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pdfSection 1115 Eligibility and Coverage
Demonstrations Monitoring Metrics
Technical Specifications
Version 1
June 27, 2019
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TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
CONTENTS
METRICS ..................................................................................................................................................... vii
ACRONYMS ................................................................................................................................................xv
I
BACKGROUND AND INTRODUCTION .......................................................................................... 1
A. Overview of eligibility and coverage monitoring metrics............................................................ 1
B. Reporting eligibility and coverage demonstration monitoring metrics ..................................... 16
C. Using technical specifications.................................................................................................. 22
II
TECHNICAL SPECIFICATIONS .................................................................................................... 23
A. Metrics to be reported for any demonstration with premiums, premium assistance,
health behavior incentives, community engagement requirements, or retroactive
eligibility waivers ...................................................................................................................... 23
1. Enrollment ......................................................................................................................... 23
2. Mid-year loss of demonstration eligibility .......................................................................... 27
3. Enrollment duration at time of disenrollment .................................................................... 29
4. Renewal ............................................................................................................................ 31
5. Cost sharing limit............................................................................................................... 35
6. Appeals and grievances .................................................................................................... 35
7. Access to care ................................................................................................................... 38
8. Quality of care and health outcomes ................................................................................ 45
9. Administrative cost ............................................................................................................ 51
B. Additional metrics to be reported for demonstrations that require premiums or
account payments ................................................................................................................... 52
1. Enrollment by premium payment status............................................................................ 52
2. Cumulative enrollment duration in states with time-variant premium policies .................. 55
3. Mid-year change in circumstance by premium amount .................................................... 57
4. Disenrollment or suspension for failure to pay .................................................................. 59
5. Renewal ............................................................................................................................ 60
6. Third party premium payment ........................................................................................... 62
C. Additional metrics to be reported for demonstrations with Marketplace-focused
premium assistance programs ................................................................................................ 62
1. Enrollment by premium payment status............................................................................ 62
2. Access to care ................................................................................................................... 63
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D. Additional metrics to be reported for demonstrations with health behavior incentives ........... 64
1. Enrollment ......................................................................................................................... 64
2. Use of incentivized services: Claims-based analysis ....................................................... 64
3. Other incentivized behaviors not documented through claims-based analysis ................ 65
4. Rewards granted for completion of incentivized health behaviors ................................... 66
E. Additional metrics to be reported for demonstrations with community engagement
requirements ............................................................................................................................ 68
1. Community engagement enrollment ................................................................................. 68
2. Community engagement requirement qualifying activities ............................................... 72
3. Basis of beneficiary exemptions from community engagement requirement ................... 77
4. Supports and assistance ................................................................................................... 82
5. Reasonable modifications for beneficiaries with disabilities ............................................. 85
6. New suspensions and disenrollments during the measurement period ........................... 86
7. Reinstatement of benefits after suspension ...................................................................... 87
8. Re-entry after disenrollment .............................................................................................. 90
F. Additional metrics to be reported for demonstrations with retroactive eligibility waivers ........ 93
1. At application ..................................................................................................................... 93
2. At renewal ......................................................................................................................... 93
APPENDIX A ESTABLISHED MEASURES AND MEASURE SETS REFERENCED IN
TECHNICAL SPECIFICATIONS ................................................................................................................A-1
APPENDIX B TECHNICAL SPECIFICATIONS FOR MEDICAID QUALITY MEASURES,
ADAPTED FROM FFY 2019 ADULT CORE SET MEASURE SPECIFICATIONS ...................................B-1
APPENDIX C VALUE SETS REFERENCED IN METRIC SPECIFICATIONS ....................................... C-1
APPENDIX D REFERENCE LIST OF RELATIONSHIPS AMONG METRICS ....................................... D-1
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TABLES
1
Summary of eligibility and coverage metric modules ................................................................... 2
2
Overview of eligibility and coverage metrics standard across any demonstration with
premiums, Marketplace-focused premium assistance, health behavior incentives,
community engagement requirements, or retroactive eligibility waivers ...................................... 4
3
Additional metrics relevant for states that require premiums or account payments ..................... 7
4
Additional metrics relevant for states with Marketplace-focused premium assistance
programs ....................................................................................................................................... 9
5
Additional metrics relevant for states with programs with health behavior incentives ............... 10
6
Additional metrics relevant for states with community engagement requirements .................... 11
7
Additional metrics relevant for states with retroactive eligibility waivers .................................... 15
8
Example of alignment between demonstration years and measurement periods for a
demonstration that began on March 15, 2018 ............................................................................ 17
9
Metric reporting in quarterly and annual monitoring reports, by measurement period
and calculation lag ...................................................................................................................... 20
10
Example of metric reporting in quarterly and annual monitoring reports for the first year
of a demonstration that began on March 15, 2018 ..................................................................... 21
11
Table shell for the metrics’ technical specifications .................................................................... 22
A.1
Established measures and measure sets referenced in metric specifications ..........................A-3
B.1
Measurement period for denominators and numerators for the FFY 2019 Adult Core
Set section 1115 eligibility and coverage monitoring metrics ....................................................B-5
C.1
HEDIS value sets referenced in metric specifications .............................................................. C-3
D.1
Reference list of relationships among metrics for any demonstration with premiums,
premium assistance, health behaviors, community engagement requirements, or
retroactive eligibility waivers ..................................................................................................... D-3
D.2
Reference list of relationships among metrics for demonstrations that require premiums
or account payments ................................................................................................................ D-5
D.3
Reference list of relationships among metrics for demonstrations with Marketplacefocused premium assistance programs .................................................................................... D-6
D.4
Reference list of relationships among metrics for demonstrations with health behavior
incentives .................................................................................................................................. D-7
D.5
Reference list of relationships among metrics relevant for demonstrations with
community engagement requirements ..................................................................................... D-8
D.6
Reference list of relationships among metrics relevant for demonstrations with
retroactive eligibility waivers ................................................................................................... D-11
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METRICS
A.
Metrics to be reported for any demonstration with premiums, premium
assistance, health behavior incentives, community engagement requirements, or
retroactive eligibility waivers .................................................................................................. 23
1.
Enrollment ................................................................................................................................. 23
AD_1
Total enrollment in the demonstration ........................................................................................ 23
AD_2
Beneficiaries in suspension status for noncompliance ............................................................... 23
AD_3
Beneficiaries in a non-eligibility period who are prevented from re-enrolling for a defined
period of time .............................................................................................................................. 24
AD_4
New enrollees ............................................................................................................................. 24
AD_5
Re-enrollments or re-instatements using defined pathways after disenrollment or
suspension of benefits for noncompliance with demonstration policies ..................................... 25
AD_6
Re-enrollments or re-instatements for beneficiaries not using defined pathways after
disenrollment or suspension of benefits for noncompliance ....................................................... 26
2.
Mid-year loss of demonstration eligibility.............................................................................. 27
AD_7
Beneficiaries determined ineligible for Medicaid, any reason, other than at renewal ................ 27
AD_8
Beneficiaries no longer eligible for Medicaid, failure to provide timely change in
circumstance information ............................................................................................................ 27
AD_9
Beneficiaries determined ineligible for Medicaid after state processes a change in
circumstance reported by a beneficiary ...................................................................................... 28
AD_10
Beneficiaries no longer eligible for the demonstration due to transfer to another
Medicaid eligibility group ............................................................................................................. 28
AD_11
Beneficiaries no longer eligible for the demonstration due to transfer to CHIP .......................... 29
3.
Enrollment duration at time of disenrollment ........................................................................ 29
AD_12
Enrollment duration, 0-3 months ................................................................................................. 29
AD_13
Enrollment duration, 4-6 months ................................................................................................. 30
AD_14
Enrollment duration, 6-12 months............................................................................................... 30
4.
Renewal ..................................................................................................................................... 31
AD_15
Beneficiaries due for renewal ..................................................................................................... 31
AD_16
Beneficiaries determined ineligible for the demonstration at renewal, disenrolled from
Medicaid ...................................................................................................................................... 31
AD_17
Beneficiaries determined ineligible for the demonstration at renewal, transfer to another
Medicaid eligibility category ........................................................................................................ 32
AD_18
Beneficiaries determined ineligible for the demonstration at renewal, transferred to
CHIP ........................................................................................................................................... 32
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AD_19
Beneficiaries who did not complete renewal, disenrolled from Medicaid ................................... 33
AD_20
Beneficiaries who had pending/ uncompleted renewals and were still enrolled ........................ 33
AD_21
Beneficiaries who retained eligibility for the demonstration after completing renewal
forms ........................................................................................................................................... 34
AD_22
Beneficiaries who renewed ex parte ........................................................................................... 34
5.
Cost sharing limit ..................................................................................................................... 35
AD_23
Beneficiaries who reached 5% limit ............................................................................................ 35
6.
Appeals and grievances........................................................................................................... 35
AD_24
Appeals, eligibility ....................................................................................................................... 35
AD_25
Appeals, denial of benefits .......................................................................................................... 36
AD_26
Grievances, care quality ............................................................................................................. 36
AD_27
Grievances, provider or managed care entities .......................................................................... 37
AD_28
Grievances, other........................................................................................................................ 37
7.
Access to care .......................................................................................................................... 38
AD_29
Primary care provider availability ................................................................................................ 38
AD_30
Primary care provider active participation .................................................................................. 38
AD_31
Specialist provider availability ..................................................................................................... 39
AD_32
Specialist provider active participation........................................................................................ 39
AD_33
Preventive care and office visit utilization ................................................................................... 40
AD_34
Prescription drug use .................................................................................................................. 41
AD_35
Emergency department utilization, all use .................................................................................. 42
AD_36
Emergency department utilization, non-emergency ................................................................... 43
AD_37
Inpatient admissions ................................................................................................................... 44
8.
Quality of care and health outcomes ...................................................................................... 45
AD_38A Medical Assistance with Smoking and Tobacco Use Cessation (MSC-AD) ............................. 45
AD_38B Preventive Care and Screening Tobacco Use Screening and Cessation Intervention .............. 46
AD_39-1 Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or
Dependence (FUA-AD) ............................................................................................................... 47
AD_39-2 Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD) .............................. 47
AD_40
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment
(IET-AD) ...................................................................................................................................... 48
AD_41
PQI 01: Diabetes Short-Term Complications Admission Rate (PQI01-AD) ............................... 48
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AD_42
PQI 05: Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults
Admission Rate (PQI05-AD) ....................................................................................................... 49
AD_43
PQI 08: Heart Failure Admission Rate (PQI08-AD) .................................................................... 49
AD_44
PQI 15: Asthma in Younger Adults Admission Rate (PQI15-AD) ............................................... 50
9.
Administrative cost .................................................................................................................. 51
AD_45
Administrative cost of demonstration operation .......................................................................... 51
B.
Additional metrics to be reported for demonstrations that require premiums or
account payments .................................................................................................................... 52
1.
Enrollment by premium payment status ................................................................................ 52
PR_1
Beneficiaries subject to premium policy (or account contribution) during the month, not
exempt ........................................................................................................................................ 52
PR_2
Beneficiaries who were exempt from premiums for that month ................................................. 52
PR_3
Beneficiaries who paid a premium during the month.................................................................. 53
PR_4
Beneficiaries who were subject to premium policy but declare hardship for that month ............ 53
PR_5
Beneficiaries in short-term arrears (grace period) ...................................................................... 54
PR_6
Beneficiaries in long-term arrears ............................................................................................... 54
PR_7
Beneficiaries with collectible debt ............................................................................................... 55
2.
Cumulative enrollment duration in states with time-variant premium policies ................. 55
PR_8
Beneficiaries in enrollment duration tier 1 .................................................................................. 55
PR_9
Beneficiaries in enrollment duration tier 2 .................................................................................. 56
PR_10
Beneficiaries in enrollment duration tiers 3+............................................................................... 56
3.
Mid-year change in circumstance by premium amount ....................................................... 57
PR_11
Beneficiaries for whom the state processed a mid-year change in circumstance in
household or income information and who remained enrolled in the demonstration ................. 57
PR_12
No premium change following mid-year processing of a change in household or income
information .................................................................................................................................. 57
PR_13
Premium increase following mid-year processing of change in household or income
information .................................................................................................................................. 58
PR_14
Premium decrease following mid-year processing of change in household or income
information .................................................................................................................................. 58
4.
Disenrollment or suspension for failure to pay ..................................................................... 59
PR_15
Beneficiaries disenrolled from the demonstration for failure to pay and therefore
disenrolled from Medicaid ........................................................................................................... 59
PR_16
Beneficiaries in a non-eligibility period who were disenrolled for failure to pay and are
prevented from re-enrolling for a defined period of time ............................................................ 59
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PR_17
Beneficiaries whose benefits are suspended for failure to pay .................................................. 60
5.
Renewal ..................................................................................................................................... 60
PR_18
No premium change.................................................................................................................... 60
PR_19
Premium increase ....................................................................................................................... 61
PR_20
Premium decrease ...................................................................................................................... 61
6.
Third party premium payment ................................................................................................. 62
PR_21
Third-party premium payment ..................................................................................................... 62
C.
Additional metrics to be reported for demonstrations with Marketplace-focused
premium assistance programs ............................................................................................... 62
1.
Enrollment by premium payment status ................................................................................ 62
PA_1
Beneficiaries who lost Medicaid eligibility due to mid-year change in circumstance, and
transitioned to a qualified health plan offered in the Marketplace .............................................. 62
PA_2
Beneficiaries who lost Medicaid eligibility at renewal, and transitioned to a qualified
health plan offered in the Marketplace ....................................................................................... 63
2.
Access to care .......................................................................................................................... 63
PA_3
Wraparound service utilization, by service ................................................................................. 63
D.
Additional metrics to be reported for demonstrations with health behavior
incentives .................................................................................................................................. 64
1.
Enrollment ................................................................................................................................. 64
HB_1
Total enrollment among beneficiaries subject to health behavior incentives ............................. 64
2.
Use of incentivized services: Claims-based analysis........................................................... 64
HB_2
Beneficiaries using incentivized services that can be documented through claims, by
service ......................................................................................................................................... 64
3.
Other incentivized behaviors not documented through claims-based analysis ............... 65
HB_3
Completion of incentivized health behavior(s) not documented through claims analysis
(i.e health risk assessments), by health behavior ....................................................................... 65
HB_4
Completion of all incentivized health behaviors (both claims-based and other), if there
are multiple ................................................................................................................................. 65
4.
Rewards granted for completion of incentivized health behaviors .................................... 66
HB_5
Beneficiaries granted a premium reduction for completion of incentivized health
behaviors .................................................................................................................................... 66
HB_6
Beneficiaries granted a financial reward other than a premium reduction for completion
of incentivized health behaviors .................................................................................................. 66
HB_7
Beneficiaries granted a reward in the form of additional covered benefits for completion
of incentivized health behaviors .................................................................................................. 67
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E.
Additional metrics to be reported for demonstrations with community
engagement requirements ....................................................................................................... 68
1.
Community engagement enrollment ...................................................................................... 68
CE_1
Total beneficiaries subject to the community engagement requirement, not exempt ................ 68
CE_2
Total beneficiaries who were exempt from the community engagement requirement in
the month .................................................................................................................................... 68
CE_3
Beneficiaries with approved good cause circumstances ............................................................ 69
CE_4
Beneficiaries subject to the community engagement requirement and in suspension
status due to failure to meet requirement ................................................................................... 69
CE_5
Beneficiaries subject to the community engagement requirement and receiving benefits
who met the requirement for qualifying activities ........................................................................ 70
CE_6
Beneficiaries subject to the community engagement requirement and receiving benefits
but in a grace period or allowable month of noncompliance ...................................................... 70
CE_7
Beneficiaries who successfully completed make-up hours or other activities to retain
active benefit status after failing to meet the community engagement requirement in a
previous month ........................................................................................................................... 71
CE_8
Beneficiaries in a non-eligibility period who were disenrolled for noncompliance with the
community engagement requirement and are prevented from re-enrolling for a defined
period of time .............................................................................................................................. 71
2.
Community engagement requirement qualifying activities ................................................. 72
CE_9
Beneficiaries who met the community engagement requirement by satisfying
requirements of other programs ................................................................................................. 72
CE_10
Beneficiaries who met the community engagement requirement through employment
for the majority of their required hours ........................................................................................ 72
CE_11
Beneficiaries who met the community engagement requirement through job training or
job search for the majority of their required hours ...................................................................... 73
CE_12
Beneficiaries who met the community engagement requirement through educational
activity for the majority of their required hours ............................................................................ 74
CE_13
Beneficiaries who met the community engagement requirement who were engaged in
other qualifying activity for the majority of their required hours .................................................. 75
CE_14
Beneficiaries who met the community engagement requirement by combining two or
more activities ............................................................................................................................. 76
3.
Basis of beneficiary exemptions from community engagement requirement ................... 77
CE_15
Beneficiaries exempt from Medicaid community engagement requirements because
they were exempt from requirements of SNAP and/or TANF .................................................... 77
CE_16
Beneficiaries exempt from Medicaid community engagement requirements on the basis
of pregnancy ............................................................................................................................... 77
CE_17
Beneficiaries exempt from Medicaid community engagement requirements due to
former foster youth status ........................................................................................................... 78
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CE_18
Beneficiaries exempt from Medicaid community engagement requirements due to
medical frailty .............................................................................................................................. 78
CE_19
Beneficiaries exempt from Medicaid community engagement requirements on the basis
of caretaker status ...................................................................................................................... 79
CE_20
Beneficiaries exempt from Medicaid community engagement requirements on the basis
of unemployment insurance compensation ................................................................................ 79
CE_21
Beneficiaries exempt from Medicaid community engagement requirements due to
substance abuse treatment status .............................................................................................. 80
CE_22
Beneficiaries exempt from Medicaid community engagement requirements due to
student status .............................................................................................................................. 80
CE_23
Beneficiaries exempt from Medicaid community engagement requirements because
they were excused by a medical professional ............................................................................ 81
CE_24
Beneficiaries exempt from Medicaid community engagement requirements, other ................... 81
4.
Supports and assistance ......................................................................................................... 82
CE_25
Total beneficiaries receiving supports to participate and placement assistance ........................ 82
CE_26
Beneficiaries provided with transportation assistance ................................................................ 82
CE_27
Beneficiaries provided with childcare assistance ....................................................................... 83
CE_28
Beneficiaries provided with language supports .......................................................................... 83
CE_29
Beneficiaries assisted with placement in community engagement activities.............................. 84
CE_30
Beneficiaries provided with other non-Medicaid assistance ....................................................... 84
5.
Reasonable modifications for beneficiaries with disabilities .............................................. 85
CE_31
Beneficiaries who requested reasonable modifications to community engagement
processes or requirements due to disability ............................................................................... 85
CE_32
Beneficiaries granted reasonable modifications to community engagement processes
or requirements due to disability ................................................................................................. 85
6.
New suspensions and disenrollments during the measurement period ............................ 86
CE_33
Beneficiaries newly suspended for failure to complete community engagement
requirements ............................................................................................................................... 86
CE_34
Beneficiaries newly disenrolled for failure to complete community engagement
requirements ............................................................................................................................... 86
7.
Reinstatement of benefits after suspension .......................................................................... 87
CE_35
Total beneficiaries whose benefits were reinstated after being in suspended status for
noncompliance ............................................................................................................................ 87
CE_36
Beneficiaries whose benefits were reinstated because their time-limited suspension
period ended ............................................................................................................................... 87
CE_37
Beneficiaries whose benefits were reinstated because they completed required
community engagement activities............................................................................................... 88
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CE_38
Beneficiaries whose benefits were reinstated because they completed “on-ramp”
activities other than qualifying community engagement activities .............................................. 88
CE_39
Beneficiaries whose benefits were reinstated because they newly meet community
engagement exemption criteria or had a good cause circumstance .......................................... 89
CE_40
Beneficiaries whose benefits were reinstated after successful appeal of suspension for
noncompliance ............................................................................................................................ 89
8.
Re-entry after disenrollment .................................................................................................... 90
CE_41
Total beneficiaries re-enrolling after disenrollment for noncompliance ...................................... 90
CE_42
Beneficiaries re-enrolling after completing required community engagement activities ............. 90
CE_43
Beneficiaries re-enrolling after completing “on-ramp” activities other than qualifying
community engagement activities............................................................................................... 91
CE_44
Beneficiaries re-enrolling after re-applying, subsequent to being disenrolled for
noncompliance with community engagement requirements ...................................................... 91
CE_45
Beneficiaries re-enrolling because they newly met community engagement exemption
criteria or had a good cause circumstance ................................................................................. 92
CE_46
Beneficiaries re-enrolling after successful appeal of disenrollment for noncompliance ............. 92
F.
Additional metrics to be reported for demonstrations with retroactive eligibility
waivers ....................................................................................................................................... 93
1.
At application ............................................................................................................................ 93
RW_1
Beneficiaries who indicated that they had unpaid medical bills at the time of application ......... 93
2.
At renewal .................................................................................................................................. 93
RW_2
Beneficiaries who had a coverage gap at renewal ..................................................................... 93
RW_3
Beneficiaries who had a coverage gap at renewal and had claims denied ................................ 94
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ACRONYMS
AD
Any demonstration with eligibility and coverage policies
AHRQ
Agency for Healthcare Research and Quality
AOD
Alcohol or other drug
CAHPS
Consumer Assessment of Healthcare Providers and Systems
CE
Community engagement
CHIP
Children’s Health Insurance Program
CMS
Centers for Medicare & Medicaid Services
COPD
Chronic obstructive pulmonary disease
ED
Emergency department
EHR
Electronic health record
EPSDT
Early and periodic screening, diagnostic and treatment
FFY
Federal fiscal year
FPL
Federal poverty level
FUA -AD
Follow-Up After Emergency Department Visit for Alcohol and Other Drug
Abuse or Dependence – Adult
FUM-AD
Follow-Up After Emergency Department Visit for Mental Illness - Adult
HB
Health behavior
HCPCS
Healthcare Common Procedure Coding System
HEDIS
Healthcare Effectiveness Data and Information Set
ICD
International Classification of Diseases
IET-AD
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence
Treatment - Adult
MCO
Managed care organization
MIPS
Merit-based Incentive Payment System
MSC-AD
Medical Assistance with Smoking and Tobacco Use Cessation - Adult
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NCQA
National Committee for Quality Assurance
NQF
National Quality Forum
NYU
New York University
PA
Premium assistance
PAHP
Prepaid ambulatory health plan
PCCM
Primary Care Case Management
PIHP
Prepaid inpatient health plan
POS
Place of service
PQI
Prevention Quality Indicators
PR
Premiums
SNAP
Supplemental Nutrition Assistance Program
TANF
Temporary Assistance for Needy Families
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ACKNOWLEDGMENTS
For Proprietary Codes:
CPT® codes copyright 2018 American Medical Association (AMA). All rights reserved.
CPT is a trademark of the American Medical Association. No fee schedules, basic units, relative
values or related listings are included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to government use.
The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10CM) is published by the World Health Organization (WHO). ICD-10-CM is an official Health
Insurance Portability and Accountability Act standard.
The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD10-PCS) is published by the World Health Organization (WHO). ICD-10-PCS is an official
Health Insurance Portability and Accountability Act standard.
The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9CM) is published by the World Health Organization (WHO). ICD-9-CM is an official Health
Insurance Portability and Accountability Act standard.
The International Classification of Diseases, 9th Revision, Procedure Coding System (ICD9-PCS) is published by the World Health Organization (WHO). ICD-9-PCS is an official Health
Insurance Portability and Accountability Act standard.
The National Drug Code (NDC) Directory is published by the U.S. Food and Drug
Administration and is made available under the Open Database License at
http://opendatacommons.org/licenses/odbl/1.0/. Any rights on individual contents of the database
are licensed under the Database Contents License at
http://opendatacommons.org/licenses/dbcl/1.0/.
The American Hospital Association (AHA) holds a copyright to the Uniform Bill Codes
(“UB”) codes, including those contained in the Adult Core Set measures. The UB Codes in the
Adult Core Set are included with the permission of the AHA. The UB Codes contained in the
Adult Core Set may be used by states, health plans, and other health care delivery organizations
for the purpose of calculating and reporting Adult Core Set measure results or using Adult Core
Set measure results for their internal quality improvement purposes. All other uses of the UB
Codes require a license from the AHA. Anyone desiring to use the UB Codes in a commercial
product to generate measure results, or for any other commercial use, must obtain a commercial
use license directly from the AHA. To inquire about licensing, please contact
[email protected].
For National Committee for Quality Assurance (NCQA) measures in the technical
specifications for section 1115 eligibility and coverage demonstration monitoring metrics:
Content reproduced with permission from HEDIS 2019 Volume 2: Technical Specifications
for Health Plans by the National Committee for Quality Assurance (NCQA). HEDIS® is a
registered trademark of NCQA. HEDIS measures and specifications are not clinical guidelines
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and do not establish a standard of medical care. NCQA makes no representations, warranties, or
endorsement about the quality of any organization or physician that uses or reports performance
measures and NCQA has no liability to anyone who relies on such measures or specifications.
Anyone desiring to use or reproduce the materials without modification for a non-commercial
purpose may do so without obtaining any approval from NCQA. All commercial uses must be
approved by NCQA and are subject to a license at the discretion of NCQA.
The measure specification methodology used by CMS is different from NCQA's
methodology. NCQA has not validated the adjusted measure specifications but has granted CMS
permission to adjust. Calculated measure results, based on the adjusted HEDIS specifications,
may be called only "Uncertified, Unaudited HEDIS rates."
Measures in the CMS 1115 eligibility and coverage demonstration contain HEDIS Value
Sets (VS) developed by and included with the permission of the NCQA.
Limited proprietary coding is contained in the measure specifications and HEDIS VS for
convenience. Users of the proprietary code sets should obtain all necessary licenses from the
owners of these code sets. NCQA disclaims all liability for use or accuracy of any coding
contained in the specifications and VS.
The American Medical Association holds a copyright to the CPT® codes contained in the
measure specifications and VS.
The American Hospital Association holds a copyright to the Uniform Billing Codes
("UB") contained in the measure specifications and VS. The UB Codes are included
with the permission of the AHA. Anyone desiring to use the UB Codes in a commercial
product to calculate measure results, or for any other commercial use, must obtain a
commercial use license directly from the AHA. To inquire about licensing, c6ntact
[email protected].
For PCPI Foundation and American Medical Association (AMA) measures in the
technical specifications for section 1115 eligibility and coverage demonstration monitoring
metrics:
The Specifications Manual for PCPI Foundation Preventive Care and Screening: Tobacco
Use: Screening and Cessation Intervention (2018) is updated annually by PCPI Foundation.
Users of the Specifications Manual must update their software and associated documentation
based on the published manual production timelines.
For the New York University algorithm for the emergency department classification
scheme in the technical specifications for section 1115 eligibility and coverage
demonstration monitoring metrics:
The ICD-10 version of the emergency department utilization classification schemes was
developed by the New York University Center for Health and Public Service Research.
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TECHNICAL SPECIFICATIONS MANUAL
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Note: the emergency department classification schemes utilize only the final diagnosis on
claims and are intended for monitoring broad population-level trends in emergency department
use, not for determining retrospectively whether an individual visit was or was not emergent
based on clinical symptoms present on admission to the emergency department.
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TECHNICAL SPECIFICATIONS MANUAL
I.
MATHEMATICA POLICY RESEARCH
BACKGROUND AND INTRODUCTION
This document provides technical specifications for monitoring metrics1 for states with
section 1115 demonstrations that include the following policies: premiums or account payments,
marketplace-focused premium assistance, health behavior incentives, community engagement
(CE), and/or retroactive eligibility waivers. These demonstrations are collectively referred to as
eligibility and coverage demonstrations.
An important goal of monitoring eligibility and coverage demonstrations is to identify trends
that suggest the need for adjustments to improve demonstration performance and protect
beneficiaries. These metrics are designed to monitor demonstration performance while
minimizing state reporting burden. This set focuses on metrics that can be calculated from
Medicaid administrative data. Monitoring metrics are useful to include in formal evaluations to
provide context on demonstration operations along with more complex outcome measures and
those that draw on non-administrative data sources, including beneficiary surveys.
Eligibility and coverage monitoring metrics were developed with input from subject matter
experts in the Centers for Medicare & Medicaid Services (CMS). While most eligibility and
coverage metrics track administrative processes and monitor protections provided to
beneficiaries, a few refer to definitions included in established quality measures. Note that these
metrics are not stand-alone quality measures themselves and were not tested as such. They are
intended only for monitoring the status and progress of eligibility and coverage demonstrations.
This technical specifications manual is organized as follows: Section A of this chapter
provides an overview of the metrics and Section B provides reporting instructions that apply to
the metrics. Chapter II presents technical specifications for each metric.
