CMS-10398 #45 Maternal and Infant Health (MIH) Quality Screenshot #6 (

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

MIH_2015_Postpartum Women_6

GenIC #45 (Extension w/o change): Maternal and Infant Health Quality

OMB: 0938-1148

Document [pdf]
Download: pdf | pdf
10/1/2015

Annual Report Admin Screen

Maternal and Infant Health Initiative Developmental Measure: Use of
Contraceptive Methods by Postpartum Women
Medicaid Adult Core Quality Measure ­ OR ­ 2015

Federal Fiscal Year

Request Technical Assistance

Clear

View All Responses

2015
Are you reporting on this measure? *

View Implementation Guide

Yes
No

Status of Data Reported
+/­
What is the status of the data being reported? *
Provisional
Final
Same data as reported in a previous year’s annual report
Specify the year of annual report in which data previously reported *
2014

Measurement Specification
+/­
Rate 1: Most effective or moderately effective contraception
Office of Population Affairs/Centers for Disease Control and Prevention
Other
Explain *

Rate 2: Long­acting reversible contraception
Office of Population Affairs/Centers for Disease Control and Prevention
Other
Explain *

Data Source
+/­
Rate 1: Most effective or moderately effective contraception
Administrative Data

From where is the Administrative Data coming?
Must select one or more

Medicaid Management Information System (MMIS)
Other

* Specify

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Other

Rate 2: Long­acting reversible contraception
Administrative Data

Specify *

From where is the Administrative Data coming?
Must select one or more

Medicaid Management Information System (MMIS)
Other

* Specify

Other

Specify *

Date Range
+/­
For all measures, states should report start and end dates for the measurement period. For some measures, the specifications require a “look­back period” 
before or after the measurement period to determine eligibility or utilization. The measurement period entered in the Start and End Date fields should not 
include the “look­back period."
Start Date
April
Month

2009
Year

End Date
August
Month

2013
Year

Definition of Population Included in the Measure
+/­
Definition of Denominator
Select all that apply (Must select at least one)
Denominator includes Medicaid population
Denominator includes CHIP population (e.g. pregnant women.)
Denominator includes Medicare and Medicaid Dually­Eligible population
Other
Specify *

Does this denominator represent your total measure eligible population as defined by the Technical Specifications for this measure? *
Yes
No

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Which delivery systems are represented in the Denominator?
Select all delivery systems that apply in your state (must select at least one); for each delivery system selected, enter the percentage of the measure eligible population
represented by that service delivery system. For example, if the measure­eligible population represents all managed care enrollees, enter 100 percent for MCO.

Fee­for­Service

Percentage of total state FFS population represented *

The percentage provided here should represent the percentage of the denominator
population(s) included in the measure (i.e., Medicaid, CHIP, etc.) that receives
items/services through the selected delivery system. For example, if the population
included in the reported data represents all managed care enrollees and half of
your state’s fee­for­service enrollees, select managed care and enter 100, and
select fee­for­service and enter 50.

Primary Care Case Management (PCCM)

Percentage of total state PCCM population represented *

The percentage provided here should represent the percentage of the denominator
population(s) included in the measure (i.e., Medicaid, CHIP, etc.) that receives
items/services through the selected delivery system. For example, if the population
included in the reported data represents all managed care enrollees and half of
your state’s fee­for­service enrollees, select managed care and enter 100, and
select fee­for­service and enter 50.

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

Number of Health Plans *

Percentage of total state MCO/PIHP population represented *

The percentage provided here should represent the percentage of the denominator
population(s) included in the measure (i.e., Medicaid, CHIP, etc.) that receives
items/services through the selected delivery system. For example, if the population
included in the reported data represents all managed care enrollees and half of
your state’s fee­for­service enrollees, select managed care and enter 100, and
select fee­for­service and enter 50.

Integrated Care Models (ICM)

Percentage of total state ICM population represented *

The percentage provided here should represent the percentage of the denominator
population(s) included in the measure (i.e., Medicaid, CHIP, etc.) that receives
items/services through the selected delivery system. For example, if the population
included in the reported data represents all managed care enrollees and half of
your state’s fee­for­service enrollees, select managed care and enter 100, and
select fee­for­service and enter 50.

Other

Describe *

Percentage of total other population represented *

The percentage provided here should represent the percentage of the denominator
population(s) included in the measure (i.e., Medicaid, CHIP, etc.) that receives
items/services through the selected delivery system. For example, if the population
included in the reported data represents all managed care enrollees and half of
your state’s fee­for­service enrollees, select managed care and enter 100, and
select fee­for­service and enter 50.

If applicable, list the number of Health Plans represented *

Other Performance Measure
+/­
Rate 1: Most effective or moderately effective contraception
Please describe the other methodology used *

Character count: 0/100

https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3MqN…

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Please describe the rate (e.g.,
18­64)

Annual Report Admin Screen
Numerator

Denominator

Rate

No items available

+ Additional/Other Rate(s)
Rate 2: Long­acting reversible contraception
Please describe the other methodology used *

Character count: 0/100

Please describe the rate (e.g.,
18­64)

Numerator

Denominator

Rate

No items available

+ Additional/Other Rate(s)

Combined Rate(s) from Multiple Reporting Units
+/­
Rate 1: Most effective or moderately effective contraception

If yes, indicate whether the state­level rate is weighted

Did you Combine Rates from Multiple Reporting Units (e.g., health
plans, delivery systems, programs) to Create a State­Level Rate?  *

