-Disease Interactions in the
Elderly
Use of High-Risk Medications in the Elderly
Medicare Health Outcomes Survey
Falls Risk Management (collected in Medicare
Health Outcomes Survey)
Management of Urinary Incontinence in Older Adults
(collected in Medicare Health Outcomes Survey)
Osteoporosis Testing in Older Women (collected in
Medicare Health Outcomes Survey)
Physical Activity in Older Adults (collected in
Medicare Health Outcomes Survey)
Flu Shots for Older Adults (collected in CAHPS)
Medical Assistance With Smoking Cessation
(collected in CAHPS)
Pneumonia Vaccination Status for Older Adults
(collected in CAHPS)
Access /Availability of Care
Adults’ Access to Preventive/Ambulatory Health
Services
Initiation and Engagement of Alcohol and Other
Drug Dependence Treatment
Call Answer Timeliness

4

MA HMO,
§1876
MSA, PFFS,
Cost
E-PFFS & PPO Contracts
Contracts

SNP*
PBPs

X

X

X

-

-

X

X

X

X

X
X

X
X

X
X*

X

X

X*

X

X

X*

X

X

X*

X

X

X*

X

X

X

X

X

X

X

X

X

X

X

X

FSP
AMB
IPU
IAD
MPT
ABX
PCR
BCR
ENP
EBS
LDM
RDM
TLM

Utilization and Relative Resource Use**
Frequency of Selected Procedures
Ambulatory Care
Inpatient Utilization - General Hospital/Acute Care
Identification of Alcohol and Other Drug Services
Mental Health Utilization
Antibiotic Utilization
Plan All-Cause Readmissions
Health Plan Descriptive Information
Board Certification
Enrollment by Product Line
Enrollment by State
Language Diversity of Membership
Race/Ethnicity Diversity of Membership
Total Membership

1

X
X
X
X
X
X
X

X
X
X
X
X
X

X
X
X
X
X
X

X
X
X
X
X
X

X
X

HbA1c control <7% for a selected population is not required for Medicare contracts.
* Contracts with exclusively SNP plan benefit packages – see also specific HOS requirements in
this memorandum.
** 1876 Cost Contracts do not have to report the inpatient measures since they do not have inpatient
claims.

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2013 HOS and HOS-M Reporting Requirements
Who Must Report HOS
The following types of MAOs and other organization types with Medicare contracts in effect on or
before January 1, 2012 are required to report the Baseline HOS in 2013, provided that they have
a minimum enrollment of 500 members:
•
•
•
•
•

All Coordinated Care contracts, including health maintenance organizations (HMOs), local
and regional PPOs and contracts with exclusively SNP plan benefit packages
Continuing cost contracts that held §1876 cost contracts with open enrollment
PFFS contracts
MSA contracts
Employer/Union Only Direct Contract PFFS contracts

In addition, all MAOs that reported a Cohort 14 Baseline Survey in 2011 are required to administer
a Cohort 14 Follow-up Survey in 2013.
To report HOS, all organizations must contract with an NCQA-certified HOS survey vendor and
notify NCQA of their survey vendor choice no later than January 18, 2013. You will receive
further correspondence from NCQA regarding your HOS participation.
If the above organizations do not submit HOS data they will automatically receive a rating of one
star for the HOS data that are updated on Medicare Plan Finder, which also impacts the MA Quality
Bonus Payments.
Optional HOS Reporting for FIDE SNPs
MAOs sponsoring fully integrated dual eligible (FIDE) SNPs may elect to report HOS at the FIDE
SNP level to determine eligibility for a frailty adjustment payment under the Affordable Care Act,
similar to those payments provided to PACE programs. Voluntary reporting will be in addition to
standard HOS requirements for quality reporting at the contract level.
Who Must Report HOS-M
The HOS-M is an abbreviated version of the Medicare HOS. The HOS-M assesses the physical and
mental health functioning of the beneficiaries enrolled in PACE Programs to generate information
for payment adjustment.
All PACE Programs with Medicare contracts in effect on or before January 1, 2012 are required by
CMS to administer the HOS-M survey in 2013, provided that they have a minimum enrollment of
30 members.
To report HOS-M, eligible plans must contract with the CMS-certified HOS-M survey vendor, no
later than January 18, 2013. You will receive further correspondence from NCQA regarding your
HOS-M participation.
For additional information on 2013 HOS or HOS-M reporting requirements, please email
[email protected].
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CAHPS Survey Requirements
The following types of organizations are included in the CAHPS survey administration provided
that they have a minimum enrollment of 600 eligible members as of July 1, 2012:
•
•
•

All MAOs, including all coordinated care contracts, PPOs, PFFS contracts and MSA
contracts
Section 1876 (§1876) cost contracts even if they are closed for enrollment
Employer/union only contracts

PACE and HCPP 1833 cost contracts are excluded from the CAHPS administration.
MAOs are required to contract with an approved MA & PDP CAHPS vendor for the 2013 survey
administration. Approved CAHPS survey vendors are listed on www.MA-PDPCAHPS.org. CMS
will issue additional HPMS memorandums about the CAHPS survey for 2013.
If an approved CAHPS vendor does not submit a contract’s CAHPS data by the data submission
deadline of June 13, 2013, the contract will automatically receive a rating of one star for the
required CAHPS measures for the data that are updated on Medicare Plan Finder (in the fall of
2013), which also impacts the MA Quality Bonus Payments.
For additional information on the CAHPS survey, please email [email protected].

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