A. Overview of eligibility and coverage monitoring metrics
The eligibility and coverage metrics are organized into six modules by policy type (Table 1).
States should report the metrics in module 1, since these metrics are applicable for all eligibility
and coverage demonstrations, plus the metrics corresponding to the policies in the state’s
demonstration. For example, a state with section 1115 authority for premiums and health
behavior incentives would report the metrics in modules 1, 2, and 4. Depending on the
operational details of a state’s demonstration, some metrics in modules 2 through 6 may not be
applicable. States need only report the metrics that are relevant to the state’s overall
demonstration design. CMS will work with states to refine reporting instructions to align with
specific state policies as needed.
1
The manual uses the term “metrics” because most of the data collected in the demonstration monitoring effort
track processes associated with demonstration policies. A small number of metrics are formally endorsed quality
measures.
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TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table 1. Summary of eligibility and coverage metric modules
Module
Demonstration typed
Metric
# prefix
Total
Number of
metrics
Number of
required
metrics
1
Any demonstration with premiums, marketplace-focused
premium assistance, health behavior incentives, community
engagement requirements, or retroactive eligibility waivers
AD
45
30
2
Demonstrations with premiums or account payments
PR
21
9
3
Demonstrations with marketplace-focused premium
assistance
PA
3
2
4
Demonstrations with health behavior incentives
HB
7
7
5
Demonstrations with community engagement requirements
CE
46
29
6
Demonstrations with retroactive eligibility waivers
RW
3
3
125
80
Total
Tables 2 through 7, placed at the end of this section, list eligibility and coverage monitoring
metrics in modules 1 through 6, respectively. The tables indicate whether each metric is required
or recommended. The tables also summarize key reporting parameters, such as the reporting
subpopulations and measurement period. Metrics in each module are organized into categories
(such as enrollment or access to care). The remainder of this section describes the criteria used to
define a metric as required or recommended, as well as the subpopulations measurement periods.
In addition to Tables 2 through 7 there are technical specifications for each metric in Chapter II.
Required or Recommended. Metrics are either required or recommended.
-
Required metrics provide information that is critical for monitoring the success of
eligibility and coverage demonstrations and could be constructed with data that are
readily available to states.
-
Recommended metrics might be more difficult to report than required metrics, but still
provide important information on the operation of a demonstration.
Subpopulations. Some populations may be uniquely impacted by eligibility and coverage
demonstrations. When instructed by metric specifications, calculate and report metrics
separately by subpopulation, assigning beneficiaries to subpopulations based on their
characteristics as of the last day of the measurement period. For disenrollment metrics,
disenrolled beneficiaries should be assigned to subpopulations based on status at the time of
disenrollment. The subpopulations are organized under four groups: (1) income groups; (2)
specific demographic groups; (3) exempt groups; and (4) specific eligibility groups. The
various categories within each of these subpopulation groups are delineated as follows:
-
Income groups includes reported income subpopulations defined as less than 50% of the
federal poverty level (FPL), 50-100% FPL, and greater than 100% FPL. States should
report income subpopulations using these categories, unless states have finer gradations
for income groups along which a policy varies (e.g., 100-115% FPL and 115%+ FPL), in
which case those should be reported instead.
o States should only report income groups that are relevant for a given metric. For
example, the state does not need to report the <50% FPL income group for metric
2
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
PR_1 if the state only requires premiums for beneficiaries in income groups above
50% FPL.
-
Specific demographic groups includes age, sex, race, and ethnicity.
o Age is defined in groups as follows: 19-26, 27-35, 36-45, 46-55, or 56-64.
o Sex is defined as male or female.
o Race is defined as White, Black or African American, Asian, American Indian or
Alaskan Native, other, or unknown.
o Ethnicity is defined Hispanic, non-Hispanic, or unknown.
-
Exempt groups are in eligibility and income groups that are enrolled in the
demonstration but are not required to participate in elements of the demonstration (such
as paying premiums) for reasons other than income. For example, exempt groups may
include geographic exemptions, employer sponsored insurance exemptions or
exemptions due to medical frailty. Exempt groups will vary by state based on the special
terms and conditions (STCs) authorizing a demonstration. Exempt groups are included
in metrics in the any demonstration module (module 1), but states are asked to report on
them separately.
-
Specific eligibility groups include section 1931 parents, the new adult group, transitional
medical assistance beneficiaries, and other Medicaid eligibility groups included in the
state’s demonstration. Eligibility groups will vary by state based on STCs authorizing a
demonstration. Reporting by specific eligibility groups is required where noted in metric
specifications.
-
In some instances, states may choose to phase in demonstration policies and
requirements by cohort, using age groups or other criteria, as a tool to manage the
gradual implementation of new operational processes or to support evaluation goals. In
these scenarios, in addition to the defined categories within an applicable subpopulation
group, states should report monitoring metrics by phase-in cohort, if they are different
from the defined subpopulation categories. However, in consultation with CMS and on a
case-by-case basis, it may suffice for a state to report certain metrics only by phase-in
cohort subpopulations.
Measurement period. This parameter identifies the measurement period (the data collection
time frame) for each metric. The measurement period may be a month, quarter,
demonstration year, or calendar year. Section B provides detailed guidance and reporting
instructions for measurement period.
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TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table 2. Overview of eligibility and coverage metrics standard across any demonstration with premiums,
Marketplace-focused premium assistance, health behavior incentives, community engagement
requirements, or retroactive eligibility waivers
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
Enrollment
AD_1
Total enrollment in the demonstration
Required
X
X
X
X
Month (30 days)
AD_2
Beneficiaries in suspension status for
noncompliance
Required
X
X
X
X
Month (30 days)
AD_3
Beneficiaries in a non-eligibility period who are
prevented from re-enrolling for a defined period of
time
Required
X
X
X
X
Month (30 days)
AD_4
New enrollees
Required
X
X
X
X
Month (30 days)
AD_5
Re-enrollments or re-instatements using defined
pathways after disenrollment or suspension of
benefits for noncompliance with demonstration
policies
Required
X
X
X
X
Month (30 days)
AD_6
Re-enrollments or re-instatements for
beneficiaries not using defined pathways after
disenrollment or suspension of benefits for
noncompliance
Required
X
X
X
X
Month (30 days)
Mid-year loss of demonstration eligibility
AD_7
Beneficiaries determined ineligible for Medicaid,
any reason, other than at renewal
Required
X
X
X
X
Month (30 days)
AD_8
Beneficiaries no longer eligible for Medicaid,
failure to provide timely change in circumstance
information
Required
X
X
X
X
Month (30 days)
AD_9
Beneficiaries determined ineligible for Medicaid
after state processes a change in circumstance
reported by a beneficiary
Required
X
X
X
X
Month (30 days)
AD_10
Beneficiaries no longer eligible for the
demonstration due to transfer to another Medicaid
eligibility group
Required
X
X
X
X
Month (30 days)
AD_11
Beneficiaries no longer eligible for the
demonstration due to transfer to CHIP
Recommended
X
X
X
X
Month (30 days)
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TECHNICAL SPECIFICATIONS MANUAL
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Table 2 (continued)
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
Enrollment duration at time of disenrollment
AD_12
Enrollment duration 0-3 months
Recommended
X
Month (30 days)
AD_13
Enrollment duration 4-6 months
Recommended
X
Month (30 days)
AD_14
Enrollment duration 6-12 months
Recommended
X
Month (30 days)
AD_15
Beneficiaries due for renewal
Required
X
X
X
X
Month (30 days)
AD _16
Beneficiaries determined ineligible for the
demonstration at renewal, disenrolled from
Medicaid
Required
X
X
X
X
Month (30 days)
AD_17
Beneficiaries determined ineligible for the
demonstration at renewal, transfer to another
Medicaid eligibility category
Required
X
X
X
X
Month (30 days)
AD_18
Beneficiaries determined ineligible for the
demonstration at renewal, transferred to CHIP
Required
X
X
X
X
Month (30 days)
AD_19
Beneficiaries who did not complete renewal,
disenrolled from Medicaid
Required
X
X
X
X
Month (30 days)
AD_20
Beneficiaries who had pending/ uncompleted
renewals and were still enrolled
Required
X
X
X
X
Month (30 days)
AD_21
Beneficiaries who retained eligibility for the
demonstration after completing renewal forms
Required
X
X
X
X
Month (30 days)
AD_22
Beneficiaries who renewed ex parte
Recommended
X
X
X
X
Month (30 days)
Required
X
X
X
X
Month (30 days)
Renewal
Cost sharing limit
AD_23
Beneficiaries who reached 5% limit
Appeals and grievances
AD_24
Appeals, eligibility
Recommended
Quarter (no lag)
AD_25
Appeals, denial of benefits
Recommended
Quarter (no lag)
AD_26
Grievances, care quality
Recommended
Quarter (no lag)
AD_27
Grievances, provider or managed care entities
Recommended
Quarter (no lag)
AD_28
Grievances, other
Recommended
Quarter (no lag)
Access to care
AD_29
Primary care provider availability
Required
Quarter (90 days)
AD_30
Primary care provider active participation
Required
Quarter (90 days)
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TECHNICAL SPECIFICATIONS MANUAL
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Table 2 (continued)
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
AD_31
Specialist provider availability
Required
Quarter (90 days)
AD_32
Specialist provider active participation
Required
AD_33
Preventive care and office visit utilization
Recommended
X
X
X
X
Quarter (90 days)
AD_34
Prescription drug use
Recommended
X
X
X
X
Quarter (90 days)
AD_35
Emergency department utilization, total
Recommended
X
X
X
X
Quarter (90 days)
AD_36
Emergency department utilization, nonemergency
Recommended
X
X
X
X
Quarter (90 days)
AD_37
Inpatient admissions
Recommended
X
X
X
X
Quarter (90 days)
Quarter (90 days)
Quality of care and health outcomes
AD_38A
Medical Assistance with Smoking and Tobacco
Use Cessation (MSC-AD)
Required (AD_38A
or AD_38B)
X
X
Calendar year
(90 days)
AD_38B
Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention
Required (AD_38A
or AD_38B)
X
X
Calendar year
(90 days)
AD_39-1
Follow-Up After Emergency Department Visit for
Alcohol and Other Drug Abuse or Dependence
(FUA -AD)
Required
X
X
Calendar year
(90 days)
AD_39-2
Follow-Up After Emergency Department Visit for
Mental Illness (FUM-AD)
Required
X
X
Calendar year
(90 days)
AD_40
Initiation and Engagement of Alcohol and Other
Drug Abuse or Dependence Treatment (IET-AD)
Required
X
X
Calendar year
(90 days)
AD_41
PQI 01: Diabetes Short-Term Complications
Admission Rate (PQI01-AD)
Required
X
X
Calendar year
(90 days)
AD_42
PQI 05: Chronic Obstructive Pulmonary Disease
(COPD) or Asthma in Older Adults Admission
Rate (PQI05-AD)
Required
X
X
Calendar year
(90 days)
AD_43
PQI 08: Heart Failure Admission Rate (PQI08-AD)
Required
X
X
Calendar year
(90 days)
AD_44
PQI 15: Asthma in Younger Adults Admission
Rate (PQI15-AD)
Required
X
X
Calendar year
(90 days)
Administrative cost
AD_45
Administrative cost of demonstration operation
Recommended
Demonstration year
(no lag)
6
TECHNICAL SPECIFICATIONS MANUAL
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Table 3. Additional metrics relevant for states that require premiums or account payments
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
Enrollment by premium payment status
PR_1
Beneficiaries subject to premium policy (or
account contribution) during the month, not
exempt
Required
X
X
Month (30 days)
PR_2
Beneficiaries who were exempt from premiums
for that month
Required
X
X
Month (30 days)
PR_3
Beneficiaries who paid a premium during the
month
Required
X
X
Month (30 days)
PR_4
Beneficiaries who were subject to premium policy
but declare hardship for that month
Required
X
X
Month (30 days)
PR_5
Beneficiaries in short-term arrears (grace period)
Recommended
X
X
Month (30 days)
PR_6
Beneficiaries in long-term arrears
Recommended
X
X
Month (30 days)
PR_7
Beneficiaries with collectible debt
Required
X
X
Month (30 days)
Cumulative enrollment duration in states with time-variant premium policies
PR_8
Beneficiaries in enrollment duration tier 1
Recommended
X
X
Month (30 days)
PR_9
Beneficiaries in enrollment duration tier 2
Recommended
X
X
Month (30 days)
PR_10
Beneficiaries in enrollment duration tiers 3+
Recommended
X
X
Month (30 days)
Mid-year change in circumstance by premium amount
PR_11
Beneficiaries for whom the state processed a midyear change in circumstance in household or
income information and who remained enrolled in
the demonstration
Recommended
X
X
Month (30 days)
PR_12
No premium change following mid-year
processing of a change in household or income
information
Recommended
X
X
Month (30 days)
PR_13
Premium increase following mid-year processing
of change in household or income information
Recommended
X
X
Month (30 days)
PR_14
Premium decrease following mid-year processing
of change in household or income information
Recommended
X
X
Month (30 days)
7
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table 3 (continued)
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
Disenrollment or suspension for failure to pay
PR_15
Beneficiaries disenrolled from the demonstration
for failure to pay and therefore disenrolled from
Medicaid
Required
X
X
X
Month (30 days)
PR_16
Beneficiaries in a non-eligibility period who were
disenrolled for failure to pay and are prevented
from re-enrolling for a defined period of time
Required
X
X
X
Month (30 days)
PR_17
Beneficiaries whose benefits are suspended for
failure to pay
Required
X
X
X
Month (30 days)
PR_18
No premium change
Recommended
X
X
Month (30 days)
PR_19
Premium increase
Recommended
X
X
Month (30 days)
PR_20
Premium decrease
Recommended
X
X
Month (30 days)
Required
X
X
Month (30 days)
Renewal
Third party premium payment
PR_21
Third-party premium payment
8
TECHNICAL SPECIFICATIONS MANUAL
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Table 4. Additional metrics relevant for states with Marketplace-focused premium assistance programs
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
Enrollment by premium payment status
PA_1
Beneficiaries who lost Medicaid eligibility due
to mid-year change in circumstance, and
transitioned to a qualified health plan offered in
the Marketplace
Required
X
X
X
Month (30 days)
PA_2
Beneficiaries who lost Medicaid eligibility at
renewal, and transitioned to a qualified health
plan offered in the Marketplace
Required
X
X
X
Month (30 days)
Recommended
X
X
X
Quarter (90 days)
Access to care
PA_3
Wraparound service utilization, by service
9
TECHNICAL SPECIFICATIONS MANUAL
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Table 5. Additional metrics relevant for states with programs with health behavior incentives
Subpopulations
Metric
Metric name
Income
groups
Specific
demographic
groups
Required
X
X
X
Quarter (90 days)
Required
X
X
X
Quarter (90 days)
Required or
recommended
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
Enrollment
HB_1
Total enrollment among beneficiaries subject to
health behavior incentives
Use of incentivized services: claims-based analysis
HB_2
Beneficiaries using incentivized services that can be
documented through claims, by service
Other incentivized behaviors not documented through claims-based analysis
HB_3
Completion of incentivized health behavior(s) not
documented through claims analysis (i.e. health risk
assessments), by health behavior
Required
X
X
X
Quarter (90 days)
HB_4
Completion of all incentivized health behaviors (both
claims-based and other), if there are multiple
Required
X
X
X
Quarter (90 days)
Rewards granted for completion of incentivized health behaviors
HB_5
Beneficiaries granted a premium reduction for
completion of incentivized health behaviors
Required
X
X
X
Quarter (90 days)
HB_6
Beneficiaries granted a financial reward other than a
premium reduction for completion of incentivized
health behaviors
Required
X
X
X
Quarter (90 days)
HB_7
Beneficiaries granted a reward in the form of
additional covered benefits for completion of
incentivized health behaviors
Required
X
X
X
Quarter (90 days)
10
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table 6. Additional metrics relevant for states with community engagement requirements
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
Community engagement enrollment
CE_1
Total beneficiaries subject to the community
engagement requirement, not exempt
Required
X
X
Month (30 days)
CE_2
Total beneficiaries who were exempt from
community engagement requirements in the
month
Required
X
X
Month (30 days)
CE_3
Beneficiaries with approved good cause
circumstances
Required
X
X
Month (30 days)
CE_4
Beneficiaries subject to the community
engagement requirement and in suspension
status due to failure to meet requirement
Required
X
X
Month (30 days)
CE_5
Beneficiaries subject to the community
engagement requirement and receiving benefits
who met the requirement for qualifying activities
Required
X
X
Month (30 days)
CE_6
Beneficiaries subject to the community
engagement requirement and receiving benefits
but in a grace period or allowable month of
noncompliance
Required
X
X
Month (30 days)
CE_7
Beneficiaries who successfully completed makeup hours or other activities to retain active benefit
status after failing to meet the community
engagement requirement in a previous month
Required
X
X
Month (30 days)
CE_8
Beneficiaries in a non-eligibility period who were
disenrolled for noncompliance with the community
engagement requirement and are prevented from
re-enrolling for a defined period of time
Required
X
X
Month (30 days)
Community engagement requirement qualifying activities
CE_9
Beneficiaries who met the community
engagement requirement by satisfying
requirements of other programs
Required
X
X
Month (30 days)
CE_10
Beneficiaries who met the community
engagement requirement through employment for
the majority of their required hours
Required
X
X
Month (30 days)
11
TECHNICAL SPECIFICATIONS MANUAL
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Table 6. (continued)
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
CE_11
Beneficiaries who met the community
engagement requirement through job training or
job search for the majority of their required hours
Required
X
X
Month (30 days)
CE_12
Beneficiaries who met the community
engagement requirement through educational
activity for the majority of their required hours
Required
X
X
Month (30 days)
CE_13
Beneficiaries who met the community
engagement requirement who were engaged in
other qualifying activity for the majority of their
required hours
Required
X
X
Month (30 days)
CE_14
Beneficiaries who met the community
engagement requirement by combining two or
more activities
Required
X
X
Month (30 days)
Basis of beneficiary exemptions from community engagement requirement
CE_15
Beneficiaries exempt from Medicaid community
engagement requirements because they were
exempt from requirements of SNAP and/or TANF
Required
X
X
Month (30 days)
CE_16
Beneficiaries exempt from Medicaid community
engagement requirements on the basis of
pregnancy
Required
X
X
Month (30 days)
CE_17
Beneficiaries exempt from community
engagement requirements due to former foster
youth status
Required
X
X
Month (30 days)
CE_18
Beneficiaries exempt from Medicaid community
engagement requirements due to medical frailty
Required
X
X
Month (30 days)
CE_19
Beneficiaries exempt from Medicaid community
engagement requirements on the basis of
caretaker status
Required
X
X
Month (30 days)
CE_20
Beneficiaries exempt from Medicaid community
engagement requirements due to unemployment
insurance compensation
Required
X
X
Month (30 days)
CE_21
Beneficiaries exempt from Medicaid community
engagement requirements due to substance
abuse treatment status
Required
X
X
Month (30 days)
CE_22
Beneficiaries exempt from Medicaid community
engagement requirements due to student status
Required
X
X
Month (30 days)
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TECHNICAL SPECIFICATIONS MANUAL
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Table 6. (continued)
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
CE_23
Beneficiaries exempt from community
engagement requirements because they were
excused by a medical professional
Required
X
X
Month (30 days)
CE_24
Beneficiaries exempt from Medicaid community
engagement requirements, other
Required
X
X
Month (30 days)
Supports and assistance
CE_25
Total number of beneficiaries receiving supports
to participate and placement assistance
Required
X
X
Month (30 days)
CE_26
Beneficiaries provided with transportation
assistance
Recommended
X
X
Month (30 days)
CE_27
Beneficiaries provided with childcare assistance
Recommended
X
X
Month (30 days)
CE_28
Beneficiaries provided with language supports
Recommended
X
X
Month (30 days)
CE_29
Beneficiaries assisted with placement in
community engagement activities
Recommended
X
X
Month (30 days)
CE_30
Beneficiaries provided with other non-Medicaid
assistance
Recommended
X
X
Month (30 days)
Reasonable modifications for beneficiaries with disabilities
CE_31
Beneficiaries who requested reasonable
modifications to community engagement
processes or requirements due to disability
Recommended
X
X
Month (30 days)
CE_32
Beneficiaries granted reasonable modifications to
community engagement processes or
requirements due to disability
Recommended
X
X
Month (30 days)
New suspensions and disenrollments during the measurement period
CE_33
Beneficiaries newly suspended for failure to
complete community engagement requirements
Required
X
X
Month (30 days)
CE_34
Beneficiaries newly disenrolled for noncompliance
with community engagement requirement
Required
X
X
Month (30 days)
Reinstatement of benefits after suspension
CE_35
Total beneficiaries whose benefits were reinstated
after being in suspended status for noncompliance
Required
X
X
Month (30 days)
CE_36
Beneficiaries whose benefits were reinstated
because their time-limited suspension period
ended
Recommended
X
X
Month (30 days)
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Table 6. (continued)
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
CE_37
Beneficiaries whose benefits were reinstated
because they completed required community
engagement activities
Recommended
X
X
Month (30 days)
CE_38
Beneficiaries whose benefits were reinstated
because they completed “on-ramp” activities other
than qualifying community engagement activities
Recommended
X
X
Month (30 days)
CE_39
Beneficiaries whose benefits were reinstated
because they newly meet community engagement
exemption criteria or had a good cause
circumstance
Recommended
X
X
Month (30 days)
CE_40
Beneficiaries whose benefits were reinstated after
successful appeal of suspension for
noncompliance
Recommended
X
X
Month (30 days)
Re-entry after disenrollment
CE_41
Total beneficiaries re-enrolling after disenrollment
for noncompliance
Required
X
X
Month (30 days)
CE_42
Beneficiaries re-enrolling after completing required
community engagement activities
Recommended
X
X
Month (30 days)
CE_43
Beneficiaries re-enrolling after completing “onramp” activities other than qualifying community
engagement activities
Recommended
X
X
Month (30 days)
CE_44
Beneficiaries re-enrolling after re-applying,
subsequent to being disenrolled for
noncompliance with community engagement
requirements
Recommended
X
X
Month (30 days)
CE_45
Beneficiaries re-enrolling because they newly met
community engagement exemption criteria or had
a good cause circumstance
Recommended
X
X
Month (30 days)
CE_46
Beneficiaries re-enrolling after successful appeal
of disenrollment for noncompliance
Recommended
X
X
Month (30 days)
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Table 7. Additional metrics relevant for states with retroactive eligibility waivers
Subpopulations
Metric
Metric name
Required or
recommended
Income
groups
Specific
demographic
groups
Exempt
groups
Specific
eligibility
groups
Measurement period
(calculation lag)
At application
RW_1
Beneficiaries who indicated that they had unpaid
medical bills at the time of application
Required
Month (30 days)
At renewal
RW_2
Beneficiaries who had a coverage gap at renewal
Required
Quarter (90 days)
RW_3
Beneficiaries who had a coverage gap at renewal
and had claims denied
Required
Quarter (90 days)
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B. Reporting eligibility and coverage demonstration monitoring metrics
This section provides reporting guidance applicable to section 1115 eligibility and coverage
demonstration monitoring metrics. The technical specifications for calculating each metric are
presented in Chapter II.
Technical assistance. To help states collect, report, and use the section 1115 eligibility and
coverage demonstration monitoring metrics, CMS offers technical assistance. Please submit
technical assistance requests to: [email protected]. When you
contact this mailbox, please copy your CMS project officer on the message.
Measurement periods baseline year. When reporting eligibility and coverage
demonstration monitoring metrics, use the following guidance for determining the measurement
periods and baseline year.
For metrics with a monthly measurement period, the first monthly measurement period
consists of the full calendar month in which the demonstration started (approval start date).
For example, if the demonstration started on March 15, the first month is March 1 through
March 31. The second month is April 1 through April 30.
For metrics with a quarterly measurement period, the first quarterly measurement period
begins on the first day of the month in which the demonstration started (approval start date),
and consists of the first three calendar months of the demonstration. For example, if the
demonstration started on March 15, the first quarter is March 1 through May 31. The second
quarter is June 1 through August 31.
For the CMS-constructed metric with a demonstration year measurement period, the first
measurement period begins on the first day of the month in which the demonstration started
(approval start date), and consists of 12 consecutive calendar months of the demonstration.
For example, if the demonstration started on March 15, 2018, the demonstration year
measurement period is March 1, 2018 through February 28, 2019. The only CMSconstructed metric in the set of eligibility and coverage monitoring metrics with a
demonstration year measurement period is AD_45 (Administrative cost of demonstration
operation). All other yearly metrics are quality of care and health outcomes metrics, which
have a calendar year measurement period.
For the quality of care and health outcomes metrics, the first measurement period is the first
calendar year that includes at least six months of the demonstration period. For example, if
the demonstration started on March 15, 2018, the measurement period is January 1, 2018
through December 31, 2018, to align with the measurement period for these measures in
other quality reporting programs. However for a demonstration that started on August 15,
2018, the baseline year for quality of care and health outcomes will be January 1, 2019
through December 31, 2019.
Certain metrics with calendar year measurement periods may require more than one year of
data. For example, metric AD_40 includes a negative diagnosis history review 60 days prior
to the index episode start date. When available, states should use data prior to the
demonstration start to establish a negative diagnosis history or total length of Medicaid
enrollment for purposes of qualifying for inclusion in the quality of care and health
outcomes metrics. Refer to the metric specifications for additional details on measurement
periods for these metrics.
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The quality of care and health outcome metrics that require two years of data (AD_38A and
AD_38B) will be reported for the first time following the second calendar year that includes
at least six months of the demonstration period. The measures should be reported annually
thereafter, using the two most recent years of data.
For metrics that require monthly or quarterly data collection and reporting, as well as the
CMS-constructed metric that is reported for the demonstration year (AD_45), the baseline
year will begin on the first day of the month in which the demonstration started (approval
start date), and consist of 12 consecutive calendar months of the demonstration. For
example, for a demonstration started on March 15, 2018, the baseline year is March 1, 2018
through February 28, 2019.
For quality of care and health outcomes metrics, the first calendar year that includes at least
six months of the demonstration will be the baseline year. For example, for a demonstration
started on March 15, 2018, the baseline year for quality of care and health outcomes metrics
will be January 1, 2018 through December 31, 2018. However for a demonstration that
started on July 15, 2018, the baseline year for quality of care and health outcomes will be
January 1, 2019 through December 31, 2019.
Requirements for individual metrics vary and the baseline year should be determined in
consultation with CMS and documented in the state monitoring protocols. Please confirm
these measurement periods for your state with your CMS project officer.
Table 8 illustrates these guidelines, using the demonstration start date of March 15, 2018 as
an example.
Table 8. Example of alignment between demonstration years and
measurement periods for a demonstration that began on March 15, 2018
Monthly reporting
Start
date
End
date
Demonstration
year
Baseline
year
Quarterly reporting
Start
date
End
date
Year 3
Start
date
End
date
Mar 1
Apr 1
May 1
June 1
…
Feb 1
Mar 31
Apr 30
May 31
June 30
….
Feb 28
Mar 1
June 1
Sep 1
Dec 1
May 31
Aug 31
Nov 30
Feb 28
Monthly as defined
in the baseline year
row
Quarterly as defined
in the baseline year
row
Year 4
17
Start
date
End
date
Quality of care and
health outcomes
metrics
CMS-constructed metrics
Year 1
Year 2
Annual reporting
Mar 1,
2018
Feb 28,
2019
Jan 1,
2018
Dec 31,
2018
Mar 1,
2019
Feb 29,
2020
Jan 1,
2019
Dec 31,
2019
Mar 1,
2020
Feb 28,
2021
Jan 1,
2020
Dec 31,
2020
Mar 1,
2021
Feb 28,
2022
Jan 1,
2021
Dec 31,
2021
Mar 1,
2022
Feb 28,
2023
Jan 1,
2022
Dec 31,
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TECHNICAL SPECIFICATIONS MANUAL
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Metric calculation and reporting. States should report data to CMS in accordance with the
agreed-upon reporting schedule and format. Most metrics should be calculated with a lag
following the last day of the measurement period to allow for more complete reconciliation of
enrollment actions and delays in provider claiming and reporting (claims run-out). The length of
the lag period varies by metric, as noted in Chapter II. Most metrics are calculated after a 30-day
lag. Claims-based metrics and other closely connected metrics should be calculated after a onequarter (90-day) lag.
Guidelines for including metrics and narrative information in monitoring reports are as
follows:
Each quarterly report should contain (1) narrative information on implementation for the
most recent demonstration quarter; (2) monthly metrics from the most recent quarter (note
all monthly metrics have a 30-day lag); (3) quarterly metrics that do not require a lag from
the most recent quarter; and (4) quarterly metrics that require a 90-day lag from the prior
quarter.