Must select one *

Yes
No

The rates are weighted based on the size of the measure­eligible
population for each reporting unit
The rates are weighted based on another weighting factor
The rates are not weighted

Rate 2: Long­acting reversible contraception

If yes, indicate whether the state­level rate is weighted

Did you Combine Rates from Multiple Reporting Units (e.g., health
plans, delivery systems, programs) to Create a State­Level Rate?  *

Must select one *

Yes
No

The rates are weighted based on the size of the measure­eligible
population for each reporting unit
The rates are weighted based on another weighting factor
The rates are not weighted

Additional Notes
+/­

Rate 1: Most effective or moderately effective contraception
Additional Notes/Comments on Measure (Optional)

Character count: 0/2000

Rate 2:  Long­acting reversible contraception
Additional Notes/Comments on Measure (Optional)

Character count: 0/2000

Optional Measure Stratification
https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3MqN…

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Optional Measure Stratification

+/­
If this measure is also reported by additional classifications/sub­categories, e.g. racial, ethnic, gender, language, disability status, or geography, 
complete the following as applicable.
Check all that apply
Race (Non­Hispanic)
White
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

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Row

0

0

0

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Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Black or African American
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
American Indian or Alaska Native
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3MqN…

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Age Range: 15­20

0

0

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Row

Age Range: 21­44

0

0

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Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Asian
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Native Hawaiian or Other Pacific Islander
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception

https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3MqN…

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Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Please define the race *

Delete Race

dd
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

0

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Row

Age Range: 21­44

0

0

0

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Row

0

0

0

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Row

 

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

0

Clear
Row

Age Range: 21­44

0

0

0

Clear
Row

0

0

0

Clear
Row

 

+ Additional/Alternative Classification/Sub­category
+ Additional Race(s)
Ethnicity
Hispanic or Latino
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3MqN…

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0

0

0

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Row

+ Additional/Alternative Classification/Sub­category
Not Hispanic or Latino
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

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Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

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Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Please define the ethnicity *

Delete Ethnicity

ff
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

0

Clear
Row

Age Range: 21­44

0

0

0

Clear
Row

0

0

0

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Row

 

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

0

Clear
Row

Age Range: 21­44

0

0

0

Clear
Row

0

0

0

Clear
Row

 

+ Additional/Alternative Classification/Sub­category
+ Additional Ethnicity(ies)
Sex

https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3MqN…

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Male

Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

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Row

Age Range: 21­44

0

0

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Row

0

0

0

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Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Female
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Primary Spoken Language
English
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

Clear
Row

Age Range: 21­44

0

0

Clear
Row

https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3MqN…

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0

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+ Additional/Alternative Classification/Sub­category
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Classification/Sub­category

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Denominator

Rate

Age Range: 15­20

0

0

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Row

Age Range: 21­44

0

0

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Row

0

0

0

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Row

+ Additional/Alternative Classification/Sub­category
Spanish
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

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Row

Age Range: 21­44

0

0

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Row

0

0

0

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Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

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Row

Age Range: 21­44

0

0

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Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Please define the language *

Delete Language

df
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

0

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Row

Age Range: 21­44

0

0

0

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Row

0

0

0

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Row

 

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category
Age Range: 15­20

Numerator

Denominator

Rate

0

0

0

Clear
Row

https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3Mq…

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Age Range: 21­44

 

0

0

0

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Row

0

0

0

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Row

+ Additional/Alternative Classification/Sub­category
+ Additional Primary Spoken Language(s)
Disability Status
SSI
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

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Row

Age Range: 21­44

0

0

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0

0

0

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+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

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Rate

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0

0

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Row

Age Range: 21­44

0

0

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Row

0

0

0

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+ Additional/Alternative Classification/Sub­category
Non­SSI
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

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Row

Age Range: 21­44

0

0

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0

0

0

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Row

+ Additional/Alternative Classification/Sub­category
Rate 2: Long­acting reversible contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

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Row

Age Range: 21­44

0

0

Clear
Row

0

0

0

Clear
Row

+ Additional/Alternative Classification/Sub­category
Please define the disability status *

https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3Mq…

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Please define the disability status *

Delete Disability Status

gh
Rate 1: Most effective or moderately effective contraception
Classification/Sub­category

Numerator

Denominator

Rate

Age Range: 15­20

0

0

0

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Age Range: 21­44

0

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+ Additional/Alternative Classification/Sub­category
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Geography
Urban
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+ Additional/Alternative Classification/Sub­category
Rural
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+ Additional/Alternative Classification/Sub­category
Please define the geographical region *

Delete Geographical Region

kl
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+ Additional/Alternative Classification/Sub­category
+ Additional Geographical Region(s)
Program Authority
Waiver/SPA
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https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3Mq…

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+ Additional/Alternative Classification/Sub­category
General Medicaid
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+ Additional/Alternative Classification/Sub­category
Delivery System
Managed Care
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+ Additional/Alternative Classification/Sub­category
Primary Care Case Management(PCCM)
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Classification/Sub­category

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+ Additional/Alternative Classification/Sub­category
Please describe the stratification

Other

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Classification/Sub­category

Numerator

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https://gmacbistest.appiancloud.com/suite/tempo/actions/item/ksBbrxGjzbwMkxqSHejGZN_ZSosJLv6Nrrrb8n7aYwTAzlYDD­POsL­zSgvZF_z5YQuT3Mq…

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+ Additional/Alternative Classification/Sub­category

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