Demonstration year metrics should be included in the annual report.
Calendar year metrics should be reported in the first quarterly (or annual) report that allows
for 90 days of run-out after the end of the calendar year (assuming the calendar year
includes at least 6 months of demonstration implementation, per definition of the baseline
year). The demonstration year end date determines the appropriate quarterly report for
reporting these metrics.
Table 9 outlines the reporting schedule by measurement period and calculation lag. Table 10
illustrates these guidelines, using the demonstration start date of March 15, 2018 as an example.
Measurement period and calculation lag are defined for each metric in Chapter II.
Given the dynamic nature of Medicaid data, states should calculate metrics at the same time
for each measurement period throughout the demonstration. This practice applies even if data are
not shared with CMS until a later date. Therefore, if a state submits monitoring data to CMS on a
quarterly basis, the state should calculate each monthly metric 30 days, or about one month, after
the last day of the measurement month, and the submission should contain three monthly values
for each monthly metric. For example, if the quarterly measurement period is March 1 through
May 31, the state should calculate metrics for the calendar month of March on April 30, for the
calendar month of April on May 31, and for the calendar month of May on June 30. The
quarterly submission to CMS should contain three monthly metric values, each for March, April,
and May.
General guidance. When reporting eligibility and coverage demonstration monitoring
metrics, please follow these guidelines for all metrics:
Enrolled in the demonstration. Beneficiaries “enrolled in the demonstration” includes
beneficiaries enrolled in the demonstration and actively receiving benefits. For monthly
metrics that count active beneficiaries, any beneficiary enrolled in the section 1115
demonstration and actively receiving benefits (not suspended) for at least one day in the
month is eligible for inclusion in monthly metrics. Do not count beneficiaries whose
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benefits are suspended as enrolled. For example, if a beneficiary is in suspended status for
the entire month, the beneficiary should be excluded from metrics that count enrollment for
that month. Beneficiaries enrolled in the section 1115 demonstration and actively receiving
benefits for at least one month (30 consecutive days) during the measurement period for
quarterly and annual metrics are eligible for inclusion in metric calculations; however, there
may be different measure-specific continuous eligibility requirements for the quality of care
and health outcomes measures.
Enrollment spell. An enrollment spell is a period of continuous enrollment with no breaks.
This is applicable to metrics that reference enrollment spells. For example, AD_3 Monthly
count of re-enrollments using defined pathways after disenrollment for noncompliance with
demonstration policies refers to beneficiaries who began a new enrollment spell during the
measurement period.
Claim type. When specified, include only paid claims or paid, suspended, pending, and
denied claims, as instructed in the metric’s technical specification.
Quality of care and health outcomes metrics. Some metrics included in the technical
specifications are health care quality measures used in other CMS programs.2 To help states
calculate these metrics, the technical specifications for measures in the Adult Core Set can
be found in Appendix B: Technical Specifications for Medicaid Quality Measures, Adapted
from FFY 2019 Adult Core Set Measure Specifications.
Established value sets. A small number of eligibility and coverage metrics reference
Healthcare Effectiveness Data and Information Set (HEDIS) value sets or other lists that
contain complete sets of codes used to identify a treatment service or diagnosis.3 When
referenced, use these value sets to calculate a metric. Established value sets typically change
as measure stewards update them. When referenced, states should use the most current
versions of established code sets (or data elements) in the established value sets to calculate
a metric. Established value sets are available to states upon request by contacting
[email protected].
State-specific typologies for appeals and grievances. Metrics AD_24 through AD_28
require states to report types of appeals and grievances according to the state’s typology. For
example, for metric AD_24, a state can report all appeals relevant to eligibility even if the
appeals are coded using multiple categories in the state’s system. Along with metric values,
states should submit definitions for their typology.
State-specific typologies for primary care and specialist providers. Metrics AD_29
through AD_32 specify that states should report providers by state classification of primary
care provider or specialist provider. Along with metric values, states should submit the list
of state-specific provider type or specialties included.
2
Metrics that are health care quality measures include: AD_38A, AD_38B, AD_39, AD_40, AD_41, AD_42,
AD_43, and AD_44. See Appendix A.
3
See Appendix C for a complete list of value sets referenced in metric specifications in Chapter II, by metric, and
accompanying instructions. States can obtain these value sets upon request from CMS. Appendix C does not list
value sets that are necessary for the nine quality of care and health outcome metrics.
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Table 9. Metric reporting in quarterly and annual monitoring reports, by measurement period and
calculation lag
DY1 Q1 report
DY1 Q2 report
DY1 Q3 report
DY1 Q4
(annual) report
DY2 Q1 report
DY2 Q2 report
DY2 Q3 report
Due 60 days
after quarter
ends
Due 60 days
after quarter
ends
Due 60 days
after quarter
ends
Due 90 days
after quarter
ends
Due 60 days
after quarter
ends
Due 60 days
after quarter
ends
Due 60 days
after quarter
ends
Metric measurement
periods, by calculation laga
Narrative information on
implementation
Month
DY1 Q1
DY1 Q2
DY1 Q3
DY1 Q4
DY2 Q1
DY2 Q2
DY2 Q3
DY1 Q1
DY1 Q2
DY1 Q3
DY1 Q4
DY2 Q1
DY2 Q2
DY2 Q3
Quarter, no lag
DY1 Q1
DY1 Q2
DY1 Q3
DY1 Q4
DY2 Q1
DY2 Q2
DY2 Q3
Quarter, 90 days
NA
DY1 Q1
DY1 Q2
DY1 Q3
DY1 Q4
DY2 Q1
DY2 Q2
Demonstration year, no lag
NA
NA
NA
DY1
NA
NA
NA
Calendar year, 90 daysb
NA
NA
CY 1 if DY
ends 6/30
CY 1 if DY ends
1/31 – 5/31
CY1 if DY ends
12/31
CY 2 if DY ends
9/30 – 11/30
CY 2 if DY ends
7/31– 8/31
Report name:
Report due date:
a All
monthly metrics have a 30-day calculation lag, the annual DY metric has no lag; all annual CY metrics have a 90-day lag
due dates for calendar year metrics are defined in terms of the demonstration year measurement period. The demonstration year measurement period
begins on the first day of the month in which the demonstration started (approval start date). For example, a demonstration that begins on July 15 would have a
demonstration year start date of July 1 and end date of June 30. To determine which report should include the calendar year metrics for a demonstration that begins
on July 15, identify the report associated with a demonstration year end of June 30 (i.e., DY1 Q3 report).
DY = Demonstration year
CY = Calendar year
CY 1 = The calendar year during which the demonstration begins
CY 2 = The calendar year that immediately follows CY 1
NA = not applicable (information not expected to be included in report)
b Report
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Table 10. Example of metric reporting in quarterly and annual monitoring reports for the first year of a
demonstration that began on March 15, 2018
DY1 Q1 report
DY1 Q2 report
DY1 Q3 report
DY1 Q4
(annual)
report
Due 60 days
after quarter
ends
Due 60 days
after quarter
ends
Due 60 days
after quarter
ends
Due 90 days
after quarter
ends
Due 60 days
after quarter
ends
Due 60 days
after quarter
ends
Due 60 days
after quarter
ends
Narrative information on
implementation
Mar 1, 2018 –
Mar 31, 2018
Apr 1, 2018 –
Apr 30, 2018
May 1, 2018 –
May 31, 2018
Jun 1, 2018 –
Jun 30, 2019
Jul 1, 2019 –
Jul 31, 2019
Aug 1, 2019 –
Aug 31, 2019
Sep 1, 2019 –
Sep 30, 2019
Month
Mar 1, 2018 –
Mar 31, 2018
Apr 1, 2018 –
Apr 30, 2018
May 1, 2018 –
May 31, 2018
Jun 1, 2018 –
Jun 30, 2019
Jul 1, 2019 –
Jul 31, 2019
Aug 1, 2019 –
Aug 31, 2019
Sep 1, 2019 –
Sep 30, 2019
Quarter, no lag
Mar 1, 2018 –
May 31, 2018
Jun 1, 2018 –
Aug 31, 2018
Sep 1, 2018 –
Nov 30, 2018
Dec 1, 2018 –
Feb 28, 2019
Mar 1, 2019 –
May 31, 2019
Jun 1, 2019 –
Aug 31, 2019
Sep 1, 2019 –
Nov 30, 2019
Quarter, 90 days
NA
Mar 1, 2018 –
May 31, 2018
Jun 1, 2018 –
Aug 31, 2018
Sep 1, 2018 –
Nov 31, 2018
Dec 1, 2018 –
Feb 28, 2019
Mar 1, 2019 –
May 31, 2019
Jun 1, 2019 –
Aug 31, 2019
Demonstration year, no lag
NA
NA
NA
Mar 1, 2018 –
Feb 28, 2019
NA
NA
NA
Calendar year, 90 days
NA
NA
NA
Jan 1, 2018 –
Dec 31, 2018
NA
NA
NA
Report name:
Report due date:
DY2 Q1 report
DY2 Q2 report
DY2 Q3 report
Metric measurement periods,
by calculation lag
The quarters this demonstration are as follows: Q1 = Mar 1 - May 31, Q2 = Jun 1 – Aug 31, Q3 = Sep 1 – Nov 30, Q4 = Dec 1 – Feb 28
DY = Demonstration year
NA = not applicable (information not expected to be included in report)
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C. Using technical specifications
Table 11 defines the elements included in specifications for metrics in Chapter II. The
description column explains each metric element.
Table 11. Table shell for the metrics’ technical specifications
Metric #: Metric name
Metric element
Description
Measure
sets/endorsements
Names the measure steward and describes whether the metric is included in
other measure sets (such as the Adult Core Set) and is endorsed by NQF. This
element only appears where applicable.
Description
Brief measure description.
Counted variable
When the metric is a count, this element describes the counted variable. This
element only appears when the metric is a count.
Numerator
When the metric is a rate, this element describes the numerator in the rate
equation.
This element is excluded when the metric is a count and from metrics that
reference existing quality measures.
Denominator
When the metric is a rate, this element describes the denominator in the rate
equation.
This element is excluded when the metric is a count and from metrics that
reference existing quality measures.
Metric calculation
When the metric is a rate, this element provides instructions for calculating the
metric. This element is excluded when the metric is a count.
Additional guidance
Any additional guidance required to report this metric. This field only appears
where applicable.
Required or
recommended
Indicates whether the metric is required or recommended.
Measurement period
(calculation lag)
Describes whether the measurement period is a month, quarter, demonstration
year, or calendar year. (Indicates whether there is a 30-day, 90-day, or no
calculation lag)
Subpopulations
Describes population subgroups that states must report separately.
Relationship to other
metricsa
Describes components of this metric that are used in other eligibility and
coverage demonstration monitoring metrics. This field only appears where
applicable.
Data source
Describes the likely data source(s) used to report this metric.
Claim type
Describes the types of claims to include when calculating the metric. This field
only appears where applicable.
a
Appendix D lists all relationships to other metrics, by individual metric.
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II. TECHNICAL SPECIFICATIONS
A. Metrics to be reported for any demonstration with premiums, premium
assistance, health behavior incentives, community engagement
requirements, or retroactive eligibility waivers
1.
Enrollment
Metric AD_1: Total enrollment in the demonstration
Metric element
Description
Description
The unduplicated number of beneficiaries enrolled in the demonstration at any time during the
measurement period. This indicator is a count of total program enrollment. It includes those
newly enrolled during the measurement period and those whose enrollment continues from a
prior period. This indicator is not a point-in-time count. It captures beneficiaries who were
enrolled for at least one day during the measurement period.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration for at least one day during the
measurement period.
Step 2. Count unique beneficiaries (de-duplicated) who meet the criteria in Step 1.
Required or recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric provides an overall count of demonstration enrollment that can be used to check
against other enrollment metrics (each should be equal to or smaller than this metric).
Data source
Administrative records
Metric AD_2: Beneficiaries in suspension status for noncompliance
Metric element
Description
Description
The number of demonstration beneficiaries in suspension status for noncompliance with
demonstration policies as of the last day of the measurement period
Counted variable
Step 1. Identify beneficiaries who were in suspension status from Medicaid benefits during the
measurement period as a result of noncompliance with demonstration policies in the current or a
prior measurement period and who remained in suspended status as of the last day of the
measurement period.
Step 2. Count unique demonstration beneficiaries (deduplicated) who meet the criteria in Step 1.
Required or recommended
Required if state has a suspension policy
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Note: Exempt groups may not be an applicable subpopulation for this metric in every state. For
example, this metric is not applicable to states that have a demonstration that focuses solely on
one eligibility and coverage policy, such as community engagement. Only states that have
multiple eligibility and coverage policies, where some groups are exempt from noncompliance
penalties associated with one policy, but not others, should report exempt subgroups for this
metric.
Relationship to other
metrics
Beneficiaries in suspension status are not included in AD_1
Data source
Administrative records
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Metric AD_3: Beneficiaries in a non-eligibility period who are prevented
from re-enrolling for a defined period of time
Metric element
Description
Description
The number of prior demonstration beneficiaries who are in a non-eligibility period, meaning they
are prevented from re-enrolling for some defined period of time, because they were disenrolled for
noncompliance with demonstration policies. The count should include those prevented from reenrolling until their redetermination date.
Counted variable
Step 1. Identify beneficiaries who were in a non-eligibility period as of the last day of the
measurement period.
Step 2. Include beneficiaries who are prevented from re-enrolling until their redetermination date or
another date established by the state.
Step 3. Count unique beneficiaries (deduplicated) who met the criteria in Steps 1 and 2.
Required or
recommended
Required if state has a non-eligibility period policy
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Note: Exempt groups may not be an applicable subpopulation for this metric in every state. For
example, this metric is not applicable to states that have a demonstration that focuses solely on
one eligibility and coverage policy, such as community engagement. Only states that have multiple
eligibility and coverage policies, where some groups are exempt from noncompliance penalties
associated with one policy, but not others, should report exempt subgroups for this metric.
Data source
Administrative records
Metric AD_4: New enrollees
Metric element
Description
Description
Number of beneficiaries in the demonstration who began a new enrollment spell during the
measurement period, have not had Medicaid coverage within the prior 3 months and are not using
a state-specific pathway for re-enrollment after being disenrolled for noncompliance.
Counted variable
Step 1. Identify beneficiaries in the demonstration who began a new enrollment spell during the
measurement period.
Step 2. Retain beneficiaries who had not had a previous spell of enrollment that ended within the
prior 3 months (i.e., were not enrolled at any time within the prior 3 months).
Step 3. [This step is only applicable in states that disenroll beneficiaries for noncompliance with
demonstration policies.] Retain beneficiaries who were not using a state-defined re-enrollment
pathway after being previously disenrolled for noncompliance with demonstration requirements.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Data source
Administrative records
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Metric AD_5: Re-enrollments or re-instatements using defined pathways
after disenrollment or suspension of benefits for noncompliance with
demonstration policies
Metric element
Description
Description
Number of beneficiaries in the demonstration who began a new enrollment spell (or had benefits
re-instated) in the current measurement period by using a state-defined pathway for re-enrollment
(or re-instatement of benefits), i.e., meeting certain requirements, after being disenrolled (or having
benefits suspended) for noncompliance with premium requirements, community engagement
requirements, or other demonstration-specific requirements.
Counted variable
Step 1. Identify beneficiaries in the demonstration who began a new enrollment spell (or had
benefits re-instated) during the measurement period.
Step 2. Retain beneficiaries who had a previous enrollment spell that ended within the prior 3
months (i.e., who were enrolled at some time in the previous three months) or whose benefits were
in suspension status as of the last day of the prior month.
Step 3. Retain beneficiaries that used a state-defined re-enrollment or re-instatement pathway.
Defined pathways may include, but are not limited to, the following:
Paying owed premiums
Completing sufficient community engagement hours
Specialty community engagement activities such as state-approved educational courses
This should include only beneficiaries who were previously disenrolled or had benefits suspended
for noncompliance with any of the following:
Premium requirements
Community engagement requirements
Other demonstration-specific requirements
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2 and 3.
Required or
recommended
Required for states with a defined re-enrollment or re-instatement pathway
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Note: Exempt groups may not be an applicable subpopulation for this metric in every state. For
example, this metric is not applicable to states that have a demonstration that focuses solely on
one eligibility and coverage policy, such as community engagement. Only states that have multiple
eligibility and coverage policies, where some groups are exempt from noncompliance penalties
associated with one policy, but not others, should report exempt subgroups for this metric.
Data source
Administrative records
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Metric AD_6: Re-enrollments or re-instatements for beneficiaries not using
defined pathways after disenrollment or suspension of benefits for
noncompliance
Metric element
Description
Description
Number of beneficiaries in the demonstration who began a new enrollment spell (or had benefits
re-instated) in the current measurement period, have had Medicaid coverage within the prior 3
months, and are not using a state-specific pathway for re-enrollment after being disenrolled for
noncompliance (or re-instatement of benefits after being suspended for noncompliance).
Counted variable
Step 1. Identify beneficiaries in the demonstration who began a new enrollment spell (or had
benefits re-instated) during the measurement period.
Step 2. Retain beneficiaries who had a previous enrollment spell that ended within the prior 3
months (i.e., who were enrolled at some time in the previous three months) or whose benefits were
in suspension status as of the last day of the prior month.
Step 3. [This step is only applicable in states that disenroll or suspend benefits for beneficiaries for
noncompliance with demonstration policies.] Retain beneficiaries who were not using a statedefined re-enrollment pathway after disenrollment for noncompliance with the following:
Premium requirements
Community engagement requirements
Other demonstration-specific requirements
For example, beneficiaries may begin a new enrollment spell or have benefits re-instated due to
changes in their household income, eligibility group status, or resolution of appeals.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Note: Exempt groups may not be an applicable subpopulation for this metric in every state. For
example, this metric is not applicable to states that have a demonstration that focuses solely on
one eligibility and coverage policy, such as community engagement. Only states that have multiple
eligibility and coverage policies, where some groups are exempt from noncompliance penalties
associated with one policy, but not others, should report exempt subgroups for this metric.
Data source
Administrative records
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Mid-year loss of demonstration eligibility
Metric AD_7: Beneficiaries determined ineligible for Medicaid, any reason,
other than at renewal
Metric element
Description
Description
Total number of beneficiaries in the demonstration determined ineligible for Medicaid and
disenrolled during the measurement period (separate reasons reported in other indicators), other
than at renewal
Counted variable
Step 1. Identify beneficiaries who were enrolled in the demonstration for at least one day during the
measurement period (AD_1).
Step 2. Retain those determined ineligible for Medicaid during the measurement period and who
were ineligible as of the last day of the month.
Step 3. Exclude beneficiaries determined ineligible at renewal.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2 and 3.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
Metric AD_7 is the sum of metrics AD_12, AD_13, and AD_14
Data source
Administrative records
Metric AD_8: Beneficiaries no longer eligible for Medicaid, failure to provide
timely change in circumstance information
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and who lost eligibility for Medicaid during
the measurement period due to failure to provide timely change in circumstance information
Counted variable
Step 1. Identify beneficiaries who were enrolled in the demonstration for at least one day during the
measurement period (AD_1).
Step 2. Retain those determined ineligible for Medicaid during the measurement period for the
following reason and who were ineligible as of the last day of the measurement period:
Failure to provide timely change in circumstance information
Step 3. Exclude beneficiaries determined ineligible at renewal.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 3, and 3.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of Metric AD_7
Data source
Administrative records
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Metric AD_9: Beneficiaries determined ineligible for Medicaid after state
processes a change in circumstance reported by a beneficiary
Metric element
Description
Description
Number of beneficiaries who were enrolled in the demonstration and lost eligibility for Medicaid
during the measurement period because they are determined ineligible after the state processes a
change in circumstance.
Counted variable
Step 1. Identify beneficiaries who were enrolled in the demonstration for at least one day during
the measurement period (AD_1).
Step 2. Retain those determined ineligible for Medicaid during the measurement period for the
following reason and who were ineligible as of the last day of the measurement period:
State processed a change in circumstance
Step 3. Exclude beneficiaries determined ineligible at renewal.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2 and 3.
Required or recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of Metric AD_7
Data source
Administrative records
Metric AD_10: Beneficiaries no longer eligible for the demonstration due to
transfer to another Medicaid eligibility group
Metric element
Description
Description
Number of beneficiaries who were enrolled in the demonstration and transferred from the
demonstration to a Medicaid eligibility group not included in the demonstration during the
measurement period
Counted variable
Step 1. Identify beneficiaries who were enrolled in the demonstration for at least one day during the
measurement period (AD_1).
Step 2. Retain those determined ineligible for the demonstration during the measurement period,
who remained eligible for Medicaid coverage under an eligibility group not included in the
demonstration and who were transferred to that eligibility group. Status should be assessed as of
the last day of the measurement period.
Step 3. Exclude beneficiaries determined ineligible at renewal.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Data source
Administrative records
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Metric AD_11: Beneficiaries no longer eligible for the
demonstration due to transfer to CHIP
Metric element
Description
Description
Number of beneficiaries who were enrolled in the demonstration and transferred from the
demonstration to CHIP during the measurement period
Counted variable
Step 1. Identify beneficiaries who were enrolled in the demonstration for at least one day during the
measurement period (AD_1).
Step 2. Retain those determined ineligible for Medicaid during the measurement period who
remained eligible for CHIP coverage and were transferred to CHIP. Status should be assessed as
of the last day of the measurement period.
Step 3. Exclude beneficiaries determined ineligible at renewal.
Step 4. Count unique beneficiaries (deduplicated) that meet the criteria in Steps 1, 2 and 3.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of Metric AD_7
Data source
Administrative records
3.
Enrollment duration at time of disenrollment
Metric AD_12: Enrollment duration, 0-3 months
Metric element
Description
Description
Number of demonstration beneficiaries who lost eligibility for Medicaid during the measurement
period and whose enrollment spell had lasted 3 or fewer months at the time of disenrollment
Counted variable
Step 1. Identify demonstration beneficiaries determined ineligible for Medicaid during the
measurement period, other than at renewal (metric AD_7).
Step 2. Retain beneficiaries whose enrollment spell had lasted 3 or fewer months at the time of
disenrollment.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Relationship to other
metrics
Subset of metric AD_7
Data source
Administrative records
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Metric AD_13: Enrollment duration, 4-6 months
Metric element
Description
Description
Number of demonstration beneficiaries who lose eligibility for Medicaid during the measurement
period whose enrollment spell had lasted between 4 and 6 months at the time of disenrollment
Counted variable
Step 1. Identify demonstration beneficiaries determined ineligible for Medicaid during the
measurement period, other than at renewal (metric AD_7).
Step 2. Retain beneficiaries whose enrollment spell had lasted between 4 and 6 months at the time
of disenrollment.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Relationship to other
metrics
Subset of metric AD_7
Data source
Administrative records
Metric AD_14: Enrollment duration, 6-12 months
Metric element
Description
Description
Number of demonstration beneficiaries who lost eligibility for Medicaid during the measurement
period whose enrollment spell had lasted 6 or more months (up to 12 months) at the time of
disenrollment
Counted variable
Step 1. Identify demonstration beneficiaries determined ineligible for Medicaid during the
measurement period, other than at renewal (metric AD_7).
Step 2. Retain beneficiaries whose enrollment spell had lasted 6 or more months (up to 12 months)
at the time of disenrollment.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Relationship to other
metrics
Subset of metric AD_7
Data source
Administrative records
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Renewal
Metric AD_15: Beneficiaries due for renewal
Metric element
Description
Description
Total number of beneficiaries enrolled in the demonstration who were due for renewal during the
measurement period
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration during the measurement period (metric
AD_1).
Step 2. Retain beneficiaries due for renewal during the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Additional guidance
All annual renewals that came up for redetermination during the measurement period should be
included, regardless of the disposition (including pending, determined eligible, determined
ineligible, and/or ineligible due to failure to return documentation).
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is equal to the sum of metrics AD_16, AD_17, AD_18, AD_19, AD_20, AD_21, and
AD_22
Data source
Administrative records
Metric AD_16: Beneficiaries determined ineligible for the demonstration at
renewal, disenrolled from Medicaid
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and due for renewal during the
measurement period who complete the renewal process and are determined ineligible for Medicaid
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were due for renewal during the
measurement period (metric AD_15).
Step 2. Retain beneficiaries who completed the renewal process.
Step 3. Retain beneficiaries determined ineligible for Medicaid.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Additional guidance
Exclude beneficiaries determined ineligible outside the annual renewal process. Beneficiaries
determined ineligible at mid-year due to a change in circumstance are counted in metrics AD_7
through AD_11.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_15
Data source
Administrative records
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Metric AD_17: Beneficiaries determined ineligible for the demonstration at
renewal, transfer to another Medicaid eligibility category
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and due for renewal during the
measurement period who complete the renewal process and move from the demonstration to a
Medicaid eligibility group not included in the demonstration
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were due for renewal during the
measurement period (metric AD_15).
Step 2. Retain beneficiaries who completed the renewal process.
Step 3. Retain beneficiaries who transferred to another Medicaid eligibility group.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Additional guidance
Exclude beneficiaries determined ineligible outside the annual renewal process. Beneficiaries
determined ineligible at mid-year due to a change in circumstance are counted in metrics AD_7
through AD_11.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_15
Data source
Administrative records
Metric AD_18: Beneficiaries determined ineligible for the demonstration at
renewal, transferred to CHIP
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and due for renewal during the
measurement period who complete the renewal process but move from the demonstration to CHIP
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were due for renewal during the
measurement period (metric AD_15).
Step 2. Retain beneficiaries who completed the renewal process.
Step 3. Retain beneficiaries who transferred to CHIP.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Additional guidance
Exclude beneficiaries determined ineligible outside the annual renewal process. Beneficiaries
determined ineligible at mid-year due to a change in circumstance are counted in metrics AD_7
through AD_11.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_15
Data source
Administrative records
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Metric AD_19: Beneficiaries who did not complete renewal, disenrolled
from Medicaid
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and due for renewal during the
measurement period who are disenrolled from Medicaid for failure to complete the renewal process
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were due for renewal during the
measurement period (metric AD_15).
Step 2. Retain beneficiaries who were disenrolled from Medicaid for failure to complete the renewal
process.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Additional guidance
Exclude beneficiaries determined ineligible outside the annual renewal process. Beneficiaries
determined ineligible at mid-year due to a change in circumstance are counted in metrics AD_7
through AD_11.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_15
Data source
Administrative records
Metric AD_20: Beneficiaries who had pending/ uncompleted renewals and
were still enrolled
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and due for renewal during the
measurement period for whom the state had not completed renewal determination by the end of
the measurement period and were still enrolled
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were due for renewal during the
measurement period (metric AD_15).
Step 2. Retain beneficiaries for whom the state had not completed renewal determination by the
last day of the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Additional guidance
Some pending renewal determinations will be completed between the last day of the measurement
period and the time that enrollment monitoring metrics should be generated - 30 days after the
close of the measurement period. Renewal dispositions during this time window that result in
demonstration ineligibility should be counted with AD_16 - AD_19. Renewal dispositions during this
time window that resulted in continued demonstration eligibility without breaks in coverage for
services (for example, if the state covers services back to the renewal date) should be counted in
AD_21.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_15
Data source
Administrative records
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Metric AD_21: Beneficiaries who retained eligibility for the demonstration
after completing renewal forms
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and due for renewal during the
measurement period who remained enrolled in the demonstration after responding to renewal
notices
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were due for renewal during the
measurement period (metric AD_15).
Step 2. Retain beneficiaries who completed the renewal process by responding to beneficiary
notices.
Step 3. Retain beneficiaries who remained enrolled.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_15
Data source
Administrative records
Metric AD_22: Beneficiaries who renewed ex parte
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and due for renewal during the
measurement period who remained enrolled as determined by third-party data sources or available
information, rather than beneficiary response to renewal notices
Counted variable
Step 1. Identify beneficiaries due for renewal during the measurement period (metric AD_15).
Step 2. Retain beneficiaries who remained enrolled as of the last day during the measurement
period as determined by third-party data sources or available information, rather than beneficiary
response to renewal notices.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_15
Data source
Administrative records
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Cost sharing limit
Metric AD_23: Beneficiaries who reached 5% limit
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration who reached the 5% of income limit on cost
sharing and premiums during the month.
Counted variable
Step 1. Identify beneficiaries enrolled for the demonstration (metric AD_1).
Step 2. Retain beneficiaries who reached the 5% of income limit on cost sharing and premiums
during the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required for states with cost-sharing or premiums.
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Data source
Administrative records
6.
Appeals and grievances
Metric AD_24: Appeals, eligibility
Metric element
Description
Description
Number of appeals filed by beneficiaries enrolled in the demonstration during the measurement
period regarding Medicaid eligibility
Counted variable
Step 1. Identify appeals regarding Medicaid eligibility filed by demonstration beneficiaries during
the measurement period.
Step 2. Count each appeal identified in Step 1 once, regardless of whether more than one appeal
is filed by the same beneficiary. Appeals that are processed through multiple levels of review
should only be counted once.
Additional guidance
There is no typology for tracking appeals filed by Medicaid beneficiaries; each state tracks and
categorizes appeals differently. States should map their own categories onto those in AD_24 (for
eligibility-related categories) and AD_25 (for categories related to denial of benefits).
Required or
recommended
Recommended
Measurement period
(calculation lag)
Quarter (no lag)
Data source
Administrative records
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Metric AD_25: Appeals, denial of benefits
Metric element
Description
Description
Number of appeals filed by beneficiaries enrolled in the demonstration during the measurement
period regarding denial of benefits
Counted variable
Step 1. Identify appeals regarding denial of benefits filed by demonstration beneficiaries during the
measurement period.
Step 2. Count each appeal identified in Step 1 once, regardless of whether more than one appeal
is filed by the same beneficiary. Appeals that are processed through multiple levels of review
should only be counted once.
Additional guidance
There is no typology for tracking appeals filed by Medicaid beneficiaries; each state tracks and
categorizes appeals differently. States should map their own categories onto those in AD_24 (for
eligibility-related categories) and AD_25 (for categories related to denial of benefits).
Required or
recommended
Recommended
Measurement period
(calculation lag)
Quarter (no lag)
Data source
Administrative records
Metric AD_26: Grievances, care quality
Metric element
Description
Description
Number of grievances filed by beneficiaries enrolled in the demonstration during the measurement
period regarding the quality of care or services provided
Counted variable
Step 1. Identify grievances regarding the quality of care services provided filed by demonstration
beneficiaries during the measurement period.
Step 2. Count each grievance identified in Step 1 once, regardless of whether more than one
grievance is filed by the same enrollee.
Additional guidance
There is no national typology for tracking grievances filed by Medicaid beneficiaries; each state
tracks and categorizes grievances differently. States should map their own categories onto those in
AD_26 (for categories related to care quality), AD_27 (for provider/managed care entity-related
categories), and AD_28 (for categories that cannot be classified into either care quality or
provider/managed care entities).
Required or
recommended
Recommended
Measurement period
(calculation lag)
Quarter (no lag)
Data source
Administrative records
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Metric AD_27: Grievances, provider or managed care entities
Metric element
Description
Description
Number of grievances filed by beneficiaries enrolled in the demonstration during the measurement
period regarding a provider or managed care entity. Managed care entities include Managed Care
Organizations (MCO), Prepaid Inpatient Health Plans (PIHP), and Prepaid Ambulatory Health
Plans (PAHP).
Counted variable
Step 1. Identify grievances filed by demonstration beneficiaries during the measurement period
regarding a provider (including primary care case management providers) or managed care entity.
Step 2. Count each grievance identified in Step 1 once, regardless of whether more than one
grievance is filed by the same beneficiary.
Additional guidance
There is no national typology for tracking grievances filed by Medicaid beneficiaries; each state
tracks and categorizes grievances differently. States should map their own categories onto those in
AD_26 (for categories related to care quality), AD_27 (for provider/managed care entity-related
categories), and AD_28 (for categories that cannot be classified into either care quality or
provider/managed care entities).
Required or
recommended
Recommended
Measurement period
(calculation lag)
Quarter (no lag)
Data source
Administrative records
Metric AD_28: Grievances, other
Metric element
Description
Description
Number of grievances filed by beneficiaries enrolled in the demonstration during the measurement
period regarding other matters that are not subject to appeal
Counted variable
Step 1. Identify grievances regarding other matters that are not subject to appeal filed by
demonstration beneficiaries during the measurement period. Exclude grievances counted in AD_26
and AD_27.
Step 3. Count each grievance identified in Step 1 once, regardless of whether more than one
grievance is filed by the same beneficiary.
Additional guidance
There is no national typology for tracking grievances filed by Medicaid beneficiaries; each state
tracks and categorizes grievances differently. States should map their own categories onto those in
AD_26 (for categories related to care quality), AD_27 (for provider/managed care entity-related
categories), and AD_28 (for categories that cannot be classified into either care quality or
provider/managed care entities).
Required or
recommended
Recommended
Measurement period
(calculation lag)
Quarter (no lag)
Data source
Administrative records
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MATHEMATICA POLICY RESEARCH
Access to care
Metric AD_29: Primary care provider availability
Metric element
Description
Description
Number of primary care providers enrolled to deliver Medicaid services at the end of the
measurement period
Counted variable
Step 1. Identify primary care providers who were enrolled to deliver Medicaid services to
demonstration beneficiaries and were qualified to deliver Medicaid services as of the last day of
the measurement period.
Step 2. Count unique primary care providers (deduplicated) who meet the criteria in Step 1.
Additional guidance
Standards for classifying, enrolling, and qualifying physician providers vary by state. States
should report which providers were considered primary care providers for this metric.
Sources for physician provider data also vary by state. These data may be available in provider
enrollment databases maintained by the state or by the managed care organizations the state
contracts with to serve beneficiaries.
The metric is intended to capture the set of providers potentially available to demonstration
beneficiaries. If there is a distinction between all providers enrolled and qualified to deliver
Medicaid services and those available to demonstration beneficiaries, the metric should only
include providers available to demonstration beneficiaries.
Required or recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Data source
Provider enrollment databases
Metric AD_30: Primary care provider active participation
Metric element
Description
Description
Number of primary care providers enrolled to deliver Medicaid services with service claims for 3
or more demonstration beneficiaries during the measurement period
Counted variable
Step 1. Identify all primary care providers enrolled to deliver Medicaid services to demonstration
beneficiaries as of the last day of the measurement period (metric AD_29).
Step 2. Retain primary care providers that are identified as the servicing or billing provider on
claims that have service end dates during the measurement period.
Step 3. Retain primary care providers from Step 2 that have claims for 3 or more unique
demonstration beneficiaries (at least one claim per beneficiary) during the measurement period.
Step 4. Count unique providers (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Additional guidance
Standards for classifying, enrolling, and qualifying physician providers vary by state. States
should report which providers were considered primary care providers for this metric.
Sources for physician provider data also vary by state. These data may be available in provider
enrollment databases maintained by the state or by the managed care organizations the state
contracts with to serve beneficiaries.
Required or recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Data source
Provider enrollment databases and claims and encounters
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
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Metric AD_31: Specialist provider availability
Metric element
Description
Description
Number of specialists enrolled to deliver Medicaid services at the end of the measurement period
Counted variable
Step 1. Identify specialist providers who were enrolled to deliver Medicaid services to
demonstration beneficiaries and were qualified to deliver Medicaid services as of the last day of the
measurement period.
Step 2. Count unique specialist providers (deduplicated) who meet the criteria in Step 1.
Additional guidance
Standards for classifying, enrolling, and qualifying specialist providers vary by state. States should
report which providers were considered specialty providers for this metric.
Sources for specialist provider data also vary by state. These data may be available in provider
enrollment databases maintained by the state or by the managed care organizations the state
contracts with to serve beneficiaries.
The metric is intended to capture the set of providers potentially available to demonstration
beneficiaries. If there is a distinction between all providers enrolled and qualified to deliver
Medicaid services and those available to demonstration beneficiaries, the metric should only
include providers available to demonstration beneficiaries.
Required or
recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Data source
Provider enrollment databases
Metric AD_32: Specialist provider active participation
Metric element
Description
Description
Number of specialists enrolled to deliver Medicaid services with service claims for 3 or more
demonstration beneficiaries during the measurement period
Counted variable
Step 1. Identify specialist providers enrolled to deliver Medicaid services to demonstration
beneficiaries as of the last day of the measurement period (metric AD_31).
Step 2. Retain specialist providers that are identified as the servicing or billing provider on claims
that have service end dates during the measurement period.
Step 3. Retain specialist providers from Step 2 if they have claims for 3 or more unique
beneficiaries (at least one claim per beneficiary) during the measurement period.
Step 4. Count unique providers (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Additional guidance
Standards for classifying, enrolling, and qualifying specialist providers vary by state. States should
report which providers were considered specialty providers for this metric.
Sources for specialist provider data also vary by state. These data may be available in provider
enrollment databases maintained by the state or by the managed care organizations the state
contracts with to serve beneficiaries.
Required or
recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Data source
Provider enrollment databases and claims and encounters
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
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Metric AD_33: Preventive care and office visit utilization
Metric element
Description
Description
Total utilization of preventive care and office visits per 1,000 demonstration beneficiary months
during the measurement period
Numerator
Step 1. Identify all preventive care and office visits with service end dates during the measurement
period for demonstration beneficiaries included in the denominator. To identify preventive care and
office visits, count professional and institutional claims that include any of the codes in the
following:
HEDIS Well-Care Value Set
HEDIS Ambulatory Visits Value Set
HEDIS Other Ambulatory Visits Value Set
Step 2. Keep all professional claims and only outpatient institutional claims that meet either of the
following conditions:
Type of Bill is 71X or 77X (where X is any third digit)
Type of Bill is 85X (where X is any third digit) AND Revenue Center Code starts with
096, 097, or 098)
Step 3. Count the unique number of claim headers (visits) identified in Steps 1 and 2.
Denominator
Total number of months of beneficiary demonstration enrollment during the measurement period.
Beneficiaries that are continuously enrolled during the reporting quarter contribute 3 months to the
denominator.
Metric calculation
Calculate the rate by dividing the number of claim headers (visits) in the numerator by the number
of beneficiary months in the denominator and then multiply by 1,000, as follows:
(Number of visits / Number of demonstration beneficiary months) * 1,000
Additional guidance
To view the HEDIS Value Sets used in this metric, submit a technical assistance request to
[email protected].
Required or
recommended
Recommended
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Data source
Claims and encounters; other administrative records
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
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Metric AD_34: Prescription drug use
Metric element
Description
Description
Total utilization of 30-day prescription fills per 1,000 demonstration beneficiary months in the
measurement period.
Numerator
Step 1. Identify all prescription fill claims with a prescription fill date during the measurement period
for demonstration beneficiaries included in the denominator.
Step 2. Standardize prescription fills into 30-day fills using the following logic:
a. Claims for a 30-day supply or less than 30-days supply count as one prescription fill.
b. Claims for supply greater than 30 days should be standardized into 30-day fills. For
example, a 60-day supply equals two prescription fills, a 90-day supply equals three
prescription fills.
Step 3. Count the total number of standardized 30-day prescription fills identified in Step 2.
Denominator
Total number of months of beneficiary demonstration enrollment during the measurement period.
Beneficiaries that are continuously enrolled during the reporting quarter contribute 3 months to the
denominator.
Metric calculation
Calculate the rate by dividing the number of prescription fills in the numerator by the number of
beneficiary months in the denominator and then multiply by 1,000, as follows:
(Number of prescription fills / Number of demonstration beneficiary months) * 1,000
Required or
recommended
Recommended
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Data source
Claims and encounters; other administrative records
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
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Metric AD_35: Emergency department utilization, all use
Metric element
Description
Description
Total number of emergency department (ED) visits per 1,000 demonstration beneficiary months
during the measurement period
Numerator
Step 1. Identify the total number of ED visits with service end dates during the measurement period
for demonstration beneficiaries in the denominator. Use either of the following to identify ED visits:
HEDIS ED Value Set
A procedure code in the HEDIS ED Procedure Code Value Set with a place of service
code in the HEDIS ED POS Value Set
Step 2. Count each visit to an ED once, regardless of the intensity or duration of the visit. Count
multiple ED visits to the same facility on the same ending date of service as one visit.
Step 3. Calculate the number of ED visits identified in Steps 1 and 2.
Denominator
Total number of months of beneficiary demonstration enrollment during the measurement period.
Beneficiaries that are continuously enrolled during the reporting quarter contribute 3 months to the
denominator.
Metric Calculation
Calculate the rate by dividing the number of ED visits in the numerator by the number of
beneficiary months in the denominator and then multiply by 1,000, as follows:
(Number of ED visits / Number of demonstration beneficiary months) * 1,000
Additional guidance
To view the HEDIS Value Sets used in this metric, submit a technical assistance request to
[email protected].
Required or
recommended
Recommended
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Data source
Claims and encounters; other administrative records
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
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Metric AD_36: Emergency department utilization, non-emergency
Metric element
Description
Description
Total number of ED visits for non-emergency conditions per 1,000 demonstration beneficiary
months during the measurement period.
If the state differentiates emergent/non-emergent visit copayments, then non-emergency visits
should be identified for monitoring purposes using the same criteria used to assess the differential
copayment.
If the state does not differentiate emergent/non-emergent copayments, then non-emergency visits
should be defined as all visits not categorized as emergent using the method below.
Numerator
Step 1. Identify the total number of ED visit claims with service end dates during the measurement
period for demonstration beneficiaries in the denominator. Use either of the following to identify ED
visits:
HEDIS ED Value Set
A procedure code in the HEDIS ED Procedure Code Value Set with a place of service
code in the HEDIS ED POS Value Set
This should be the same set of ED claims counted in the numerator of AD_35. If the state
differentiates emergent/non-emergent visit copayments, follow Step 2 and then skip to Step 7. If
the state does not differentiate emergent/non-emergent copayments, follow Steps 3 through 7 to
identify non-emergency visits.
Step 2. Using the state-defined criteria for identifying non-emergency visits, identify ED visits for
which the state charged the beneficiary a non-emergency ED visit co-pay. Skip to Step 7.
Step 3. Classify ED visits that resulted in an inpatient stay as emergent. An ED visit resulted in an
inpatient stay if there is an inpatient stay claim for the same beneficiary with an admission date on
the ED service end date or the following day. Use the following to Identify inpatient stay claims:
HEDIS Inpatient Stay Value Set
Step 4. To classify the remaining visits, download the algorithm for the New York University ED
classification schemes for ICD-10, found here: (https://wagner.nyu.edu/faculty/billings/nyuedbackground). Note: the ED classification schemes utilize only the primary diagnosis on claims
and are intended for monitoring broad population-level trends, not for determining whether an
individual visit was or was not emergent based on clinical symptoms present on admission to the
ED.
Step 5. Using the probabilities in the classification schemes, classify ED visits with service dates
during the measurement period as likely emergent or non-emergent. Drop visits that meet the
following criteria:
Visits with a primary diagnosis code for
Injury as identified in the classification scheme, where the variable “injury”
generated by the algorithm equals 100%.
Substance abuse as identified in the classification scheme, where the variable
“drug” generated by the algorithm equals 100%.
Alcohol as identified in the classification scheme, where the variable “alcohol”
generated by the algorithm equals 100%.
Mental health as identified in the classification scheme, where the variable “psych”
generated by the algorithm equals 100% or 67%.
Unclassified as identified in the classification scheme, where the variable
“unclassified” generated by the algorithm equals 100%.
Visits with a primary diagnosis code where the sum of probabilities across the following
emergent category variables generated by the algorithm is greater than or equal to 70%:
ED_Care_Needed__not_Preventable
ED_Care_Needed__Preventable_Avoi
Emergent__PC_Treatable
Step 6. Classify all remaining ED visits as non-emergent.
Step 7. Count the unique number of non-emergent ED visits defined in Step 2 (if the state
differentiates emergent/non-emergent visit copayments) or Step 6. Count each visit to an ED once,
regardless of the intensity or duration of the visit. Count multiple ED visits to the same facility on
the same ending date of service as one visit.
Denominator
Total number of months of beneficiary demonstration enrollment during the measurement period.
Beneficiaries that are continuously enrolled during the reporting quarter contribute 3 months to the
denominator.
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Metric AD_36: Emergency department utilization, non-emergency
Metric element
Description
Metric Calculation
Calculate the rate by dividing the number of non-emergent ED visits in the numerator by the
number of beneficiary months in the denominator and then multiply by 1,000, as follows:
(Number of non-emergent ED visits / Number of demonstration beneficiary months) * 1,000
Additional guidance
To view the HEDIS Value Sets used in this metric, submit a technical assistance request to
[email protected].
Required or
recommended
Recommended. Required for states with copayments for non-emergency use.
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Data source
Claims and encounters and other administrative records
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
Metric AD_37: Inpatient admissions
Metric element
Description
Description
Total number of inpatient admissions per 1,000 demonstration beneficiary months during the
measurement period
Numerator
Step 1. Identify all inpatient stays (acute and non-acute) with discharge dates during the
measurement period for demonstration beneficiaries in the denominator. Use the following to
identify inpatient stays:
HEDIS Inpatient Stay Value Set
Step 2. Retain only stays with discharge dates that fall during the measurement period.
Step 3. Calculate the number of inpatient admissions using all stays identified in steps 1 and 2.
Count each stay once regardless of the duration of the stay.
Denominator
Total number of months of beneficiary demonstration enrollment during the measurement period.
Beneficiaries that are continuously enrolled during the reporting quarter contribute 3 months to the
denominator.
Metric calculation
Calculate the rate by dividing the number of inpatient stays in the numerator by the number of
beneficiary months in the denominator and then multiply by 1,000, as follows:
(Number of inpatient stays/Number of demonstration beneficiary months) * 1,000
Additional guidance
To view the HEDIS Value Sets used in this metric, submit a technical assistance request to
[email protected].
Required or
recommended
Recommended
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Exempt groups
Specific eligibility groups (required)
Data source
Claims and encounters and other administrative records
Claim type
Only use paid claims. (Do not use suspended, pending, or denied claims.)
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MATHEMATICA POLICY RESEARCH
Quality of care and health outcomes
Metric AD_38A: Medical Assistance with Smoking
and Tobacco Use Cessation (MSC-AD)
Metric element
Description
Measure
sets/endorsement
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set) (NQF#
0027)
Measure steward: NCQA
Description
This metric consists of the following components; each assesses different facets of providing
medical assistance with smoking and tobacco use cessation:
Advising smokers and tobacco users to quit
Discussing cessation medications
Discussing cessation strategies
Metric calculation
Instructions for calculating this metric can be found in Appendix B: Technical Specifications for
Medicaid Quality Measures, Adapted from FFY 2019 Adult Core Set Measure Specifications.
Required or
recommended
Required (38A or 38B. States do not have to report both).
Measurement period
(calculation lag)
Calendar year (90 days). See Appendix B for additional information on the measurement period.
Subpopulations
Income groups
Specific eligibility groups (required if sampling allows for reporting at this level)
Data source
Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan survey, Adult
Version
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Metric AD_38B: Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention
Metric element
Description
Measure
sets/endorsement
2018 Merit-Based Incentive Payment System (MIPS) Quality Measures (NQF# 0028)
Measure steward: PCPI Foundation
Description
This metric consists of the following components:
1. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use
one or more times within 24 months
2. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use
and identified as a tobacco user who received tobacco cessation intervention
3. Percentage of beneficiaries aged 18 years and older who were screened for tobacco use
one or more times within 24 months AND who received cessation intervention if identified
as a tobacco user
Metric calculation
Instructions for calculating this metric can be found in the MIPS Quality Measure Technical
Specifications for 2018 reporting, Quality ID #226 (NQF# 0028) Preventive Care and Screening:
Tobacco Use: Screening and Cessation Intervention
Beneficiaries who have been enrolled in the demonstration for at least one continuous month (30
days) in the measurement period, and who meet the additional criteria in the MIPS Technical
Specifications, should be included in this calculation.
Additional guidance
The 2018 PCPI Foundation measure specifications are available at:
https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-RegistryMeasures/2018_Measure_226_Claims.pdf
This measure specification includes clinical concepts and claim codes that are not typically found in
Medicaid claims. As such, states are encouraged to explore the feasibility of reporting this measure.
States may also choose to work with providers to encourage providers to include the codes on
claims they submit.
Required or
recommended
Required (AD_38A or AD_38B. States do not have to report both.)
Measurement period
(calculation lag)
Calendar year (90 days). See measure steward specifications for additional information on the
measurement period.
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Claims and encounters
Claim type
Use all paid, suspended, pending and denied claims
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Metric AD_39-1: Follow-Up After Emergency Department Visit for Alcohol
and Other Drug Abuse or Dependence (FUA-AD)
Metric element
Description
Measure
sets/endorsement
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set) (NQF#
2605)
Measure steward: NCQA
Description
Percentage of ED visits for beneficiaries age 18 and older who have a principal diagnosis of alcohol
or other drug (AOD) abuse or dependence, and who had a follow-up visit with a corresponding
principal diagnosis for AOD. Two rates are reported:
1. Percentage of ED visits for AOD abuse or dependence for which the beneficiary received
follow-up within 30 days of the ED visit (31 total days).
2. Percentage of ED visits for AOD abuse or dependence for which the beneficiary received
follow-up within 7 days of the ED visit (8 total days).
Metric calculation
Instructions for calculating this metric can be found in Appendix B: Technical Specifications for
Medicaid Quality Measures, Adapted from FFY 2019 Adult Core Set Measure Specifications.
Required or
recommended
Required
Measurement period
(calculation lag)
Calendar year (90 days). See Appendix B for additional information on the measurement period.
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Claims and encounters
Claim type
Use all paid, suspended, pending and denied claims
Metric AD_39-2: Follow-Up After Emergency Department Visit for Mental
Illness (FUM-AD)
Metric element
Description
Measure
sets/endorsement
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set) (NQF#
2605)
Measure steward: NCQA
Description
Percentage of ED visits for beneficiaries age 18 and older who have a principal diagnosis of mental
illness or intentional self-harm, and who had a follow-up visit with a corresponding principal
diagnosis for mental illness. Two rates are reported:
1. Percentage of ED visits for mental illness or intentional self-harm for which the beneficiary
received follow-up within 30 days of the ED visit (31 total days).
2. Percentage of ED visits for mental illness or intentional self-harm for which the beneficiary
received follow-up within 7 days of the ED visit (8 total days).
Metric calculation
Instructions for calculating this metric can be found in Appendix B: Technical Specifications for
Medicaid Quality Measures, Adapted from FFY 2019 Adult Core Set Measure Specifications.
Required or
recommended
Required
Measurement period
(calculation lag)
Calendar year (90 days). See Appendix B for additional information on the measurement period.
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Claims and encounters
Claim type
Use all paid, suspended, pending and denied claims
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Metric AD_40: Initiation and Engagement of Alcohol and Other Drug Abuse
or Dependence Treatment (IET-AD)
Metric element
Description
Measure
sets/endorsement
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set) (NQF#
0004)
Measure steward: NCQA
Description
Percentage of beneficiaries age 18 and older with a new episode of AOD abuse or dependence
who received the following:
1. Initiation of AOD Treatment. Percentage of beneficiaries who initiate treatment through
an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial
hospitalization, telehealth, or medication assisted treatment (MAT) within 14 days of the
diagnosis
2. Engagement of AOD Treatment. Percentage of beneficiaries who initiate treatment and
who had two or more additional AOD services or MAT within 34 days of the initiation visit
The following diagnosis cohorts are reported for each rate: (1) Alcohol abuse or dependence, (2)
Opioid abuse or dependence, (3) Other drug abuse or dependence, and (4) Total AOD abuse or
dependence. A total of 8 separate rates are reported for this measure.
Metric calculation
Instructions for calculating this metric can be found in Appendix B: Technical Specifications for
Medicaid Quality Measures, Adapted from FFY 2019 Adult Core Set Measure Specifications.
Required or
recommended
Required
Measurement period
(calculation lag)
Calendar year (90 days). See Appendix B for additional information on the measurement period.
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Claims and encounters or EHR
Claim type
Use all paid, suspended, pending and denied claims
Metric AD_41: PQI 01: Diabetes Short-Term Complications Admission Rate
(PQI01-AD)
Metric element
Description
Measure
sets/endorsement
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set) (NQF#
0272)
Measure steward: AHRQ
Description
Number of inpatient hospital admissions for diabetes short-term complications (ketoacidosis,
hyperosmolarity, or coma) per 100,000 beneficiary months for beneficiaries age 18 and older
Metric calculation
Instructions for calculating this metric can be found in Appendix B: Technical Specifications for
Medicaid Quality Measures, Adapted from FFY 2019 Adult Core Set Measure Specifications.
Required or
recommended
Required
Measurement period
(calculation lag)
Calendar year (90 days). See Appendix B for additional information on the measurement period.
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Claims and encounters
Claim type
Use paid claims only
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Metric AD_42: PQI 05: Chronic Obstructive Pulmonary Disease (COPD) or
Asthma in Older Adults Admission Rate (PQI05-AD)
Metric element
Description
Measure
sets/endorsement
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set) (NQF#
0275)
Measure steward: AHRQ
Description
Number of inpatient hospital admissions for chronic obstructive pulmonary disease (COPD) or
asthma per 100,000 beneficiary months for beneficiaries age 40 and older
Metric calculation
Instructions for calculating this metric can be found in Appendix B: Technical Specifications for
Medicaid Quality Measures, Adapted from FFY 2019 Adult Core Set Measure Specifications.
Required or
recommended
Required
Measurement period
(calculation lag)
Calendar year (90 days). See Appendix B for additional information on the measurement period.
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Claims and encounters
Claim type
Use paid claims only
Metric AD_43: PQI 08: Heart Failure Admission Rate (PQI08-AD)
Metric element
Description
Measure
sets/endorsement
FFY 2019 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set) (NQF#
0277)
Measure steward: AHRQ
Description
Number of inpatient hospital admissions for heart failure per 100,000 beneficiary months for
beneficiaries age 18 and older
Metric calculation
Instructions for calculating this metric can be found in Appendix B: Technical Specifications for
Medicaid Quality Measures, Adapted from FFY 2019 Adult Core Set Measure Specifications.
Required or
recommended
Required
Measurement period
(calculation lag)
Calendar year (90 days). See Appendix B for additional information on the measurement period.
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Claims and encounters
Claim type
Use paid claims only
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Metric AD_44: PQI 15: Asthma in Younger Adults Admission Rate (PQI15AD)
Metric element
Description
Measure
sets/endorsement
2019 Medicaid Adult Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set)
(NQF# 0283)
Measure steward: AHRQ
Description
Number of inpatient hospital admissions for asthma per 100,000 beneficiary months for
beneficiaries aged 18 to 39
Metric calculation
Instructions for calculating this metric can be found in Appendix B: Technical Specifications for
Medicaid Quality Measures
Required or
recommended
Required
Measurement period
(calculation lag)
Calendar year (90 days). See Appendix B for additional information on the measurement period.
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Claims and encounters
Claim type
Use paid claims only
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Administrative cost
Metric AD_45: Administrative cost of demonstration operation
Metric element
Description
Description
Cost of contracts or contract amendments and staff time equivalents required to administer
demonstration policies, including premium collection, health behavior incentives, premium
assistance, community engagement requirements and/or retroactive eligibility waivers
Counted variable
Step 1. Calculate the total costs in dollars incurred during the measurement period for contracts or
contract amendments. Costs include those related to the following:
Premium collection
Health behavior incentives
Premium assistance
Community engagement policies
Retroactive eligibility waivers
Include costs from:
Managed care organizations that serve beneficiaries covered by the demonstration, if the
marginal administrative cost beyond the medical coverage capitation rate can be
identified.
Modifications or new contracts for information technology support required for data
systems changes.
Any stand-alone contracts with other vendors that the state established or modified to
support demonstration implementation (for example, additional call center support).
Step 2. Identify the number of full time equivalent (FTE) staff devoted to administering
demonstration policies. Include both new hires as well existing staff whose work is being redirected
to administration of the demonstration. Group FTEs into labor categories defined by the state.
Include staff administering the following:
Premium collection
Health behavior incentives
Premium assistance
Community engagement requirements
Retroactive eligibility waivers
Step 3. Calculate the dollar value of FTEs by multiplying the median salary and value of benefits
for each labor category by the number of FTEs in the category. Sum across all labor categories to
obtain the total cost of staff time.
Step 4. Calculate total administrative costs in dollars by summing the costs calculated in Steps 1
and 3.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Demonstration year (no lag)
Data source
Administrative records
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B. Additional metrics to be reported for demonstrations that require
premiums or account payments
1.
Enrollment by premium payment status
Metric PR_1: Beneficiaries subject to premium policy (or account
contribution) during the month, not exempt
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the premium policy (or account contribution policy), regardless of whether they paid or
did not pay during the measurement period.
Counted variable
Step 1. Identify beneficiaries who were enrolled in the demonstration as of the last day of the
month.
Step 2. Retain beneficiaries whose income and eligibility group were subject to the premium policy
(or account contribution policy) during the measurement period, regardless of whether they pay or
do not pay during the measurement period.
Step 3. Exclude beneficiaries in income and eligibility groups who are subject to premiums, but
who have an individual exemption from the policy. These individuals are counted in metric PR_2.
Step 4. Count unique beneficiaries (deduplicated) who meet criteria for Steps 1, 2, and 3.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is equal to the sum of metrics PR_3, PR_4, PR_5, and PR_6.
Data source
Administrative records
The number of beneficiaries identified in Step 1 should be a smaller number than metric AD_1,
which includes beneficiaries enrolled at any time of the month, including those no longer enrolled
as of the last day of the month. Metric AD_1 also includes individuals who have an exemption from
the premium policy but those individuals are excluded from this measure.
Metric PR_2: Beneficiaries who were exempt from premiums for that month
Metric element
Description
Description
Among beneficiaries enrolled in the demonstration who were subject to the premium (or account
contribution) policy on the basis of income or eligibility group, the count of those exempt from
owing premiums or other monthly payments, and therefore not required to make payments. For
example, demonstration policies may exempt beneficiaries who would otherwise be subject to
premiums as incentives for health behaviors or other activities.
Counted variable
Count unique beneficiaries (deduplicated) in income and eligibility groups subject to premium (or
account contribution) policy who were enrolled in the demonstration but were exempt from the
premium policy as of the last day of the measurement period. Exclude hardship exemptions, which
should be counted under PR_4.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Administrative records
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Metric PR_3: Beneficiaries who paid a premium during the month
Metric element
Description
Description
Among beneficiaries enrolled in the demonstration whose income and eligibility group were subject
to the premium (or account contribution) policy, number of beneficiaries who paid this month
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the premium policy (or account contribution policy) (metric PR_1).
Step 2. Retain beneficiaries who paid premiums or other monthly payment during the
measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric PR_1
Data source
Administrative records
Metric PR_4: Beneficiaries who were subject to premium policy but declare
hardship for that month
Metric element
Description
Description
Among beneficiaries enrolled in the demonstration whose income and eligibility group were subject
to the premium (or account contribution) policy, number of beneficiaries who were able to claim
temporary hardship and were therefore not required to make a payment in the measurement period
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the premium policy (or account contribution policy) (metric PR_1).
Step 2. Retain beneficiaries who successfully claimed temporary hardship and were therefore not
required to make payment. Beneficiaries whose payments were deferred, but must still be paid,
should not be counted.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required for states that allow beneficiaries to avoid paying premiums or other monthly payments
by claiming temporary hardship
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric PR_1
Data source
Administrative records
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Metric PR_5: Beneficiaries in short-term arrears (grace period)
Metric element
Description
Description
Among beneficiaries enrolled in the demonstration whose income and eligibility group were subject
to the premium (or account contribution) policy, the number of those who did not pay in the
measurement period, but have not yet exceeded their grace period
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the premium policy (or account contribution policy) (metric PR_1).
Step 2. Retain beneficiaries who did not pay during the measurement period, but had not yet
exceeded their grace period (if the state has a grace period), as of the last day of the measurement
period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required if state has a grace period
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric PR_1
Data source
Administrative records
Metric PR_6: Beneficiaries in long-term arrears
Metric element
Description
Description
Among beneficiaries enrolled in the demonstration whose income and eligibility group were subject
to the premium (or account contribution) policy, number of beneficiaries who did not pay this
month, and who remain enrolled even though they have exceeded the grace period.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the premium policy (or account contribution policy) (metric PR_1).
Step 2. Retain beneficiaries who did not pay during the measurement period and who remained
enrolled even though they have exceeded their grace period (if the state has a grace period), as of
the last day of the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required if state has a grace period and allows continued enrollment for any income and eligibility
groups otherwise subject to premiums once the grace period has been exceeded
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric PR_1
Data source
Administrative records
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Metric PR_7: Beneficiaries with collectible debt
Metric element
Description
Description
Among beneficiaries enrolled in the demonstration whose income and eligibility group were subject
to the premium policy (or account contribution policy), number of beneficiaries who had collectible
debt.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the premium policy (or account contribution policy) (metric PR_1).
Step 2. Retain beneficiaries who had collectible debt as of the last day of the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric PR_1.
This metric could include beneficiaries who are counted in metrics PR_2, PR_3, PR_4, PR_5, or
PR_6, depending on state debt and enrollment policies. For example, a beneficiary may have paid
the amount due for the current measurement period, and be included in the count for PR_3, but
have unpaid amounts from prior measurement periods.
Data source
Administrative records
2.
Cumulative enrollment duration in states with time-variant premium policies
Metric PR_8: Beneficiaries in enrollment duration tier 1
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and subject to premium policies whose
cumulative length of enrollment fell in tier 1 – the shortest enrollment duration, during which
beneficiaries are subject to the first set of program rules and requirements. Tiers are defined in
terms of enrollment periods that are distinguished by different premium or copayment liabilities.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the premium policy (or account contribution policy) (metric PR_1).
Step 2. Retain beneficiaries whose cumulative length of enrollment fell into tier 1 as of the last day
of the measurement period.
Tier 1 refers to the first set of program rules and requirements beneficiaries are subject
to upon enrollment.
Tiers are distinguished by different premium or copayment liabilities.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended in states with time-variant premium policies
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Administrative records
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Metric PR_9: Beneficiaries in enrollment duration tier 2
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and subject to premium policies whose
cumulative length of enrollment fell in tier 2 - the enrollment duration that follows tier 1, during
which beneficiaries are subject to the set of program rules and requirements in effect after
exceeding the enrollment duration for tier 1. Tiers are defined in terms of enrollment periods that
are distinguished by different premium or copayment liabilities.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the premium policy (or account contribution policy) (metric PR_1).
Step 2. Retain beneficiaries (deduplicated) whose cumulative length of enrollment fell into tier 2 as
of the last day of the measurement period.
Tier 2 refers to the first set of program rules and requirements beneficiaries are subject
to after exceeding the timeframe for tier 1.
Tiers are distinguished by different premium or copayment liabilities.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended in states with time-variant premium policies
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Administrative records
Metric PR_10: Beneficiaries in enrollment duration tiers 3+
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration and subject to premium policies whose
cumulative length of enrollment fell in tier 3 – the enrollment duration that follows tier 2, during
which beneficiaries are subject to the set of program rules and requirements in effect after
exceeding the enrollment duration for tier 2. Tiers are defined in terms of enrollment periods that
are distinguished by different premium or copayment liabilities.
States with more than three tiers of program rules should calculate additional metrics to report
enrollment counts for current enrollees within each tier.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the premium policy (or account contribution policy) (metric PR_1).
Step 2. Retain beneficiaries whose cumulative length of enrollment fell into tier 3 as of the last day
of the measurement period.
Tier 3 refers to the first set of program rules and requirements beneficiaries are subject
to after exceeding the timeframe for tier 2.
Tiers are distinguished by different premium or copayment liabilities.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Additional guidance
In addition to reporting for Tier 3, report separately for each Tier above Tier 3 following the
specifications for Tier 3.
Required or
recommended
Recommended in states with time-variant premium policies
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Administrative records
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Mid-year change in circumstance by premium amount
Metric PR_11: Beneficiaries for whom the state processed a mid-year
change in circumstance in household or income information and who
remained enrolled in the demonstration
Metric element
Description
Description
Among beneficiaries enrolled in the demonstration who were not in their renewal month, number of
beneficiaries for whom the state processed a change in household size or income during the
measurement period and who remained enrolled in the demonstration
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the premium policy (or account contribution policy) (metric PR_1).
Step 2. Retain beneficiaries for whom the state processed a change in household size or income
during the measurement period.
Step 3. Exclude beneficiaries who were in their renewal month.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is equal to the sum of metrics PR_12, PR_13, and PR_14
Data source
Administrative records
Metric PR_12: No premium change following mid-year processing of a
change in household or income information
Metric element
Description
Description
Among beneficiaries enrolled in the demonstration who experienced a change in household size or
income during the month (not their renewal month) and remained enrolled in the demonstration as
of the last day of the measurement period, the number whose premium obligations or other
monthly payments did not change.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration for whom the state processed a change
in household size or income during the measurement period (not in their renewal month) and who
remain enrolled in the demonstration in an income and eligibility group subject to premiums (metric
PR_11).
Step 2. Retain beneficiaries whose premium obligations or other monthly payments were the same
on both the last day of the measurement period and the first enrolled date in the measurement
period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric PR_11
Data source
Administrative records
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Metric PR_13: Premium increase following mid-year processing of change
in household or income information
Metric element
Description
Description
Among beneficiaries enrolled in the demonstration who experienced a change in household size or
income during the month (not their renewal month) and remained enrolled in the demonstration as
of the last day of the measurement period, the number whose premium obligations or other
monthly payments increased
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration for whom the state processed a change
in household size or income during the measurement period (not in their renewal month) and who
remain enrolled in the demonstration in an income and eligibility group subject to premiums (metric
PR_11).
Step 2. Retain beneficiaries whose premium obligations or other monthly payments were greater
on the last day of the measurement period than on the first enrolled date in the measurement
period. This includes beneficiaries who were not previously required to make payments, but must
begin making payments following the change in circumstance.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric PR_11
Data source
Administrative records
Metric PR_14: Premium decrease following mid-year processing of change
in household or income information
Metric element
Description
Description
Among beneficiaries enrolled in the demonstration who experienced a change in household size or
income during the month (not their renewal month) and remained enrolled in the demonstration as
of the last day of the measurement period, the number whose premium obligations or other
monthly payments decreased
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration for whom the state processed a change
in household size or income during the measurement period (not in their renewal month) and who
remain enrolled in the demonstration in an income and eligibility group subject to premiums (metric
PR_11).
Step 2. Retain beneficiaries whose premium obligations or other monthly payments were lower on
the last day of the measurement period than on the first enrolled date in the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric PR_11
Data source
Administrative records
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Disenrollment or suspension for failure to pay
Metric PR_15: Beneficiaries disenrolled from the demonstration for failure
to pay and therefore disenrolled from Medicaid
Metric element
Description
Description
Number of demonstration beneficiaries disenrolled from Medicaid as of the last day of the
measurement period for failure to pay premiums
Counted variable
Step 1. Identify beneficiaries determined ineligible for Medicaid other than at renewal (AD_7).
Step 2. Retain beneficiaries who were disenrolled from Medicaid during the measurement period
for failure to pay premiums and who remained disenrolled as of the last day of the measurement
period.
Step 3. Count unique demonstration beneficiaries (deduplicated) who meet the criteria in Steps 1
and 2.
Required or
recommended
Required only for states with premiums or monthly payment with a policy of termination for failure
to pay
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_7, relevant only for demonstrations with monthly payment
requirements
Data source
Administrative records
Metric PR_16: Beneficiaries in a non-eligibility period who were disenrolled
for failure to pay and are prevented from re-enrolling for a defined period of
time
Metric element
Description
Description
The number of prior demonstration beneficiaries who were disenrolled from Medicaid for failure to
pay premiums and are in a non-eligibility period, meaning they are prevented from re-enrolling for
some defined period of time, including those prevented from re-enrolling until their redetermination
date.
Counted variable
Step 1. Identify beneficiaries who were in a non-eligibility period status as of the last day of the
measurement period (metric AD_3).
Step 2. Retain beneficiaries who were in a non-eligibility period for failure to pay premiums in the
current or a prior measurement period.
Step 3. Count unique beneficiaries (deduplicated) who met the criteria in Steps 1 and 2.
Required or
recommended
Required if state has a non-eligibility period policy
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Data source
Administrative records
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Metric PR_17: Beneficiaries whose benefits are suspended for failure to pay
Metric element
Description
Description
Number of demonstration beneficiaries whose benefits were suspended during the measurement
period for failure to pay premiums
Counted variable
Step 1. Identify demonstration beneficiaries who were suspended from Medicaid benefits during
the measurement period for failure to pay premiums and remained in suspension status as of the
last day of the measurement period.
Step 2. Count unique demonstration beneficiaries (deduplicated) who meet the criteria in Step 1.
Required or
recommended
Required only for states with premiums or monthly payment with a policy of suspending benefits
(without disenrollment) for failure to pay
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_2
Data source
Administrative records
5.
Renewal
Metric PR_18: No premium change
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration due for renewal during the measurement
period who are redetermined as eligible for the demonstration and remain in income and eligibility
groups subject to premiums, with no change in premiums or other monthly payments.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were due for renewal during the
measurement period and redetermined as eligible for the demonstration (include beneficiaries in
metrics AD_21 and AD_22).
Step 2. Retain beneficiaries who were in income and eligibility groups subject to the premium policy
(or account contribution policy) as of the last day of the measurement period.
Step 3. Retain beneficiaries whose premiums or other monthly payments were the same on both
the last day of the measurement period and the first enrolled date in the measurement period
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
The sum of metrics PR_18, PR_19, and PR_20 should equal the sum of metrics AD_21 and
AD_22 among beneficiaries required to pay premiums
Data source
Administrative records
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Metric PR_19: Premium increase
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration due for renewal during the measurement
period who were redetermined as eligible for the demonstration and remain in income and eligibility
groups subject to premiums, with an increase in required premiums or other monthly payments.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were due for renewal during the
measurement period and redetermined as eligible for the demonstration (include beneficiaries in
metrics AD_21 and AD_22).
Step 2. Retain beneficiaries who were in income and eligibility groups subject to the premium
policy (or account contribution policy) as of the last day of the measurement period.
Step 3. Retain beneficiaries whose premiums or other monthly payments were greater on the last
day of the measurement period than on the first enrolled date in the measurement period. This
includes beneficiaries who were not previously required to make payments, but must begin making
payments following renewal.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
The sum of metrics PR_18, PR_19, and PR_20 should equal the sum of metrics AD_21 and
AD_22, among beneficiaries required to pay premiums
Data source
Administrative records
Metric PR_20: Premium decrease
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration due for renewal during the measurement
period who were redetermined as eligible for the demonstration and remained in income and
eligibility groups subject to the demonstration, with a decrease in required premiums or other
monthly payments
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were due for renewal during the
measurement period and redetermined as eligible for the demonstration (include beneficiaries in
metrics AD_21 and AD_22).
Step 2. Retain beneficiaries who were in income and eligibility groups subject to the premium
policy (or account contribution policy) as of the last day of the measurement period.
Step 3. Retain beneficiaries whose premiums or other monthly payments were smaller on the last
day of the measurement period than on the first enrolled date in the measurement period.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Relationship to other
metrics
The sum of metrics PR_18, PR_19, and PR_20 should equal the sum of metrics AD_21 and
AD_22, among beneficiaries required to pay premiums
Data source
Administrative records
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Third party premium payment
Metric PR_21: Third-party premium payment
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration who had any portion of their premium or
other monthly payments paid by a third party.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were in income and eligibility
groups subject to the premium policy (or account contribution policy) and who were not exempt
(metric PR_1).
Step 2. Retain beneficiaries who had any portion of their premium or other monthly payments paid
by a third party.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific eligibility groups (required)
Data source
Administrative records
C. Additional metrics to be reported for demonstrations with Marketplacefocused premium assistance programs
1.
Enrollment by premium payment status
Metric PA_1: Beneficiaries who lost Medicaid eligibility due to mid-year
change in circumstance, and transitioned to a qualified health plan offered
in the Marketplace
Metric element
Description
Description
Number of demonstration beneficiaries who lost eligibility for Medicaid during the measurement
period due to a change in circumstance who transitioned to a qualified health plan offered in the
Marketplace (Health Insurance Exchange).
Counted variable
Step 1. Identify demonstration beneficiaries determined ineligible for Medicaid after state
processed a change in circumstance reported by a beneficiary (metric AD_9).
Step 2. Retain beneficiaries who transitioned to a qualified health plan offered in the Marketplace
(Health Insurance Exchange) as of the last day of the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required if identifying his transition is feasible
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_9
Data source
Administrative records
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Metric PA_2: Beneficiaries who lost Medicaid eligibility at renewal, and
transitioned to a qualified health plan offered in the Marketplace
Metric element
Description
Description
Number of demonstration beneficiaries who lost eligibility for Medicaid during the measurement
period due to the outcome of eligibility renewal processes and transitioned to a qualified health
plan offered in the Marketplace (Health Insurance Exchange).
Counted variable
Step 1. Identify demonstration beneficiaries determined ineligible for the demonstration at renewal,
disenrolled from Medicaid (metric AD_16).
Step 2. Retain beneficiaries who transitioned to a qualified health plan offered in the Marketplace
(Health Insurance Exchange) as of the last day of the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required if identifying his transition is feasible
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_16
Data source
Administrative records
2.
Access to care
Metric PA_3: Wraparound service utilization, by service
Metric element
Description
Description
Total utilization of wraparound services during the measurement period per 1,000 demonstration
beneficiary months during the measurement period
Numerator
Step 1. Identify all claims Medicaid paid for wraparound services provided to demonstration
beneficiaries during the measurement period. Wraparound services will vary by state. Examples of
wraparound services are:
Non-emergency medical transportation
EPSDT services for 19 – 20 year olds
Dental services
Vision services
Family planning services
Step 2. Retain only claims with service end dates that fall during the measurement period.
Step 3. Calculate the unique number of services identified in Steps 1 and 2. Count multiple claim
headers with overlapping service dates (based on service begin date and service end date) and
the same procedure code as one service.
Denominator
Number of demonstration beneficiary months during the measurement period. Beneficiaries that
are continuously enrolled during the reporting quarter contribute 3 months to the denominator.
Metric calculation
Calculate the rate by dividing the number of wraparound service claims in the numerator by the
number of beneficiary months in the denominator and then multiply by 1,000, as follows:
(Number of wraparound service claims / Number of demonstration beneficiary months) * 1,000
Required or
recommended
Recommended
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Data source
Claims and encounters
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D. Additional metrics to be reported for demonstrations with health behavior
incentives
1.
Enrollment
Metric HB_1: Total enrollment among beneficiaries subject to health
behavior incentives
Metric element
Description
Description
Number of beneficiaries subject to health behavior incentive policies who were enrolled in the
demonstration at any time during the measurement period
Counted variable
Step 1. Identify beneficiaries who were enrolled in the demonstration at any time during the
measurement period.
Step 2. Retain beneficiaries who were subject to health behavior incentive policies during the
measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric serves as a denominator to pair with metrics HB_2, HB_3, and HB_4 to create rates.
Note, because this measure is quarterly, the number of beneficiaries identified in Step 1 may
exceed the count of ever-enrolled beneficiaries in a reporting month (AD_1).
Data source
Administrative records
2.
Use of incentivized services: Claims-based analysis
Metric HB_2: Beneficiaries using incentivized services that can be
documented through claims, by service
Metric element
Description
Description
Total number of beneficiaries enrolled in the demonstration at any point during the
measurement period who utilized financially incentivized services that can be documented
through claims since the beginning of their enrollment spell
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration at any time during the measurement
period and subject to health behavior incentives (metric HB_1).
Step 2. Retain beneficiaries who utilized financially incentivized services that can be
documented through claims at any time since the beginning of the beneficiary’s enrollment
spell. The claim service date does not need to be during the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Additional guidance
Specific services vary by state; report a separate metric for each incentivized service if state
has multiple services through which beneficiaries can accrue financial benefit
Required or recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Data source
Administrative records, claims and encounters
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Other incentivized behaviors not documented through claims-based analysis
Metric HB_3: Completion of incentivized health behavior(s) not documented
through claims analysis (i.e. health risk assessments), by health behavior
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration at any point during the measurement period
who have completed each incentivized health behavior not documented through claims analysis
(i.e. health risk assessments) since the beginning of their enrollment spell
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration at any time during the measurement
period and subject to health behavior incentives (metric HB_1).
Step 2. Retain beneficiaries who completed each incentivized health behavior not documented
through claims analysis (i.e. health risk assessments) since the beginning of their enrollment spell.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Additional guidance
Specific health behaviors incentives vary by state; report separate metrics for each incentivized
health behavior if state has multiple behaviors through which beneficiaries can accrue financial
benefit
Required or
recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Data source
Administrative records
Metric HB_4: Completion of all incentivized health behaviors (both claimsbased and other), if there are multiple
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration at any point during the measurement period
who have completed all incentivized health behaviors (including incentivized services documented
through claims and other health behaviors not documented through claims) since the beginning of
their enrollment spell
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration at any time during the measurement
period and subject to health behavior incentives (metric HB_1).
Step 2. Retain beneficiaries who completed all incentivized health behaviors since the beginning of
their enrollment spell. Include incentivized services documented through claims and other health
behaviors documented through administrative records when determining if a beneficiary has
completed all behaviors.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Additional guidance
Specific incentivized health behaviors vary by state
Required or
recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Data source
Administrative records, claims and encounters
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Rewards granted for completion of incentivized health behaviors
Metric HB_5: Beneficiaries granted a premium reduction for completion of
incentivized health behaviors
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration who were flagged for or granted a reward
related to premium obligations during the measurement period, regardless of whether the premium
reduction occurs during the measurement period or in the future.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration at any time during the measurement
period and subject to health behavior incentives (metric HB_1).
Step 2. Retain beneficiaries who were flagged for a reward or granted a reward related to premium
obligations during the measurement period, regardless of whether the premium reduction occurs
during the measurement period or in a future time period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric can be compared to numbers in metrics HB_2, HB_3, and/or HB_4, to understand
whether behavior completions are resulting in accrual of rewards, depending on state policy
Data source
Administrative records
Metric HB_6: Beneficiaries granted a financial reward other than a premium
reduction for completion of incentivized health behaviors
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration who were flagged for or granted a reward
other than a premium reduction during the measurement period, regardless of when the reward is
realized
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration at any time during the measurement
period and subject to health behavior incentives (metric HB_1).
Step 2. Retain beneficiaries who were flagged for or granted a reward other than a premium
reduction during the measurement period, regardless of when the reward is realized. For example,
some states might award gift cards or credits to accounts that can be used for additional benefits.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric can be compared to numbers in metrics HB_2, HB_3, and/or HB_4 to understand
whether behavior completions are resulting in accrual of rewards, depending on state policy
Data source
Administrative records
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Metric HB_7: Beneficiaries granted a reward in the form of additional
covered benefits for completion of incentivized health behaviors
Metric element
Description
Description
Number of beneficiaries enrolled in the demonstration who were flagged for or granted a reward
that takes the form of an additional covered benefit or service, by benefit or service type, during the
measurement period.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration at any time during the measurement
period and subject to health behavior incentives (metric HB_1).
Step 2. Retain beneficiaries who were flagged for or granted a reward that takes the form of an
additional covered benefit or service, by benefit or service type, during the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2 by benefit
or service type. For example, if beneficiaries can earn additional dental and vision coverage, the
number of people gaining these coverages should be counted separately. Individuals earning both
types of coverage would be included in both counts.
Additional guidance
Benefit or service types will vary by state. States should report this metric by each benefit or
service type applicable to their demonstration policies.
Required or
recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Subpopulations
Income groups
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric can be compared to numbers in metrics HB_2, HB_3, and/or HB_4, to understand
whether behavior completions are resulting in accrual of rewards, depending on state policy.
Data source
Administrative records
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E. Additional metrics to be reported for demonstrations with community
engagement requirements
1.
Community engagement enrollment
Metric CE_1: Total beneficiaries subject to the community engagement
requirement, not exempt
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration whose income and eligibility group were
subject to the community engagement requirement and who did not have an individual exemption
from the requirement or an approved good cause circumstance
Counted variable
Step 1. Identify beneficiaries who were enrolled in the demonstration and receiving benefits as of
the last day of the measurement period.
Step 2. Retain beneficiaries whose income and eligibility group were subject to community
engagement requirements during the measurement period.
Step 3. Exclude beneficiaries in income and eligibility groups who were subject to community
engagement requirements, but who had an individual exemption from the policy or who had an
approved good cause circumstance on the last day of the measurement period. These individuals
are counted in metrics CE_2 and CE_3 respectively.
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria for Steps 1, 2, and 3.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
Metrics CE_1, CE_2, and CE_3 should sum to the total number of enrolled beneficiaries receiving
benefits in income and eligibility groups subject to community engagement requirements
Data source
Administrative records
Metric CE_2: Total beneficiaries who were exempt from the community
engagement requirement in the month
Metric element
Description
Description
The number of beneficiaries enrolled in income and eligibility groups that were subject to the
community engagement requirement, but had an individual exemption from the policy. This
excludes circumstances that give rise to good cause.
Counted variable
Step 1. Identify beneficiaries who were enrolled in the demonstration in income and eligibility
groups subject to community engagement requirements.
Step 2. Retain beneficiaries who were exempt from the community engagement requirement for
any reason as of the last day of the measurement period. Beneficiaries with circumstances that
gave rise to good cause should not be retained.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria for Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
Metrics CE_1, CE_2, and CE_3 should sum to the total number of enrolled beneficiaries receiving
benefits in income and eligibility groups subject to community engagement requirements
Data source
Administrative records
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Metric CE_3: Beneficiaries with approved good cause circumstances
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who met the state criteria for good
cause circumstances, such as serious illness, birth or death of a family member, severe weather,
family emergencies, or life-changing event
Counted variable
Step 1. Identify beneficiaries who were enrolled in the demonstration in income and eligibility
groups subject to community engagement requirements.
Step 2. Retain beneficiaries who met the state criteria for good cause circumstances, such as
serious illness, birth or death of a family member, severe weather, family emergencies, or lifechanging event, as of the last day of the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria for Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
Metrics CE_1, CE_2, and CE_3 should sum to the total number of enrolled beneficiaries receiving
benefits in income and eligibility groups subject to community engagement requirements
Data source
Administrative records
Metric CE_4: Beneficiaries subject to the community engagement
requirement and in suspension status due to failure to meet requirement
Metric element
Description
Description
The number of demonstration beneficiaries in suspension status due to failure to meet the
community engagement requirement, including those newly suspended for noncompliance during
the measurement period
Counted variable
Step 1. Identify beneficiaries who were in suspension status for noncompliance with demonstration
policies as of the last day of the measurement period (AD_2).
Step 2. Retain beneficiaries who were in suspension status during the measurement period for
failure to meet the community engagement requirement in the current or a prior measurement
period and remained in suspended status as of the last day of the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required if state has a suspension policy
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric AD_2
Data source
Administrative records
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Metric CE_5: Beneficiaries subject to the community engagement
requirement and receiving benefits who met the requirement for qualifying
activities
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement and met the requirement by engaging in qualifying activities
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration and subject to the community
engagement requirement and receiving benefits as of the last day of the measurement period
(metric CE_1).
Step 2. Retain beneficiaries who are flagged as having met the requirement for qualifying activities
as of the last day of the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_1
Data source
Administrative records
Metric CE_6: Beneficiaries subject to the community engagement
requirement and receiving benefits but in a grace period or allowable
month of noncompliance
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement but did not meet the requirement. This includes beneficiaries who have
not yet begun qualifying activities and those who logged some hours, but failed to meet total
required hours.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement and receiving benefits as of the last day of the measurement period
(metric CE_1).
Step 2. Retain beneficiaries who did not meet the community engagement requirement in the
measurement period. Include beneficiaries who had either:
Not yet begun qualifying activities (grace period)
Logged some hours, but failed to meet total required hours
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_1
Data source
Administrative records
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Metric CE_7: Beneficiaries who successfully completed make-up hours or
other activities to retain active benefit status after failing to meet the
community engagement requirement in a previous month
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement and met additional requirements to retain active benefit status after
previously failing to meet the requirement. This captures beneficiaries who successfully satisfy the
“opportunity to cure” and therefore are not suspended (if state has this policy).
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement and receiving benefits as of the last day of the reporting period (metric
CE_1).
Step 2. Retain beneficiaries who met additional requirements to retain active benefit status in the
measurement period, after previously failing to meet the requirement.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_1 for states with an “opportunity to cure” policy
Data source
Administrative records
Metric CE_8: Beneficiaries in a non-eligibility period who were disenrolled
for noncompliance with the community engagement requirement and are
prevented from re-enrolling for a defined period of time
Metric element
Description
Description
The number of prior demonstration beneficiaries who were disenrolled from Medicaid for
noncompliance with the community engagement requirement and are in a non-eligibility period,
meaning they are prevented from re-enrolling for some defined period of time. The count should
include those prevented from re-enrolling until their redetermination date.
Counted variable
Step 1. Identify beneficiaries who were in a non-eligibility period status as of the last day of the
measurement period (metric AD_3).
Step 2. Retain beneficiaries who were in a non-eligibility period for failure to meet the community
engagement requirement in the current or a prior measurement period.
Step 3. Count unique beneficiaries (deduplicated) who met the criteria in Steps 1 and 2.
Required or
recommended
Required if state has a non-eligibility period policy
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Data source
Administrative records
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Community engagement requirement qualifying activities
Metric CE_9: Beneficiaries who met the community engagement
requirement by satisfying requirements of other programs
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement and met the requirement by satisfying requirements in other programs
such as SNAP or TANF, regardless of whether they are “deemed” by the state to be in compliance
with Medicaid requirements or must take reporting action
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement and met the requirement by engaging in qualifying activities (metric
CE_5).
Step 2. Retain beneficiaries who met the community engagement requirement by satisfying
requirements in other programs (e.g. SNAP or TANF). Include those “deemed” by the state to be in
compliance with Medicaid requirements and those who must take reporting action.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_5
Data source
Administrative records
Metric CE_10: Beneficiaries who met the community engagement
requirement through employment for the majority of their required hours
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were subject to and met the
community engagement requirement, who were self-employed or employed in subsidized and/or
unsubsidized settings. Includes both those “deemed” by the state to be in compliance with
Medicaid requirements because they are working more than the number of required hours and
those who must report their hours.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement who met the requirement by engaging in qualifying activities (metric
CE_5).
Step 2. Retain beneficiaries who were engaged any of the following for at least half of their
required hours:
1. Self-employed
2. Employed in subsidized and/or unsubsidized settings during the measurement period.
Include those “deemed” by the state to be in compliance with Medicaid requirements because they
are working more than the number of required hours and those who must report their hours.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_5
Data source
Administrative records
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Metric CE_11: Beneficiaries who met the community engagement
requirement through job training or job search for the majority of their
required hours
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were subject to and met the
community engagement requirement, who were engaged in on-the-job training, job skills training,
vocational education and training, job search activities, job search training, a state-sponsored
workforce program, or similar activity
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement who met the requirement by engaging in qualifying activities (metric
CE_5).
Step 2. Retain beneficiaries who were engaged any of the following for at least half of their
required hours:
1. On-the-job training
2. Job skills training
3. Vocational education and training
4. Job search activities
5. Job search training
6. State-sponsored workforce program, or similar activity
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_5
Data source
Administrative records
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Metric CE_12: Beneficiaries who met the community engagement
requirement through educational activity for the majority of their required
hours
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were subject to and met the
community engagement requirement, who were engaged in education related to employment,
general education, accredited English-as-a-second-language education, accredited
homeschooling, or a state-designated class
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement who met the requirement by engaging in qualifying activities (metric
CE_5).
Step 2. Retain beneficiaries who were engaged in any of the following for at least half of their
required hours:
1. Education related to employment
2. General education
3. Accredited English-as-a-second-language education
4. Accredited homeschooling
5. State-designated class
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_5
Data source
Administrative records
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Metric CE_13: Beneficiaries who met the community engagement
requirement who were engaged in other qualifying activity for the majority
of their required hours
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement and met the requirement through a state-specified activity not captured
by other reporting categories, including community work experience, community service/public
service, volunteer work, caregiving for a dependent, participation in substance use disorder
treatment, enrollment in Medicaid employer-sponsored insurance premium assistance, or other
activity.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement who met the requirement by engaging in qualifying activities (metric
CE_5).
Step 2. Retain beneficiaries who were engaged in a state-specified activity not captured by other
reporting categories for at least half of their required hours, including:
1. Community work experience
2. Community service/public service
3. Volunteer work, caregiving for a dependent
4. Participation in substance use disorder treatment,
5. Enrollment in Medicaid employer-sponsored insurance premium assistance
6. Other activity
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_5
Data source
Administrative records
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Metric CE_14 Beneficiaries who met the community engagement
requirement by combining two or more activities
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement and met the requirement by engaging in a combination of activities
defined in metrics CE_10 through CE_13, such as a combination of employment and education
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement who met the requirement by engaging in qualifying activities (metric
CE_5).
Step 2. Retain beneficiaries who met the community engagement requirement during the
measurement period by engaging in two or more of the following activities:
1. Employment
2. Job training or job search
3. Educational activity
4. Other qualifying activity
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_5
Data source
Administrative records
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Basis of beneficiary exemptions from community engagement requirement
Metric CE_15: Beneficiaries exempt from Medicaid community engagement
requirements because they were exempt from requirements of SNAP and/or
TANF
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were exempt from the community
engagement requirement because they were exempt from the SNAP and/or TANF work
requirements. This does not include beneficiaries who are meeting SNAP and/or TANF work
requirements.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration in income and eligibility groups who
were subject to the community engagement requirement who were individually exempt in the
measurement period (metric CE_2).
Step 2. Retain beneficiaries who were exempt from the community engagement requirement as of
the last day of the measurement period because they are exempt from SNAP and/or TANF work
requirements. Exclude beneficiaries who are meeting SNAP and/or TANF work requirements.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_2
Data source
Administrative records
Metric CE_16: Beneficiaries exempt from Medicaid community engagement
requirements on the basis of pregnancy
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were exempt from the community
engagement requirement because they are pregnant
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration in income and eligibility groups who
were subject to the community engagement requirement who were individually exempt in the
measurement period (metric CE_2).
Step 2. Retain beneficiaries who were exempt from the community engagement requirement as of
the last day of the measurement period due to pregnancy.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_2
Data source
Administrative records
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Metric CE_17: Beneficiaries exempt from Medicaid community engagement
requirements due to former foster youth status
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were exempt from the community
engagement requirement because they were formerly part of the foster care system
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration in income and eligibility groups who
were subject to the community engagement requirement who were individually exempt in the
measurement period (metric CE_2).
Step 2. Retain beneficiaries who were exempt from the community engagement requirement as of
the last day of the measurement period because they were formerly part of the foster care system.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_2
Data source
Administrative records
Metric CE_18: Beneficiaries exempt from Medicaid community engagement
requirements due to medical frailty
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were exempt from the community
engagement requirement because they are identified as medically frail
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration in income and eligibility groups who
were subject to the community engagement requirement who were individually exempt in the
measurement period (metric CE_2).
Step 2. Retain beneficiaries who were exempt from the community engagement requirement as of
the last day of the measurement period because they are identified as medically frail during the
measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_2
Data source
Administrative records
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Metric CE_19: Beneficiaries exempt from Medicaid community engagement
requirements on the basis of caretaker status
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were exempt from the community
engagement requirement because they are primary caregiver of a dependent child or
incapacitated/disabled household member
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration in income and eligibility groups who
were subject to the community engagement requirement who were individually exempt in the
measurement period (metric CE_2).
Step 2. Retain beneficiaries who were exempt from the community engagement requirement as of
the last day of the measurement period because they are primary caregiver of a dependent child or
incapacitated/disabled household member.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_2
Data source
Administrative records
Metric CE_20: Beneficiaries exempt from Medicaid community engagement
requirements on the basis of unemployment insurance compensation
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were exempt from the community
engagement requirement because they are receiving unemployment insurance compensation
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration in income and eligibility groups who
were subject to the community engagement requirement who were individually exempt in the
measurement period (metric CE_2).
Step 2. Retain beneficiaries who were exempt from the community engagement requirement as of
the last day of the measure period because they are receiving unemployment insurance
compensation.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_2
Data source
Administrative records
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Metric CE_21: Beneficiaries exempt from Medicaid community engagement
requirements due to substance abuse treatment status
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were exempt the community
engagement requirement because they are participating in a drug or alcohol treatment and
rehabilitation program
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration in income and eligibility groups who
were subject to the community engagement requirement who were individually exempt in the
measurement period (metric CE_2).
Step 2. Retain beneficiaries who were exempt from the community engagement requirement as of
the last day of the measurement period because they are participating in a drug or alcohol
treatment and rehabilitation program during the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_2
Data source
Administrative records
Metric CE_22: Beneficiaries exempt from Medicaid community engagement
requirements due to student status
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were exempt from the community
engagement requirement because they are a student enrolled a number of hours/week, defined by
state
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration in income and eligibility groups who
were subject to the community engagement requirement who were individually exempt in the
measurement period (metric CE_2).
Step 2. Retain beneficiaries who were exempt from the community engagement requirement as of
the last day of the measurement period because they are a student enrolled a number of
hours/week, defined by state.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_2
Data source
Administrative records
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Metric CE_23: Beneficiaries exempt from Medicaid community engagement
requirements because they were excused by a medical professional
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were exempt from the community
engagement requirement because a medical professional determined the beneficiary had an acute
medical condition separate from disability or frailty
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration in income and eligibility groups who
were subject to the community engagement requirement who were individually exempt in the
measurement period (metric CE_2).
Step 2. Retain beneficiaries who were exempt from the community engagement requirement as of
the last day of the measurement period because a medical professional determined the beneficiary
had an acute medical condition separate from disability or frailty.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_2
Data source
Administrative records
Metric CE_24: Beneficiaries exempt from Medicaid community engagement
requirements, other
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were exempt from the community
engagement requirement because they are exempt for another reason not captured by other
reporting categories, including age above the upper limit defined by the state and enrollment in
employer-sponsored insurance through premium assistance.
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration in income and eligibility groups who
were subject to the community engagement requirement who were individually exempt in the
measurement period (metric CE_2).
Step 2. Retain beneficiaries who were exempt from the community engagement requirement as of
the last day of the measurement period because they are exempt for another reason not captured
by other reporting categories, including age above the upper limit defined by the state and
enrollment in employer-sponsored insurance through premium assistance.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_2
Data source
Administrative records
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Supports and assistance
Metric CE_25: Total beneficiaries receiving supports to participate and
placement assistance
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were given supports to enable them
to participate, including supports due to disability and assistance from other agencies and entities
complementing Medicaid efforts
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement (metric CE_1).
Step 2.Identify beneficiaries who were given supports to enable them to participate, including
supports due to disability and assistance from other agencies and entities complementing Medicaid
efforts, during the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric includes individuals counted in metrics CE_26 through CE_30. Beneficiaries may be
counted more in more than one of metrics CE_26 through CE_30, but should only be counted once
in metric CE_25, regardless of the number of different types of supports received.
Data source
Administrative records
Metric CE_26: Beneficiaries provided with transportation assistance
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were given transportation
assistance to enable participation in community engagement activities
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were given supports to enable
them to participate (CE_25).
Step 2. Retain beneficiaries who were provided with transportation assistance to enable
participation in community engagement activities.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_25
Data source
Administrative records
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Metric CE_27: Beneficiaries provided with childcare assistance
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were given childcare assistance to
enable participation in community engagement activities
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were given supports to enable
them to participate (CE_25).
Step 2. Retain beneficiaries who were given childcare assistance to enable participation in
community engagement activities.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_25
Data source
Administrative records
Metric CE_28: Beneficiaries provided with language supports
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were given language supports to
enable participation in community engagement activities
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were given supports to enable
them to participate (CE_25).
Step 2. Retain beneficiaries who were given language supports to enable participation in
community engagement activities.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_25
Data source
Administrative records
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Metric CE_29: Beneficiaries assisted with placement in community
engagement activities
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were given placement assistance,
including through state department of labor support centers
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were given supports to enable
them to participate (CE_25).
Step 2. Retain beneficiaries who were given placement assistance, including through state
department of labor support centers.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_25
Data source
Administrative records
Metric CE_30 Beneficiaries provided with other non-Medicaid assistance
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were given other assistance,
including assistance from other agencies and entities complementing Medicaid efforts, to
participate in community engagement activities
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were given supports to enable
them to participate (CE_25).
Step 2. Retain beneficiaries who were given other assistance, not captured in CE_26, 27, 28, or
29, to participate in community engagement activities.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_25
Data source
Administrative records
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Reasonable modifications for beneficiaries with disabilities
Metric CE_31: Beneficiaries who requested reasonable modifications to
community engagement processes or requirements due to disability
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who requested a reasonable
modification of community engagement processes (such as assistance with exemption requests or
appeals) or requirements (such as the number of hours) due to disability
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to (metric CE_1),
exempt from (CE_2) the community engagement requirement, or had a good cause circumstance
(CE_3).
Step 2. Retain beneficiaries who requested a reasonable modification of community engagement
processes (such as assistance with exemption requests or appeals) or requirements (such as the
number of hours) due to disability, during the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Data source
Administrative records
Metric CE_32: Beneficiaries granted reasonable modifications to
community engagement processes or requirements due to disability
Metric element
Description
Description
The number of beneficiaries enrolled in the demonstration who were granted a modification of
community engagement processes (such as assistance with exemption requests or appeals) or
requirements (such as the number of hours) due to disability
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to (metric CE_1),
exempt from (CE_2) the community engagement requirement, or had a good cause circumstance
(CE_3).
Step 2. Retain beneficiaries who were granted a reasonable modification of community
engagement processes (such as assistance with exemption requests or appeals) or requirements
(such as the number of hours) due to disability, during the measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Data source
Administrative records
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New suspensions and disenrollments during the measurement period
Metric CE_33: Beneficiaries newly suspended for failure to complete
community engagement requirements
Metric element
Description
Description
The number of demonstration beneficiaries newly suspended for noncompliance during the
measurement period (if state has a suspension policy)
Counted variable
Step 1. Identify beneficiaries who were subject to the community engagement requirement and in
suspension status due to failure to meet requirement (metric CE_4).
Step 2. Retain beneficiaries who were newly suspended for noncompliance during the
measurement period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_4
Data source
Administrative records
Metric CE_34: Beneficiaries newly disenrolled for failure to complete
community engagement requirements
Metric element
Description
Description
The number of demonstration beneficiaries newly disenrolled for noncompliance with community
engagement requirements during the measurement period
Counted variable
Count unique beneficiaries (deduplicated) who were disenrolled from Medicaid during the
measurement period for noncompliance with community engagement requirements and who
remained disenrolled as of the last day of the measurement period
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Data source
Administrative records
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Reinstatement of benefits after suspension
Metric CE_35: Total beneficiaries whose benefits were reinstated after
being in suspended status for noncompliance
Metric element
Description
Description
The number of demonstration beneficiaries whose benefits were reinstated during the
measurement period after suspension in a prior month triggered by noncompliance with community
engagement requirements, including those reinstated due to compliance, determination of
exemption, and successful appeal, or good cause circumstances
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement and met the requirement by engaging in qualifying activities (metric
CE_5), exempt from the community engagement requirement (CE_2), or who had a good cause
circumstance (CE_3).
Step 2. Retain beneficiaries who were in suspension status in a month prior to the measurement
period where the suspension was triggered by noncompliance with community engagement
requirements.
Step 3. Retain beneficiaries whose benefits were reinstated during the measurement period.
Include only beneficiaries whose benefits remained reinstated as of the last day of the
measurement period. Include those reinstated due to the following:
1. Compliance
2. Determination of exemption or good cause circumstance
3. Successful appeal
Step 4. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, and 3.
Required or
recommended
Required if state has a suspension policy
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is equal to the sum of metrics CE_36, CE_37, CE_38, CE_39, and CE_40
Data source
Administrative records
Metric CE_36: Beneficiaries whose benefits were reinstated because their
time-limited suspension period ended
Metric element
Description
Description
The number of demonstration beneficiaries whose benefits were reinstated during the
measurement period after suspension in a prior month triggered by noncompliance with community
engagement requirements (if state has a suspension policy), because a defined suspension period
ended
Counted variable
Step 1. Identify demonstration beneficiaries whose benefits were reinstated during the
measurement period after being in suspended status for noncompliance (metric CE_35).
Step 2. Retain beneficiaries whose benefits were reinstated during the measurement period
because a defined suspension period ended. Include only beneficiaries whose benefits remained
reinstated as of the last day of the month.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_35
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Data source
MATHEMATICA POLICY RESEARCH
Administrative records
Metric CE_37: Beneficiaries whose benefits were reinstated because they
completed required community engagement activities
Metric element
Description
Description
The number of demonstration beneficiaries whose benefits were reinstated during the
measurement period after suspension in a prior month triggered by noncompliance with community
engagement requirements (if state has a suspension policy), because they completed qualifying
activities
Counted variable
Step 1. Identify demonstration beneficiaries whose benefits were reinstated during the
measurement period after being in suspended status for noncompliance (metric CE_35).
Step 2. Retain beneficiaries whose benefits were reinstated during the measurement period
because they completed qualifying activities. Include only beneficiaries whose benefits remained
reinstated as of the last day of the month.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_35
Data source
Administrative records
Metric CE_38: Beneficiaries whose benefits were reinstated because they
completed “on-ramp” activities other than qualifying community
engagement activities
Metric element
Description
Description
The number of demonstration beneficiaries whose benefits were reinstated during the
measurement period after suspension in a prior month triggered by noncompliance with community
engagement requirements (if state has a suspension policy), because they used a special pathway
for re-enrollment such as a state-approved educational course
Counted variable
Step 1. Identify demonstration beneficiaries whose benefits were reinstated during the
measurement period after being in suspended status for noncompliance (metric CE_35).
Step 2. Retain beneficiaries who were reinstated during the measurement period because they
used a special pathway for re-enrollment such as a state-approved educational course. Include
only beneficiaries whose benefits remained reinstated as of the last day of the month.
Step 3. Count unique (deduplicated) beneficiaries that meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_35
Data source
Administrative records
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Metric CE_39: Beneficiaries whose benefits were reinstated because they
newly meet community engagement exemption criteria or had a good
cause circumstance
Metric element
Description
Description
The number of demonstration beneficiaries whose benefits were reinstated during the
measurement period after suspension in a prior month triggered by noncompliance with community
engagement requirements (if state has a suspension policy) because they were newly determined
exempt or had a good cause circumstance
Counted variable
Step 1. Identify demonstration beneficiaries whose benefits were reinstated during the
measurement period after being in suspended status for noncompliance (metric CE_35).
Step 2. Retain beneficiaries who were reinstated during the measurement period because they are
newly determined exempt or to have a good cause circumstance. Include only beneficiaries whose
benefits remained reinstated as of the last day of the month.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_35
Data source
Administrative records
Metric CE_40: Beneficiaries whose benefits were reinstated after
successful appeal of suspension for noncompliance
Metric element
Description
Description
The number of demonstration beneficiaries whose benefits were reinstated during the
measurement period after suspension in a prior month triggered by noncompliance with community
engagement requirements (if state has a suspension policy) because they successfully appealed
Counted variable
Step 1. Identify demonstration beneficiaries whose benefits were reinstated during the
measurement period after being in suspended status for noncompliance (metric CE_35).
Step 2. Retain beneficiaries who were reinstated during the measurement period because they
successfully appealed. Include only beneficiaries whose benefits remained reinstated as of the last
day of the month.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_35
Data source
Administrative records
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Re-entry after disenrollment
Metric CE_41: Total beneficiaries re-enrolling after disenrollment for
noncompliance
Metric element
Description
Description
Total number of beneficiaries re-enrolled in the demonstration during the measurement period after
disenrollment in the last 12 months for noncompliance or because they were in suspended status
on their redetermination date (depending on state policy), including those re-enrolling after being
determined exempt or after successful appeal
Counted variable
Step 1. Identify beneficiaries enrolled in the demonstration who were subject to the community
engagement requirement and met the requirement by engaging in qualifying activities (metric
CE_5), exempt from (CE_2) the community engagement requirement, or who had a good cause
circumstance (CE_3).
Step 2. Retain beneficiaries who were disenrolled in the last 12 months for noncompliance or
because they were in suspended status on their redetermination date.
Step 3. Retain beneficiaries who re-enrolled in the demonstration (began a new enrollment spell)
during the measurement period. Include beneficiaries who re-enrolled after being determined
exempt or after successful appeal.
Step 4. Count unique beneficiaries (unduplicated) that meet the criteria in Steps 1, 2, and 3.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is equal to the sum of metrics CE_42, CE_43, CE_44, CE_45, and CE_46
Data source
Administrative records
Metric CE_42: Beneficiaries re-enrolling after completing required
community engagement activities
Metric element
Description
Description
Total number of beneficiaries re-enrolled in the demonstration during the measurement period
because they completed qualifying activities, subsequent to disenrollment in the last 12 months for
noncompliance or because they were in suspended status on their redetermination date
(depending on state policy)
Counted variable
Step 1. Identify beneficiaries who re-enrolled in the demonstration during the measurement period
after disenrollment in the last 12 months for noncompliance or because they were in suspended
status on their redetermination date (metric CE_41).
Step 2. Retain beneficiaries who re-enrolled (began a new enrollment spell) during the
measurement period because they completed qualifying activities.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_41
Data source
Administrative records
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Metric CE_43: Beneficiaries re-enrolling after completing “on-ramp”
activities other than qualifying community engagement activities
Metric element
Description
Description
Total number of demonstration beneficiaries re-enrolled during the measurement period because
they used a special pathway for re-enrollment such as a state-approved educational course,
subsequent to disenrollment in the last 12 months for noncompliance or because they were in
suspended status on their redetermination date (depending on state policy)
Counted variable
Step 1. Identify beneficiaries who re-enrolled in the demonstration during the measurement period
after disenrollment in the last 12 months for noncompliance or because they were in suspended
status on their redetermination date (metric CE_41).
Step 2. Retain beneficiaries who re-enrolled (began a new enrollment spell) during the
measurement period because they used a special pathway for re-enrollment such as a stateapproved educational course.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_41
Data source
Administrative records
Metric CE_44: Beneficiaries re-enrolling after re-applying, subsequent to
being disenrolled for noncompliance with community engagement
requirements
Metric element
Description
Description
The number of beneficiaries re-enrolled in the demonstration during the measurement period
because they re-applied, subsequent to disenrollment in the last 12 months for noncompliance (or
because they were in suspended status on their redetermination date). This includes those who reapplied immediately after disenrollment and those who did so after a disenrollment (non-eligibility)
period.
Counted variable
Step 1. Identify beneficiaries who re-enrolled in the demonstration during the measurement period
after disenrollment in the last 12 months for noncompliance or because they were in suspended
status on their redetermination date (metric CE_41).
Step 2. Retain beneficiaries who re-enrolled (began a new enrollment spell) during the
measurement period after re-applying for coverage. Include those who re-applied immediately after
disenrollment and those who did so after a disenrollment (non-eligibility) period.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_41
Data source
Administrative records
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Metric CE_45: Beneficiaries re-enrolling because they newly met
community engagement exemption criteria or had a good cause
circumstance
Metric element
Description
Description
The number of beneficiaries re-enrolled in the demonstration during the measurement period
because they were newly determined exempt, subsequent to disenrollment in the last 12 months
for noncompliance (or because they were in suspended status on their redetermination date)
Counted variable
Step 1. Identify beneficiaries who re-enrolled in the demonstration during the measurement period
after disenrollment in the last 12 months for noncompliance or because they were in suspended
status on their redetermination date (metric CE_41).
Step 2. Retain beneficiaries who re-enrolled (began a new enrollment spell) during the
measurement period because they were newly determined exempt or had a good cause
circumstance.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_41
Data source
Administrative records
Metric CE_46: Beneficiaries re-enrolling after successful appeal of
disenrollment for noncompliance
Metric element
Description
Description
The number of beneficiaries re-enrolled in the demonstration during the measurement period after
successful appeal (including retroactive determination of a good cause circumstance by the state),
subsequent to disenrollment in the last 12 months for noncompliance (or because they were in
suspended status on their redetermination date)
Counted variable
Step 1. Identify beneficiaries who re-enrolled in the demonstration during the measurement period
after disenrollment in the last 12 months for noncompliance or because they were in suspended
status on their redetermination date (metric CE_41).
Step 2. Retain beneficiaries who re-enrolled (began a new enrollment spell) during the
measurement period because they successfully appealed disenrollment. Exclude retroactive
determination of an exemption or good cause circumstance by the state.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Required or
recommended
Recommended
Measurement period
(calculation lag)
Month (30 days)
Subpopulations
Specific demographic groups
Specific eligibility groups (required)
Relationship to other
metrics
This metric is a subset of metric CE_41
Data source
Administrative records
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F. Additional metrics to be reported for demonstrations with retroactive
eligibility waivers
1.
At application
Metric RW_1: Beneficiaries who indicated that they had unpaid medical
bills at the time of application
Metric element
Description
Description
The number of demonstration beneficiaries in income and eligibility groups that were subject to the
waiver of retroactive eligibility policy, who began a new enrollment period in the reporting month,
and who indicated at the time of application for Medicaid that they had unpaid medical bills from
the past three months
Counted variable
Step 1. Identify beneficiaries in the demonstration who began a new enrollment spell during the
measurement period (metric AD_4).
Step 2. Retain only those beneficiaries whose new enrollment spell resulted from a new application
to Medicaid.
Step 3. Retain beneficiaries who were subject to the waiver of retroactive eligibility policy.
Step 4. Retain beneficiaries who indicated on their new application for Medicaid that they had
unpaid medical bills from the past three months.
Step 5. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, 3, and 4.
Required or
recommended
Required
Measurement period
(calculation lag)
Month (30 days)
Data source
Administrative records
2.
At renewal
Metric RW_2: Beneficiaries who had a coverage gap at renewal
Metric element
Description
Description
The number of demonstration beneficiaries in income and eligibility groups that were subject to the
waiver of retroactive eligibility policy who re-enrolled in the demonstration within 90 days after a
previous enrollment spell in the demonstration ended because the beneficiary did not comply with
renewal processes on time
Counted variable
Step 1. Identify beneficiaries in the demonstration who began an enrollment spell during the
measurement period.
Step 2. Retain beneficiaries who had a previous spell of enrollment that ended within the prior 90
days (i.e., were enrolled at any time within the prior 90 days).
Step 3. Retain beneficiaries who were subject to the waiver of retroactive eligibility policy.
Step 4. Retain beneficiaries whose previous enrollment spell ended because beneficiary did not
comply with the renewal process on time.
Step 5. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1, 2, 3, and 4.
Required or
recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Data source
Administrative records
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Metric RW_3: Beneficiaries who had a coverage gap at renewal and had
claims denied
Metric element
Description
Description
The number of demonstration beneficiaries in income and eligibility groups that were subject to the
waiver of retroactive eligibility policy who re-enrolled in the demonstration within 90 days after a
previous enrollment spell in the demonstration ended, and for whom claims were submitted for
services rendered during the period of disenrollment that were denied by the state.
Counted variable
Step 1. Identify beneficiaries who had a coverage gap at renewal (RW_2).
Step 2. Retain beneficiaries for whom claims were submitted for services rendered during the
coverage gap that were denied by the state.
Step 3. Count unique beneficiaries (deduplicated) who meet the criteria in Steps 1 and 2.
Additional guidance
The coverage gap is defined as the time between the end of the previous enrollment spell and the
re-enrollment date.
Required or
recommended
Required
Measurement period
(calculation lag)
Quarter (90 days)
Relationship to other
metrics
This metric is a subset of metric RW_2
Data source
Administrative records
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APPENDIX A
ESTABLISHED MEASURES AND MEASURE SETS
REFERENCED IN TECHNICAL SPECIFICATIONS
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Table A.1 defines the established measures, measure sets, and measure set versions
referenced in the specifications for these metrics.
Table A.1 Established measures and measure sets referenced in metric
specifications
Metric
Number
Metric name
Measure set
Measure
set version
AD_38A
Medical Assistance with Smoking and Tobacco Use
Cessation (MSC-AD)
Adult Core Set
FFY 2019
AD_38B
Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention
Merit-based Incentive
Payment System (MIPS)
2018
AD_39-1
Follow-Up After Emergency Department Visit for
Alcohol and Other Drug Abuse or Dependence
(FUA -AD)
Adult Core Set
FFY 2019
AD_39-2
Follow-Up After Emergency Department Visit for
Mental Illness (FUM-AD)
Adult Core Set
FFY 2019
AD_40
Initiation and Engagement of Alcohol and Other
Drug Abuse or Dependence Treatment (IET-AD)
Adult Core Set
FFY 2019
AD_41
PQI 01: Diabetes Short-Term Complications
Admission Rate (PQI01-AD)
Adult Core Set
FFY 2019
AD_42
PQI 05: Chronic Obstructive Pulmonary Disease
(COPD) or Asthma in Older Adults Admission Rate
(PQI05-AD)
Adult Core Set
FFY 2019
AD_43
PQI 08: Heart Failure Admission Rate (PQI08-AD)
Adult Core Set
FFY 2019
AD_44
PQI 15: Asthma in Younger Adults Admission Rate
(PQI15-AD)
Adult Core Set
FFY 2019
A-3
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APPENDIX B
TECHNICAL SPECIFICATIONS FOR MEDICAID QUALITY MEASURES,
ADAPTED FROM FFY 2019 ADULT CORE SET MEASURE SPECIFICATIONS
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This appendix provides the technical specifications for the Adult Core Set measures
included in the monitoring metrics for section 1115 eligibility and coverage demonstrations.
These specifications have been adapted from state-level specifications for use in section 1115
eligibility and coverage demonstrations.
B.I. MEASURE ELEMENT DEFINITIONS
Measurement period. The measurement period is the time frame for which the data
should be collected (defined by start and end dates). The measurement period for each Adult
Core Set measure included in the section 1115 eligibility and coverage monitoring metrics
can be found in Table B.1. For many measures, the denominator measurement period for
FFY 2019 corresponds to calendar year 2018 (January 1, 2018–December 31, 2018).
However, for some measures, the measurement period begins before the calendar year. For
example, Measure AD_40: Initiation and Engagement of Alcohol and Other Drug or
Dependence Treatment (IET-AD) requires states to review utilization and continuous
enrollment prior to January 1 when constructing the denominator. This is referred to as a
“look-back period” or a negative review period.
Continuous enrollment. Continuous enrollment specifies the minimum amount of
time that a beneficiary must be enrolled in the demonstration before becoming eligible for the
measure. The continuous enrollment period is specified for each measure in Table B.1.
Allowable gap. The allowable gap specifies the maximum amount of time a beneficiary
can be disenrolled from the demonstration and still qualify for inclusion in the measure. The
allowable gap is specified for each measure in Table B.1.
Hospice exclusion. Some Adult Core Set measures included in the section 1115
eligibility and coverage monitoring metrics exclude beneficiaries who use hospice services or
elect to use a hospice benefit any time during the measurement year, regardless of when the
services began. These beneficiaries may be identified using various methods, which may
include but are not limited to enrollment data, medical record or claims/encounter data. The
Hospice Value Set is available to states upon request by contacting
[email protected]. States should remove these beneficiaries prior
to determining a measure’s eligible population. Documentation that a beneficiary is near the
end of life (e.g., comfort care, Do Not Resuscitate [DNR], Do Not Intubate [DNI]), or is in
palliative care does not meet criteria for the hospice exclusion. This applies to the following
measures: AD_39-1, AD_39-2, and AD_40.
Anchor date. Some measures include an anchor date, which is the date that an individual
must be enrolled in the demonstration to be eligible for the measure. For example, if an
enrollment gap includes the anchor date, the individual is not eligible for the measure. For
several measures, the anchor date is the last day of the measure’s FFY 2019 measurement
period (December 31, 2018). States should use the specified anchor dates along with the
continuous enrollment requirements and allowable gaps for each measure to determine the
measure-eligible population.
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CAHPS. CAHPS is a family of surveys designed to assess consumer experiences with care.
Different versions of the survey are available for use among various populations, payers, and
settings. The version of the CAHPS Survey specified in the Adult Core Set is the CAHPS
Health Plan Survey 5.0H (Medicaid).
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Table B.1. Measurement period for denominators and numerators for the FFY 2019 Adult Core Set section
1115 eligibility and coverage monitoring metrics
FFY 2019 Measurement Perioda
Measure
Denominator
Numerator
Continuous Enrollment
Period
Allowable Gap
AD_38A:
Medical Assistance
with Smoking and
Tobacco Use
Cessation (MSC-AD)
January 1, 2018 –
December 31, 2018
January 1, 2018 –
December 31, 2018
July 1, 2018 – December
31, 2018
No more than one gap in
enrollment of up to 45 days
during the continuous
enrollment period. To
determine continuous
enrollment for a beneficiary
for whom enrollment is
verified monthly, the
beneficiary may not have
more than a 1-month gap in
coverage (i.e., a beneficiary
whose coverage lapses for
2 months [60 days] is not
considered continuously
enrolled).
AD_39-1: Follow-Up
After Emergency
Department Visit for
Alcohol and Other
Drug Abuse or
Dependence (FUAAD)
Emergency Department
(ED) visit date: January 1,
2018 – December 1, 2018
7 Day Follow-up: January 1,
2018 – December 8, 2018
(ED visit date through 7
days after visit date)
January 1, 2018 –
December 31, 2018 (ED
visit date through 30 days
after visit date)
None
30 Day Follow-up: January
1, 2018 – December 31,
2018
(ED visit date through 30
days after visit date)
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FFY 2019 Measurement Perioda
Measure
AD_39-2: Follow-Up
After Emergency
Department Visit for
Mental Illness (FUMAD)
Denominator
ED visit date: January 1,
2018 – December 1, 2018
Numerator
7 Day Follow-up: January 1,
2018 – December 8, 2018
(ED visit date through 7
days after visit date)
Continuous Enrollment
Period
Allowable Gap
January 1, 2018 –
December 31, 2018 (ED
visit date through 30 days
after visit date)
None
November 2, 2017 –
January 1, 2019
(60 days prior to IESD
through 48 days after the
IESD)
None
None
None
30 Day Follow-up: January
1, 2018 – December 31,
2018
(ED visit date through 30
days after visit date)
AD_40: Initiation and
Engagement of
Alcohol and Other
Drug Abuse or
Dependence
Treatment (IET-AD)
AD_41: PQI 01:
Diabetes Short-Term
Complications
Admission Rate
(PQI01-AD)
Index episode start date
(IESD): January 1, 2018 –
November 14, 2018
Negative diagnosis history
review: November 2, 2017
– September 15, 2018
(60 days prior to IESD)
January 1, 2018 –
December 31, 2018
Initiation of AOD Treatment:
January 1 , 2018 –
November 28, 2018
(Within 14 days of the
IESD)b
Engagement of AOD
Treatment: January 2, 2018
– January 1, 2019
(Day after initiation
encounter through 34 days
after the initiation date) b
January 1, 2018 –
December 31, 2018
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FFY 2019 Measurement Perioda
Measure
Denominator
Numerator
Continuous Enrollment
Period
Allowable Gap
AD_42: PQI 05:
Chronic Obstructive
Pulmonary Disease
(COPD) or Asthma in
Older Adults (PQI05AD)
January 1, 2018 –
December 31, 2018
January 1, 2018 –
December 31, 2018
None
None
AD_43: PQI 08: Heart
Failure Admission
Rate (PQI08-AD)
January 1, 2018 –
December 31, 2018
January 1, 2018 –
December 31, 2018
None
None
AD_44: PQI 15:
Asthma in Younger
Adults Admission
Rate (PQI15-AD)
January 1, 2018 –
December 31, 2018
January 1, 2018 –
December 31, 2018
None
None
a
For some measures, the measurement period for the numerator, denominator, or continuous enrollment period varies depending on a specified date for each
enrollee (such as ED visit or the index episode start date). For these measures, two ranges are shown. The first date range identifies the full range of possible
dates that states will need to use to calculate the measure for all measure-eligible enrollees. The text in parentheses describes the measurement period that
should be used for each eligible enrollee.
b Applies to all rates: Alcohol abuse or dependence rate, Opioid abuse or dependence rate, Other drug abuse or dependence rate, and Total AOD abuse or
dependence rate.
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B.II. TECHNICAL SPECIFICATIONS
Metric AD_38A: Medical Assistance with Smoking and Tobacco Use
Cessation (MSC-AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
The following components of this measure assess different facets of providing medical
assistance with smoking and tobacco use cessation:
Advising Smokers and Tobacco Users to Quit. A rolling average represents the
percentage of beneficiaries enrolled in the demonstration age 18 and older who were
current smokers or tobacco users and who received advice to quit during the
measurement year.
Discussing Cessation Medications. A rolling average represents the percentage of
beneficiaries enrolled in the demonstration age 18 and older who were current smokers
or tobacco users and who discussed or were recommended cessation medications
during the measurement year.
Discussing Cessation Strategies. A rolling average represents the percentage of
beneficiaries enrolled in the demonstration age 18 and older who were current smokers
or tobacco users and who discussed or were provided cessation methods or strategies
during the measurement year.
Data Collection Method: Survey
Guidance for Reporting:
If the denominator is less than 100, this measure is not reported. First-year data
collection will generally not yield enough responses to be reportable. A rolling
two-year average can be used to achieve a sufficient number of respondents for
reporting. For additional guidance on calculating a two-year average, see Section
E. Calculation of Measure.
B. ELIGIBLE POPULATION
Age
Age 18 and older as of December 31 of the measurement year.
Continuous enrollment
Enrolled in the demonstration for the last six months of the
measurement period.
Allowable gap
No more than one gap in enrollment of up to 45 days during the
continuous enrollment period. To determine continuous
enrollment for a beneficiary for whom enrollment is verified
monthly, the beneficiary may not have more than a 1-month
gap in coverage (i.e., a beneficiary whose coverage lapses for
2 months [60 days] is not considered continuously enrolled).
Anchor date
December 31 of the measurement year.
Current enrollment
Currently enrolled at the time the survey is completed.
Version of Specification: HEDIS 2019
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C. PROTOCOL AND SURVEY INSTRUMENT
The data for this measure are collected annually as part of the CAHPS Health Plan Survey
5.0H, Adult Version. States must create a sample frame for the survey and contract with a
NCQA certified HEDIS 2019 survey vendor that will administer the survey according to HEDIS
protocols. The survey vendor draws the actual samples and fields the survey.
The sample size for the CAHPS Health Plan Survey should be 1,350, plus an oversample
based on the state’s prior experience with survey response rates, to yield at least 411 completed
surveys. The required sample size is based on the average number of complete and valid surveys
obtained by health plans during prior years; therefore, using the required sample size for a given
survey does not guarantee that a state will achieve the goal of 411 completed surveys or the
required denominator of 100 complete responses for each survey result. The state should work
with its survey vendor to determine the number of complete and valid surveys it can expect to
obtain without oversampling based on prior experience. Note that the sample size may need to be
increased to yield at least 100 responses that meet the eligible population criteria for the section
1115 demonstration. Refer to Section E for more information on the denominator requirements
for calculating the measure using a rolling average methodology.
NCQA maintains a list of survey vendors that have been trained and certified by NCQA to
administer the CAHPS 5.0H survey. Each survey vendor is assigned a maximum capacity of
samples. The capacity reflects the firm’s and NCQA’s projection of resources available to be
dedicated to administer the survey. A current listing of NCQA-certified HEDIS 2019 survey
vendors is available at https://www.ncqa.org/programs/data-and-information-technology/hit-anddata-certification/cahps-5-0h-survey-certification/vendor-directory/.
D. QUESTIONS INCLUDED IN THIS MEASURE
Questions
.
Response Choices
Q39
Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
Every day
Some days
Not at all If Not at all, Go
to Question 43
Don’t know If Don’t know,
Go to Question 43
Q40
In the last 6 months, how often were you
advised to quit smoking or using tobacco by a
doctor or other health provider in your plan?
Never
Sometimes
Usually
Always
Q41
In the last 6 months, how often was
medication recommended or discussed by a
doctor or health provider to assist you with
quitting smoking or using tobacco? Examples
of medication are: nicotine gum, patch, nasal
spray, inhaler, or prescription medication.
Never
Sometimes
Usually
Always
Version of Specification: HEDIS 2019
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Questions
.
Response Choices
Q42
In the last 6 months, how often did your doctor
or health provider discuss or provide methods
and strategies other than medication to assist
you with quitting smoking or using tobacco?
Examples of methods and strategies are:
telephone helpline, individual or group
counseling, or cessation program.
Never
Sometimes
Usually
Always
E. CALCULATION OF MEASURE
Rolling averages are calculated using the formula below.
Rate = (Year 1 Numerator + Year 2 Numerator) / (Year 1 Denominator + Year 2
Denominator)
If the denominator is less than 100, this measure is not reported.
If the denominator is 100 or more, a rate is calculated.
If the state did not report results for the current year (Year 2), this measure is not
reported.
If the state did not report results in the prior year (Year 1) but reports results for the
current year and achieves a denominator of 100 or more, a rate is calculated; if the
denominator is less than 100, this measure is not reported.
Component 1: Advising Smokers and Tobacco Users to Quit
Denominator
The number of beneficiaries who responded to the survey and indicated that they were
current smokers or tobacco users. Beneficiary response choices must be as follows to be
included in the denominator:
Q39 = “Every day” or “Some days.”
AND
Q40 = “Never” or “Sometimes” or “Usually” or “Always.”
Numerator
The number of beneficiaries in the denominator who indicated that they received advice to
quit from a doctor or other health provider by answering “Sometimes” or “Usually” or
“Always” to Q40.
Component 2: Discussing Cessation Medications
Denominator
The number of beneficiaries who responded to the survey and indicated that they were
current smokers or tobacco users. Beneficiary response choices must be as follows to be
included in the denominator:
Q39 = “Every day” or “Some days.”
AND
Q41 = “Never” or “Sometimes” or “Usually” or “Always.”
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Numerator
The number of beneficiaries in the denominator who indicated that their doctor or health
provider recommended or discussed cessation medications by answering “Sometimes” or
“Usually” or “Always” to Q41.
Component 3: Discussing Cessation Strategies
Denominator
The number of beneficiaries who responded to the survey and indicated that they were
current smokers or tobacco users. Beneficiary response choices must be as follows to be
included in the denominator:
Q39 = “Every day” or “Some days.”
AND
Q42 = “Never” or “Sometimes” or “Usually” or “Always.”
Numerator
The number of beneficiaries in the denominator who indicated that their doctor or health
provider discussed or provided cessation methods and strategies by answering
“Sometimes” or “Usually” or “Always” to Q42.
Percentage of Current Smokers and Tobacco Users - Supplemental Calculation
This calculation is provided to support analysis of Medical Assistance with Smoking and
Tobacco Use Cessation rates and provides additional context for unreportable results (that
is, where the denominator is less than 100). A state with a small number of smokers or
tobacco users may not be able to obtain a large enough denominator to achieve reportable
rates (that is, where the denominator is less than 100).
The percentage of current smokers and tobacco users is calculated using data collected
during the current reporting year only (not calculated as a rolling average).
Denominator
The number of beneficiaries who responded “Every day,” “Some days,” “Not at all,” or
“Don’t know” to the question “Do you now smoke cigarettes or use tobacco every day,
some days, or not at all?”
Numerator
The number of beneficiaries in the denominator who responded “Every day” or “Some
days” to the question “Do you now smoke cigarettes or use tobacco every day, some days,
or not at all?”
Version of Specification: HEDIS 2019
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Metric AD_39-1: Follow-Up After Emergency Department Visit for Alcohol
and Other Drug Abuse or Dependence (FUA -AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of emergency department (ED) visits for beneficiaries enrolled in the
demonstration age 18 and older with a principal diagnosis of alcohol or other drug (AOD)
abuse or dependence who had a follow-up visit for AOD abuse or dependence. Two rates
are reported:
Percentage of ED visits for AOD abuse or dependence for which the beneficiary
received follow-up within 30 days of the ED visit (31 total days)
Percentage of ED visits for AOD abuse or dependence for which the beneficiary
received follow-up within 7 days of the ED visit (8 total days)
Data Collection Method: Administrative
Guidance for Reporting:
The denominator should be the same for the 30-day rate and the 7-day rate.
The 30-day follow-up rate should be greater than or equal to the 7-day follow-up
rate.
When a visit code or procedure code must be used in conjunction with a
diagnosis code, the codes must be on the same claim or be found on the same
date of service.
- If a value set includes codes used on professional claims (e.g., CPT,
HCPCS) and includes codes used on facility claims (e.g., UB), use
diagnosis and procedure codes from both facility and professional claims
to identify services and diagnoses (the codes can be on the same claim or
same date of service).
- If a value set includes codes used only on facility claims (e.g., UB) then
use only facility claims to identify services and diagnoses (the codes must
be on the same claim).
Include all paid, suspended, pending and denied claims.
Beneficiaries in hospice are excluded from the eligible population. For additional
information, refer to the hospice exclusion guidance in Section I. Measure
Element Definitions.
The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM,
Modifier, POS, and UB. Refer to the Acknowledgments section at the beginning of the
manual for copyright information.
Version of Specification: HEDIS 2019
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B. ELIGIBLE POPULATION
Age
Continuous
enrollment
Allowable gap
Anchor date
Benefit
Event/diagnosis
Multiple visits in a
31-day period
ED visits followed
by inpatient
admission
Age 18 and older as of the ED visit.
Enrolled in the demonstration on the date of the ED visit through 30
days after the ED visit (31 total days).
No allowable gap during the continuous enrollment period.
None.
Medical and chemical dependency.
Note: Beneficiaries with detoxification-only chemical dependency
benefits do not meet these criteria.
An ED visit (ED Value Set) with a principal diagnosis of AOD abuse
or dependence (AOD Abuse and Dependence Value Set) on or
between January 1 and December 1 of the measurement year
where the beneficiary was age 18 or older on the date of the visit
and enrolled in the demonstration.
The denominator for this measure is based on ED visits, not on the
number of beneficiaries enrolled in the demonstration. If a
beneficiary has more than one ED visit, identify all eligible ED visits
between January 1 and December 1 of the measurement year and
do not include more than one visit per 31-day period as described
below.
If a beneficiary has more than one ED visit in a 31-day period,
include only the first eligible ED visit. For example, if a beneficiary
has an ED visit on January 1, then include the January 1 visit and
do not include ED visits that occur on or between January 2 and
January 31; then, if applicable, include the next ED visit that occurs
on or after February 1. Identify visits chronologically including only
one per 31-day period.
Note: Removal of multiple visits in a 31-day period is based on
eligible visits. Assess each ED visit for exclusion before removing
multiple visits in a 31-day period.
Exclude ED visits that result in an inpatient stay and ED visits
followed by an admission to an acute or nonacute inpatient care
setting on the date of the ED visit or within the 30 days after the ED
visit (31 total days), regardless of principal diagnosis for the
admission. To identify admissions to an acute or nonacute inpatient
care setting:
1. Identify all acute and nonacute inpatient
stays (Inpatient Stay Value Set).
2. Identify the admission date for the stay.
An ED or observation visit billed on the same claim as an inpatient
stay is considered a visit that resulted in an inpatient stay.
These events are excluded from this measure because admission
to an acute or nonacute inpatient setting may prevent an outpatient
follow-up visit from taking place.
Version of Specification: HEDIS 2019
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C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerator
30-Day Follow-Up
A follow-up visit with any practitioner, with a principal diagnosis of AOD abuse or
dependence within 30 days after the ED visit (31 total days). Include visits that occur on the
date of the ED visit.
7-Day Follow-Up
A follow-up visit with any practitioner, with a principal diagnosis of AOD abuse or
dependence within 7 days after the ED visit (8 total days). Include visits that occur on the
date of the ED visit.
For both indicators, any of the following meet criteria for a follow-up visit:
IET Stand Alone Visits Value Set with a principal diagnosis of AOD abuse or
dependence (AOD Abuse and Dependence Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
IET Visits Group 1 Value Set with IET POS Group 1 Value Set and a principal diagnosis
of AOD abuse or dependence (AOD Abuse and Dependence Value Set), with or without
a telehealth modifier (Telehealth Modifier Value Set)
IET Visits Group 2 Value Set with IET POS Group 2 Value Set and a principal diagnosis
of AOD abuse or dependence (AOD Abuse and Dependence Value Set), with or without
a telehealth modifier (Telehealth Modifier Value Set)
An observation visit (Observation Value Set) with a principal diagnosis of AOD abuse or
dependence (AOD Abuse and Dependence Value Set)
A telephone visit (Telephone Visits Value Set) with a principal diagnosis of AOD abuse
or dependence (AOD Abuse and Dependence Value Set)
An online assessment (Online Assessments Value Set) with a principal diagnosis of
AOD abuse or dependence (AOD Abuse and Dependence Value Set)
D. ADDITIONAL NOTES
There may be different methods for billing intensive outpatient visits and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate
claims for each date of service; others may be comparable to inpatient billing, with an
admission date, a discharge date, and units of service. Where billing methods are
comparable to inpatient billing, each unit of service may be counted as an individual visit.
The unit of service must have occurred during the required period for the rate (e.g., within
30 days after the ED visit or within 7 days after the ED visit).
Version of Specification: HEDIS 2019
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Metric AD_39-2: Follow-Up After Emergency Department Visit for Mental
Illness (FUM-AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of emergency department (ED) visits for beneficiaries enrolled in the
demonstration age 18 and older with a principal diagnosis of mental illness or intentional
self-harm and who had a follow-up visit for mental illness. Two rates are reported:
Percentage of ED visits for mental illness or intentional self-harm for which the
beneficiary received follow-up within 30 days of the ED visit (31 total days)
Percentage of ED visits for mental illness or intentional self-harm for which the
beneficiary received follow-up within 7 days of the ED visit (8 total days)
Data Collection Method: Administrative
Guidance for Reporting:
The denominator should be the same for the 30-day rate and the 7-day rate.
The 30-day follow-up rate should be greater than or equal to the 7-day follow-up
rate.
When a visit code or procedure code must be used in conjunction with a
diagnosis code, the codes must be on the same claim or be found on the same
date of service.
-
If a value set includes codes used on professional claims (e.g., CPT,
HCPCS) and includes codes used on facility claims (e.g., UB), use
diagnosis and procedure codes from both facility and professional claims
to identify services and diagnoses (the codes can be on the same claim or
same date of service).
-
If a value set includes codes used only on facility claims (e.g., UB) then
only use facility claims to identify services and diagnoses (the codes must
be on the same claim).
Include all paid, suspended, pending and denied claims.
Beneficiaries in hospice are excluded from the eligible population. For additional
information, refer to the hospice exclusion guidance in Section I. Measure
Element Definitions.
The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, ICD10-PCS, Modifier, POS, and UB. Refer to the Acknowledgments section at the beginning of
the manual for copyright information.
Version of Specification: HEDIS 2019
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B. ELIGIBLE POPULATION
Ages
Age 18 and older as of the date of the ED visit.
Continuous
enrollment
Enrolled in the demonstration on the date of the ED visit through 30
days after the ED visit (31 total days).
Allowable gap
No allowable gap during the continuous enrollment period.
Anchor date
None.
Benefit
Medical and mental health.
Event/diagnosis
An ED visit (ED Value Set) with a principal diagnosis of mental
illness or intentional self-harm (Mental Illness Value Set; Intentional
Self-Harm Value Set) on or between January 1 and December 1 of
the measurement year where the beneficiary was age 18 or older
on the date of the visit and enrolled in the demonstration.
The denominator for this measure is based on ED visits, not on the
number of beneficiaries enrolled in the demonstration. If a
beneficiary has more than one ED visit, identify all eligible ED visits
between January 1 and December 1 of the measurement year and
do not include more than one visit per 31-day period as described
below.
Multiple visits in a
31-day period
If a beneficiary has more than one ED visit in a 31-day period,
include only the first eligible ED visit. For example, if a beneficiary
has an ED visit on January 1, then include the January 1 visit and
do not include ED visits that occur on or between January 2 and
January 31; then, if applicable, include the next ED visit that occurs
on or after February 1. Identify visits chronologically including only
one per 31-day period.
Note: Removal of multiple visits in a 31-day period is based on
eligible visits. Assess each ED visit for exclusion before removing
multiple visits in a 31-day period.
ED visits followed
by inpatient
admission
Exclude ED visits that result in an inpatient stay and ED visits
followed by an admission to an acute or nonacute inpatient care
setting on the date of the ED visit or within the 30 days after the ED
visit (31 total days), regardless of principal diagnosis for the
admission. To identify admissions to an acute or nonacute inpatient
care setting:
1.
Identify all acute and nonacute inpatient stays (Inpatient
Stay Value Set).
2.
Identify the admission date for the stay.
An ED or observation visit billed on the same claim as an inpatient
stay is considered a visit that resulted in an inpatient stay.
These events are excluded from this measure because admission
to an acute or nonacute inpatient setting may prevent an outpatient
follow-up visit from taking place.
Version of Specification: HEDIS 2019
http://www.qualityindicators.ahrq.gov/Modules/pqi_resources.aspx
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C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerator
30-Day Follow-Up
A follow-up visit with any practitioner, with a principal diagnosis of a mental health disorder
or with a principal diagnosis of intentional self-harm and any diagnosis of mental health
disorder within 30 days after the ED visit (31 total days). Include visits that occur on the
date of the ED visit.
7-Day Follow-Up
A follow-up visit with any practitioner, with a principal diagnosis of a mental health disorder
or with a principal diagnosis of intentional self-harm and any diagnosis of a mental health
disorder within 7 days after the ED visit (8 total days). Include visits that occur on the date
of the ED visit.
For both indicators, any of the following meet criteria for a follow-up visit.
An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set)
with a principal diagnosis of a mental health disorder (Mental Health Diagnosis Value
Set), with or without a telehealth modifier (Telehealth Modifier Value Set)
An outpatient visit (BH Outpatient Value Set) with a principal diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified
Value Set with Partial Hospitalization POS Value Set), with a principal diagnosis of
mental health disorder (Mental Health Diagnosis Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
An intensive outpatient encounter or partial hospitalization (Partial
Hospitalization/Intensive Outpatient Value Set) with a principal diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set)
A community mental health center visit (Visit Setting Unspecified Value Set with
Community Mental Health Center POS Value Set), with a principal diagnosis of a
mental health disorder (Mental Health Diagnosis Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory
Surgical Center POS Value Set; Community Mental Health Center POS Value Set;
Outpatient POS Value Set; Partial Hospitalization POS Value Set) with a principal
diagnosis of a mental health disorder (Mental Health Diagnosis Value Set)
A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set),
with a principal diagnosis of a mental health disorder (Mental Health Diagnosis Value
Set), with or without a telehealth modifier (Telehealth Modifier Value Set)
An observation visit (Observation Value Set) with a principal diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set)
Version of Specification: HEDIS 2019
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An outpatient visit (Visit Setting Unspecified Value Set with Outpatient POS Value Set)
with a principal diagnosis of intentional self-harm (Intentional Self-Harm Value Set) with
any diagnosis of a mental health disorder (Mental Health Diagnosis Value Set), with or
without a telehealth modifier (Telehealth Modifier Value Set)
An outpatient visit (BH Outpatient Value Set) with a principal diagnosis of intentional
self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental health
disorder (Mental Health Diagnosis Value Set), with or without a telehealth modifier
(Telehealth Modifier Value Set)
An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified
Value Set with Partial Hospitalization POS Value Set), with a principal diagnosis of
intentional self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
An intensive outpatient encounter or partial hospitalization (Partial
Hospitalization/Intensive Outpatient Value Set) with a principal diagnosis of intentional
self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental health
disorder (Mental Health Diagnosis Value Set)
A community mental health center visit (Visit Setting Unspecified Value Set with
Community Mental Health Center POS Value Set), with a principal diagnosis of
intentional self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set), with or without a telehealth
modifier (Telehealth Modifier Value Set)
Electroconvulsive therapy (Electroconvulsive Therapy Value Set) with (Ambulatory
Surgical Center POS Value Set; Community Mental Health Center POS Value Set;
Outpatient POS Value Set; Partial Hospitalization POS Value Set) with a principal
diagnosis of intentional self-harm (Intentional Self-Harm Value Set), with any diagnosis
of a mental health disorder (Mental Health Diagnosis Value Set)
A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value Set),
with a principal diagnosis of intentional self-harm (Intentional Self-Harm Value Set), with
any diagnosis of a mental health disorder (Mental Health Diagnosis Value Set), with or
without a telehealth modifier (Telehealth Modifier Value Set)
An observation visit (Observation Value Set) with a principal diagnosis of intentional
self-harm (Intentional Self-Harm Value Set), with any diagnosis of a mental health
disorder (Mental Health Diagnosis Value Set)
D. ADDITIONAL NOTES
There may be different methods for billing intensive outpatient visits and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate
claims for each date of service; others may be comparable to inpatient billing, with an
admission date, a discharge date, and units of service. Where billing methods are
comparable to inpatient billing, each unit of service may be counted as an individual visit.
The unit of service must have occurred during the required period specified for the rate
(e.g., within 30 days after discharge or within 7 days after discharge).
Version of Specification: HEDIS 2019
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Metric AD_40: Initiation and Engagement of Alcohol and Other Drug Abuse
or Dependence Treatment (IET-AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of beneficiaries enrolled in the demonstration age 18 and older with a new
episode of alcohol or other drug (AOD) abuse or dependence who received the following:
Initiation of AOD Treatment. Percentage of beneficiaries who initiated treatment
through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or
partial hospitalization, telehealth, or medication treatment within 14 days of the
diagnosis
Engagement of AOD Treatment. Percentage of beneficiaries who initiated treatment
and who had two or more additional AOD services or medication treatment within 34
days of the initiation visit
Data Collection Method: Administrative or EHR
Guidance for Reporting:
Two rates are reported: initiation of AOD treatment and engagement of AOD
treatment. For each rate, report the following AOD diagnosis cohorts:
- Alcohol abuse or dependence
- Opioid abuse or dependence
- Other drug abuse or dependence
- Total AOD abuse or dependence
The total AOD abuse or dependence rate is not a sum of the diagnosis cohorts.
Count beneficiaries in the total denominator rate if they had at least one alcohol,
opioid, or other drug abuse or dependence diagnosis during the measurement
period. Report beneficiaries with multiple diagnoses on the Index Episode claim
only once for the total rate for the denominator.
Exclude beneficiaries from the denominator for both rates (initiation of AOD
treatment and engagement of AOD treatment) if the initiation of treatment event is
an inpatient stay with a discharge date after November 27 of the measurement
year.
Include all paid, suspended, pending, and denied claims.
Beneficiaries in hospice are excluded from the eligible population. For additional
information, refer to the hospice exclusion guidance in Section I. Measure
Element Definitions.
NCQA’s Medication List Directory (MLD) of NDC codes for Medication Treatment
for Alcohol Abuse or Dependence Medications and Medication Treatment for
Opioid Abuse or Dependence Medications can be found at
https://www.ncqa.org/hedis/measures/hedis-2019-ndc-license/hedis-2019-finalndc-lists.
The electronic specification for FFY 2019 is located on the eCQI resource center
at https://ecqi.healthit.gov/ecqm/measures/cms137v6
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The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, ICD10-PCS, Modifier, NDC, POS, and UB. Refer to the Acknowledgments section at the
beginning of the manual for copyright information.
B. DEFINITIONS
Intake period
January 1 to November 14 of the measurement year. The Intake Period
is used to capture new episodes of AOD abuse and dependence.
Index episode
The earliest eligible encounter during the Intake Period with a diagnosis
of AOD abuse or dependence. The beneficiary must be enrolled in the
demonstration during the index episode.
For ED visits that result in an inpatient stay, the inpatient discharge is
the Index Episode.
IESD
Index Episode Start Date (IESD). The earliest date of service for an
eligible encounter during the Intake Period with a diagnosis of AOD
abuse or dependence.
For an outpatient, intensive outpatient, partial hospitalization,
observation, telehealth, detoxification, or ED visit (not resulting in an
inpatient stay), the IESD is the date of service.
For an inpatient stay, the IESD is the date of discharge.
For ED and observation visits that result in an inpatient stay, the IESD
is the date of the inpatient discharge (an AOD diagnosis is not required
for the inpatient stay; use the diagnosis from the ED or observation visit
to determine the diagnosis cohort).
When an ED or observation visit and an inpatient stay are billed on
separate claims, the visit results in an inpatient stay when the
ED/observation date of service occurs on the day prior to the admission
date or any time during the admission (admission date through
discharge date). An ED or observation visit billed on the same claim as
an inpatient stay is considered a visit that resulted in an inpatient stay.
For direct transfers, the IESD is the discharge date from the last
admission (an AOD diagnosis is not required for the transfer; use the
diagnosis from the initial admission to determine the diagnosis cohort).
Negative
diagnosis
history
A period of 60 days (2 months) before the IESD when the beneficiary
had no claims/encounters with a diagnosis of AOD abuse or
dependence.
For an inpatient stay, use the admission date to determine the Negative
Diagnosis History.
For ED or observation visits that result in an inpatient stay, use the
earliest date of service (either the ED/observation date of service or the
inpatient admission date) to determine the Negative Diagnosis History.
When an ED or observation visit and an inpatient stay are billed on
separate claims, the visit results in an inpatient stay when the
ED/observation date of service occurs on the day prior to the admission
date or any time during the admission (admission date through
discharge date). An ED or observation visit billed on the same claim as
an inpatient stay is considered a visit that resulted in an inpatient stay.
For direct transfers, use the first admission to determine the Negative
Diagnosis History.
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Direct transfer
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A direct transfer is when the discharge date from the first inpatient
setting precedes the admission date to a second inpatient setting by
one calendar day or less. For example:
An inpatient discharge on June 1, followed by an admission to
another inpatient setting on June 1, is a direct transfer.
An inpatient discharge on June 1, followed by an admission to
an inpatient setting on June 2, is a direct transfer.
An inpatient discharge on June 1, followed by an admission to
another inpatient setting on June 3, is not a direct transfer;
these are two distinct inpatient stays.
Use the following method to identify admissions to and discharges from
inpatient settings.
1.
Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2.
Identify the admission and discharge dates for the stay.
C. ELIGIBLE POPULATION
Age
Age 18 and older as of December 31 of the measurement year.
AOD
diagnosis
cohorts
Report the following diagnosis cohorts:
Alcohol abuse or dependence
Opioid abuse or dependence
Other drug abuse or dependence
Total AOD abuse or dependence
Continuous
enrollment
Enrolled in Medicaid for 60 days (2 months) prior to the IESD and
enrolled in the demonstration for 48 days after the IESD.
Allowable gap
No allowable gap during the continuous enrollment period.
Anchor date
None.
Benefits
Medical, pharmacy, and chemical dependency (inpatient and
outpatient).
Note: Beneficiaries with detoxification-only chemical dependency
benefits do not meet these criteria.
Event/
diagnosis
New episode of AOD abuse or dependence during the Intake Period.
Follow the steps below to identify the eligible population, which is the
denominator for both rates.
Step 1
Identify the Index Episode. Identify all beneficiaries in the specified age
range who during the Intake Period had one of the following:
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Event/
diagnosis
(continued)
MATHEMATICA POLICY RESEARCH
An outpatient visit, telehealth, intensive outpatient visit, or partial
hospitalization with a diagnosis of AOD abuse or dependence.
Any of the following code combinations meet criteria:
- IET Stand Alone Visits Value Set with one of the
following: Alcohol Abuse and Dependence Value Set,
Opioid Abuse and Dependence Value Set, Other Drug
Abuse and Dependence Value Set, with or without a
telehealth modifier (Telehealth Modifier Value Set)
- IET Visits Group 1 Value Set with IET POS Group 1
Value Set and with one of the following: Alcohol Abuse
and Dependence Value Set, Opioid Abuse and
Dependence Value Set, Other Drug Abuse and
Dependence Value Set, with or without a telehealth
modifier (Telehealth Modifier Value Set)
- IET Visits Group 2 Value Set with IET POS Group 2
Value Set and with one of the following: Alcohol Abuse
and Dependence Value Set, Opioid Abuse and
Dependence Value Set, Other Drug Abuse and
Dependency Value Set, with or without a telehealth
modifier (Telehealth Modifier Value Set)
A detoxification visit (Detoxification Value Set) with one of the
following: Alcohol Abuse and Dependence Value Set, Opioid
Abuse and Dependence Value Set, Other Drug Abuse and
Dependence Value Set
An ED visit (ED Value Set) with one of the following: Alcohol
Abuse and Dependence Value Set, Opioid Abuse and
Dependence Value Set, Other Drug Abuse and Dependence
Value Set
An observation visit (Observation Value Set) with one of the
following: Alcohol Abuse and Dependence Value Set, Opioid
Abuse and Dependence Value Set, Other Drug Abuse and
Dependence Value Set
An acute or nonacute inpatient discharge with one of the
following: Alcohol Abuse and Dependence Value Set, Opioid
Abuse and Dependence Value Set, Other Drug Abuse and
Dependence Value Set. To identify acute and nonacute inpatient
discharges:
1. Identify all acute and nonacute inpatient stays
(Inpatient Stay Value Set).
2. Identify the discharge date for the stay.
A telephone visit (Telephone Visits Value Set) with one of the
following: Alcohol Abuse and Dependence Value Set, Opioid
Abuse and Dependence Value Set, Other Drug Abuse and
Dependence Value Set
An online assessment (Online Assessments Value Set) with one
of the following: Alcohol Abuse and Dependence Value Set,
Opioid Abuse and Dependence Value Set, Other Drug Abuse
and Dependence Value Set
For beneficiaries with more than one episode of AOD abuse or
dependence, use the first episode.
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For beneficiaries whose first episode was an ED or observation visit that
resulted in an inpatient stay, use the diagnosis from the ED or
observation visit to determine the diagnosis cohort and use the inpatient
discharge date as the IESD.
When an ED or observation visit and an inpatient stay are billed on
separate claims, the visit results in an inpatient stay when the
ED/observation date of service occurs on the day prior to the admission
date or any time during the admission (admission date through
discharge date). An ED or observation visit billed on the same claim as
an inpatient stay is considered a visit that resulted in an inpatient stay.
Step 2
Select the Index Episode and stratify based on age and AOD diagnosis
cohort.
If the beneficiary has a diagnosis of alcohol abuse or
dependence (Alcohol Abuse and Dependence Value Set), place
the beneficiary in the alcohol cohort.
If the beneficiary has a diagnosis of opioid abuse or dependence
(Opioid Abuse and Dependence Value Set), place the
beneficiary in the opioid cohort.
If the beneficiary has a drug abuse or dependence that is neither
for opioid or alcohol (Other Drug Abuse and Dependence Value
Set), place the beneficiary in the other drug cohort.
If the beneficiary has multiple substance use diagnoses for the visit,
report the beneficiary in all AOD diagnosis stratifications for which they
meet criteria.
The total is not a sum of the diagnosis cohorts. Count beneficiaries in
the total denominator rate if they had at least one alcohol, opioid, or
other drug abuse or dependence diagnosis during the measurement
period. Report beneficiaries with multiple diagnoses on the Index
Episode only once for the total rate for the denominator.
Step 3
Test for Negative Diagnosis History. Exclude beneficiaries who had a
claim/encounter with a diagnosis of AOD abuse or dependence (AOD
Abuse and Dependence Value Set), AOD medication treatment (AOD
Medication Treatment Value Set), or an alcohol or opioid dependency
treatment medication dispensing event (Medication Treatment for
Alcohol Abuse or Dependence Medications List; Medication Treatment
for Opioid Abuse or Dependence Medications List, see link to
Medication List Directory in Guidance for Reporting above) during the 60
days (2 months) before the IESD.
For an inpatient IESD, use the admission date to determine the 60-day
Negative Diagnosis History period.
For an ED or observation visit that results in an inpatient stay, use the
ED/observation date of service to determine the 60-day Negative
Diagnosis History period.
When an ED or observation visit and an inpatient stay are billed on
separate claims, the visit results in an inpatient stay when the
ED/observation date of service occurs on the day prior to the admission
date or any time during the admission (admission date through
discharge date). An ED or observation visit billed on the same claim as
an inpatient stay is considered a visit that resulted in an inpatient stay.
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Step 4
Calculate continuous enrollment. Beneficiaries must be continuously
enrolled for 60 days (2 months) before the IESD through 48 days after
the IESD (109 total days), with no gaps.
D. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerators
Numerator 1: Initiation of AOD Treatment
Initiation of AOD treatment within 14 days of the IESD.
If the Index Episode was an inpatient discharge (or an ED/observation visit that resulted in
an inpatient stay), the inpatient stay is considered initiation of treatment and the beneficiary
is compliant.
If the Index Episode was not an inpatient discharge, the beneficiary must initiate the
treatment on the start date of the Index Episode or in the 13 days after the Index Episode
(14 total days). Any of the following code combinations meet criteria for initiation:
An acute or nonacute inpatient admission with a diagnosis matching the IESD diagnosis
cohort using one of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse
and Dependence Value Set, Other Drug Abuse and Dependence Value Set. To identify
acute and nonacute inpatient admissions:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).
2. Identify the admission date for the stay.
IET Stand Alone Visits Value Set with a diagnosis matching the IESD diagnosis cohort using
one of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and
Dependence Value Set, Other Drug Abuse and Dependence Value Set, with or without a
telehealth modifier (Telehealth Modifier Value Set)
Observation Value Set with a diagnosis matching the IESD diagnosis cohort using one of
the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and Dependence
Value Set, Other Drug Abuse and Dependence Value Set
IET Visits Group 1 Value Set with IET POS Group 1 Value Set and a diagnosis matching the
IESD diagnosis cohort using one of the following: Alcohol Abuse and Dependence Value
Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value
Set with or without a telehealth modifier (Telehealth Modifier Value Set)
IET Visits Group 2 Value Set with IET POS Group 2 Value Set and a diagnosis matching the
IESD diagnosis cohort using one of the following: Alcohol Abuse and Dependence Value
Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value
Set with or without a telehealth modifier (Telehealth Modifier Value Set)
A telephone visit (Telephone Visits Value Set) with a diagnosis matching the IESD diagnosis
cohort using one of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse
and Dependence Value Set, Other Drug Abuse and Dependence Value Set
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An online assessment (Online Assessments Value Set) with a diagnosis matching the IESD
diagnosis cohort using one of the following: Alcohol Abuse and Dependence Value Set,
Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value Set
If the Index Episode was for a diagnosis of alcohol abuse or dependence (Alcohol Abuse
and Dependence Value Set) a medication treatment dispensing event (Medication
Treatment for Alcohol Abuse or Dependence Medications List, see link to Medication List
Directory in Guidance for Reporting above) or medication treatment during a visit (AOD
Medication Treatment Value Set)
If the Index Episode was for a diagnosis of opioid abuse or dependence (Opioid Abuse
and Dependence Value Set) a medication treatment dispensing event (Medication
Treatment for Opioid Abuse or Dependence Medications List, see link to Medication
List Directory in Guidance for Reporting above) or medication treatment during a visit
(AOD Medication Treatment Value Set)
For all initiation events except medication treatment (AOD Medication Treatment Value Set;
Medication Treatment for Alcohol Abuse or Dependence Medications List; Medication
Treatment for Opioid Abuse or Dependence Medications List, see link to Medication List
Directory in Guidance for Reporting above), initiation on the same day as the IESD must be
with different providers in order to count.
If a beneficiary is compliant for the Initiation numerator for any diagnosis cohort (i.e.,
alcohol, opioid, other drug), or for multiple cohorts, count the beneficiary once in the Total
Initiation numerator. The “Total” column is not the sum of the diagnosis columns.
Exclude the beneficiary from the denominator for both indicators (Initiation of AOD
Treatment and Engagement of AOD Treatment) if the initiation of treatment event is an
inpatient stay with a discharge date after November 27 of the measurement year.
Numerator 2: Engagement of AOD Treatment
Step 1
Identify all beneficiaries compliant for the Initiation of AOD Treatment numerator.
For beneficiaries who initiated treatment via an inpatient admission, the 34-day period for
the two engagement visits begins the day after discharge.
Step 2
Identify beneficiaries whose initiation of AOD treatment was a medication treatment event
(Medication Treatment for Alcohol Abuse or Dependence Medications List; Medication
Treatment for Opioid Abuse or Dependence Medications List; AOD Medication Treatment
Value Set, see link to Medication List Directory in Guidance for Reporting above).
These beneficiaries are numerator compliant if they have two or more engagement events
where only one can be an engagement medication treatment event.
Step 3
Identify the remaining beneficiaries whose initiation of AOD treatment was not a medication
treatment event (beneficiaries not identified in step 2).
These beneficiaries are numerator compliant if they meet either of the following:
At least two engagement visits
At least one engagement medication treatment event
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Two engagement visits can be on the same date of service but they must be with different
providers in order to count as two events. An engagement visit on the same date of service
as an engagement medication treatment event meets criteria (there is no requirement that
they be with different providers).
Refer to the descriptions below to identify engagement visits and engagement medication
treatment events.
Engagement Visits
Any of the following meet criteria for an engagement visit:
An acute or nonacute inpatient admission with a diagnosis matching the IESD diagnosis
cohort using one of the following: Alcohol Abuse and Dependence Value Set, Opioid
Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value Set. To
identify acute and nonacute inpatient admissions:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).
2. Identify the admission date for the stay.
IET Stand Alone Visits Value Set with a diagnosis matching the IESD diagnosis cohort
using one of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse
and Dependence Value Set, Other Drug Abuse and Dependence Value Set, with or
without a telehealth modifier (Telehealth Modifier Value Set)
Observation Value Set with a diagnosis matching the IESD diagnosis cohort using one
of the following: Alcohol Abuse and Dependence Value Set, Opioid Abuse and
Dependence Value Set, Other Drug Abuse and Dependence Value Set
IET Visits Group 1 Value Set with IET POS Group 1 Value Set with a diagnosis
matching the IESD diagnosis cohort using one of the following: Alcohol Abuse and
Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse
and Dependence Value Set, with or without a telehealth modifier (Telehealth Modifier
Value Set)
IET Visits Group 2 Value Set with IET POS Group 2 Value Set with a diagnosis
matching the IESD diagnosis cohort using one of the following: Alcohol Abuse and
Dependence Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse
and Dependence Value Set, with or without a telehealth modifier (Telehealth Modifier
Value Set)
A telephone visit (Telephone Visits Value Set) with a diagnosis matching the IESD
diagnosis cohort using one of the following: Alcohol Abuse and Dependence Value Set,
Opioid Abuse and Dependence Value Set, Other Drug Abuse and Dependence Value
Set
An online assessment (Online Assessments Value Set) with a diagnosis matching the
IESD diagnosis cohort using one of the following: Alcohol Abuse and Dependence
Value Set, Opioid Abuse and Dependence Value Set, Other Drug Abuse and
Dependence Value Set
Engagement Medication Treatment Events
Either of the following meets criteria for an engagement medication treatment event:
If the IESD diagnosis was a diagnosis of alcohol abuse or dependence (Alcohol Abuse
and Dependence Value Set), one or more medication treatment dispensing events
(Medication Treatment for Alcohol Abuse or Dependence Medications List, see link to
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Medication List Directory in Guidance for Reporting above) or medication treatment
during a visit (AOD Medication Treatment Value Set), beginning on the day after the
initiation encounter through 34 days after the initiation event (total of 34 days), meets
criteria for Alcohol Abuse and Dependence Treatment.
If the IESD diagnosis was a diagnosis of opioid abuse or dependence (Opioid Abuse
and Dependence Value Set), one or more medication dispensing events (Medication
Treatment for Opioid Abuse or Dependence Medications List, see link to Medication
List Directory in Guidance for Reporting above) or medication treatment during a visit
(AOD Medication Treatment Value Set), beginning on the day after the initiation
encounter through 34 days after the initiation event (total of 34 days), meets criteria for
Opioid Abuse and Dependence Treatment.
If a beneficiary enrolled in the demonstration is compliant for multiple cohorts, only count
the beneficiary once for the Total Engagement numerator. The Total rate is not the sum of
the diagnosis columns.
E. ADDITIONAL NOTES
There may be different methods for billing intensive outpatient encounters and partial
hospitalizations. Some methods may be comparable to outpatient billing, with separate
claims for each date of service; others may be comparable to inpatient billing, with an
admission date, a discharge date, and units of service. Where billing methods are
comparable to inpatient billing, each unit of service may be counted as an individual
visit. The unit of service must have occurred during the required time frame for the rate.
For beneficiaries in the “other drug abuse or dependence” cohort, medication treatment
does not meet numerator criteria for Initiation of AOD Treatment or Engagement of
AOD Treatment.
Methadone is not included in the medication lists for this measure. Methadone for opioid
use disorder is only administered or dispensed by federally certified opioid treatment
programs and does not show up in pharmacy claims data. The AOD Medication
Treatment Value Set includes some codes that identify methadone treatment because
these codes are used on medical claims, not pharmacy claims.
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Metric AD_41: PQI 01: Diabetes Short-Term Complications Admission Rate
(PQI01-AD)
Measure Steward: Agency for Healthcare Research and Quality
A. DESCRIPTION
Number of inpatient hospital admissions for diabetes short-term complications
(ketoacidosis, hyperosmolarity, or coma) per 100,000 beneficiary months for beneficiaries
enrolled in the demonstration age 18 and older.
Note: A lower rate indicates better performance.
Data Collection Method: Administrative
Guidance for Reporting:
States should report this measure as a rate per 100,000 beneficiary months as
opposed to per 100,000 beneficiaries enrolled in the demonstration.
A two-step process should be used to determine whether beneficiaries should be
counted in this measure:
- For each beneficiary month considered for the denominator, assess the
beneficiary’s age at either the 15th or 30th of the month (or the 28th of the
month in February). If the beneficiary was age 18 or older by that date, the
beneficiary month should be counted in the denominator. A consistent
date should be used to assess age across all months. For example, if a
state counts enrollment as of the 30th of the month and a beneficiary is
over age 18 on the 30th but was disenrolled from the demonstration on
the 27th, that month would not count toward the denominator. However, if
a state counts enrollment as of the 15th, that month would count toward
the denominator.
- For each hospital admission representing a qualifying numerator event,
assess the beneficiary’s age on the date of admission. Only admissions
for beneficiaries age 18 or older should be included in the numerator.
This measure is designed to exclude transfers from other institutions from the
numerator. However, the variables contained in the software to identify transfers,
shown in Table PQI01-B, may not exist in all data sources. If that is the case,
states should describe how transfers are identified and excluded in their
calculations.
Free software is available from the AHRQ Web site for calculation of this measure
at http://www.qualityindicators.ahrq.gov/Software/Default.aspx. Use of the AHRQ
software is optional for calculating the PQI measures.
Include paid claims only.
The following coding systems are used in this measure: ICD-10-CM and UB. Refer to the
Acknowledgments section at the beginning of the manual for copyright information.
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B. ELIGIBLE POPULATION
Beneficiary months
All beneficiary months for beneficiaries age 18 and older as
of the 15th or the 30th day of the month and who are enrolled
in the demonstration that month. Date for counting
beneficiary months must be consistent across the reporting
period.
Continuous enrollment
None.
Allowable gap
None.
Anchor date
None.
C. ADMINISTRATIVE SPECIFICATION
Denominator
Total number of months of demonstration enrollment for beneficiaries enrolled in the
demonstration age 18 and older during the measurement period.
Numerator
All inpatient hospital admissions with ICD-10-CM principal diagnosis code for short-term
complications of diabetes (ketoacidosis, hyperosmolarity, or coma) (Table PQI01-A,
available at https://www.medicaid.gov/licenseagreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adult-nonhedis-value-set-directory.zip).
Exclusions
Transfer from a hospital (different facility), a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF), or another health care facility (see Table PQI01-B
below for admission codes for transfers)
Admissions with missing age (AGE = missing),
year (YEAR = missing), or principal diagnosis (DX1 = missing),
Obstetric admissions (Note: By definition, admissions with a principal diagnosis of
diabetes with short-term complications are precluded from assignment of MDC 14 by
grouper software. Thus, obstetric admissions should not be considered in the PQI
rate.)
Table PQI01-B. Admission Codes for Transfers
SID ASOURCE Codes
2 – Another hospital
3 – Another facility, including long-term care
Point of Origin UB-04 Codes
4 – Transfer from a hospital
5 – Transfer from a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF)
6 – Transfer from another health care facility
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Metric AD_42: PQI 05: Chronic Obstructive Pulmonary Disease (COPD) or
Asthma in Older Adults Admission Rate (PQI05-AD)
Measure Steward: Agency for Healthcare Research and Quality
A. DESCRIPTION
Number of inpatient hospital admissions for chronic obstructive pulmonary disease (COPD)
or asthma per 100,000 beneficiary months for beneficiaries enrolled in the demonstration
age 40 and older.
Note: A lower rate indicates better performance.
Data Collection Method: Administrative
Guidance for Reporting:
States should report this measure as a rate per 100,000 beneficiary months as
opposed to per 100,000 beneficiaries enrolled in the demonstration.
A two-step process should be used to determine whether beneficiaries should be
counted in this measure:
- For each beneficiary month considered for the denominator, assess the
beneficiary’s age at either the 15th or 30th of the month (or the 28th of the
month in February). If the beneficiary was age 40 or older by that date, the
beneficiary month should be counted in the denominator. A consistent
date should be used to assess age across all months. For example, if a
state counts enrollment as of the 30th of the month and a beneficiary is
over age 18 on the 30th but was disenrolled from the demonstration on
the 27th, that month would not count toward the denominator. However, if
a state counts enrollment as of the 15th, that month would count toward
the denominator.
- For each hospital admission representing a qualifying numerator event,
assess the beneficiary’s age on the date of admission. Only admissions
for beneficiaries age 40 or older should be included in the numerator.
This measure is designed to exclude transfers from other institutions from the
numerator. However, the variables contained in the software to identify transfers,
shown in Table PQI05-C, may not exist in all data sources. If that is the case,
states should describe how transfers are identified and excluded in their
calculations.
Free software is available from the AHRQ Web site for calculation of this measure
at http://www.qualityindicators.ahrq.gov/Software/Default.aspx. Use of the AHRQ
software is optional for calculating the PQI measures.
Include paid claims only.
The following coding systems are used in this measure: ICD-10-CM and UB. Refer to the
Acknowledgments section at the beginning of the manual for copyright information.
http://www.qualityindicators.ahrq.gov/Modules/pqi_resources.aspx
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MATHEMATICA POLICY RESEARCH
B. ELIGIBLE POPULATION
Beneficiary months
All beneficiary months for beneficiaries age 40 and older as
of the 15th or the 30th day of the month and who are enrolled
in the demonstration that month. Date for counting
beneficiary months must be consistent across the reporting
period.
Continuous enrollment
None.
Allowable gap
None.
Anchor date
None.
C. ADMINISTRATIVE SPECIFICATION
Denominator
Total number of months of demonstration enrollment for beneficiaries enrolled in the
demonstration age 40 and older during the measurement period.
Numerator
All inpatient hospital admissions with an ICD-10-CM principal diagnosis code for:
COPD (Table PQI05-A), available at https://www.medicaid.gov/licenseagreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adultnon-hedis-value-set-directory.zip or
Asthma (Table PQI05-B), available at https://www.medicaid.gov/licenseagreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adultnon-hedis-value-set-directory.zip
Exclusions
Transfer from a hospital (different facility), a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF), or another health care facility (see Table PQI05-C
below for admission codes for transfers)
Admissions with missing age (AGE = missing),
year (YEAR = missing), or principal diagnosis (DX1 = missing)
Obstetric admissions (Note: By definition, admissions with a principal diagnosis of
COPD, asthma, or acute bronchitis are precluded from assignment of MDC 14 by
grouper software. Thus, obstetric admissions should not be considered in the PQI rate.)
ICD-10-CM diagnosis codes for cystic fibrosis and anomalies of the respiratory system
(Table PQI05-D, available at https://www.medicaid.gov/licenseagreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adultnon-hedis-value-set-directory.zip)
http://www.qualityindicators.ahrq.gov/Modules/pqi_resources.aspx
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TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table PQI05-C. Admission Codes for Transfers
SID ASOURCE Codes
Point of Origin UB-04 Codes
2 – Another hospital
3 – Another facility, including long-term care
4 – Transfer from a hospital
5 – Transfer from a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF)
6 – Transfer from another health care facility
http://www.qualityindicators.ahrq.gov/Modules/pqi_resources.aspx
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TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Metric AD_43: PQI 08: Heart Failure Admission Rate (PQI08-AD)
Measure Steward: Agency for Healthcare Research and Quality
A. DESCRIPTION
Number of inpatient hospital admissions for heart failure per 100,000 beneficiary months for
beneficiaries enrolled in the demonstration age 18 and older.
Note: A lower rate indicates better performance.
Data Collection Method: Administrative
Guidance for Reporting:
States should report this measure as a rate per 100,000 beneficiary months as
opposed to per 100,000 beneficiaries enrolled in the demonstration.
A two-step process should be used to determine whether beneficiaries should be
counted in this measure:
- For each beneficiary month considered for the denominator, assess the
beneficiary’s age at either the 15th or 30th of the month (or the 28th of the
month in February). If the beneficiary was age 18 or older by that date, the
beneficiary month should be counted in the denominator. A consistent
date should be used to assess age across all months. For example, if a
state counts enrollment as of the 30th of the month and a beneficiary is
over age 18 on the 30th but was disenrolled from the demonstration on
the 27th, that month would not count toward the denominator. However, if
a state counts enrollment as of the 15th, that month would count toward
the denominator.
- For each hospital admission representing a qualifying numerator event,
assess the beneficiary’s age on the date of admission. Only admissions
for beneficiaries age 18 or older should be included in the numerator.
This measure is designed to exclude transfers from other institutions from the
numerator. However, the variables contained in the software to identify transfers,
shown in Table PQI08-B, may not exist in all data sources. If that is the case,
states should describe how transfers are identified and excluded in their
calculations.
Free software is available from the AHRQ Web site for calculation of this measure
at http://www.qualityindicators.ahrq.gov/Software/Default.aspx. Use of the AHRQ
software is optional for calculating the PQI measures.
Include paid claims only.
The following coding systems are used in this measure: ICD-10-CM, ICD-10-PCS, and UB.
Refer to the Acknowledgments section at the beginning of the manual for copyright
information.
http://www.qualityindicators.ahrq.gov/Modules/pqi_resources.aspx
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TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
B. ELIGIBLE POPULATION
Beneficiary months
All beneficiary months for beneficiaries age 18 and older as
of the 15th or the 30th day of the month and who are enrolled
in the demonstration that month. Date for counting
beneficiary months must be consistent across the reporting
period.
Continuous enrollment
None.
Allowable gap
None.
Anchor date
None.
C. ADMINISTRATIVE SPECIFICATION
Denominator
Total number of months of demonstration enrollment for beneficiaries enrolled in the
demonstration age 18 and older during the measurement period.
Numerator
All inpatient hospital admissions with ICD-10-CM principal diagnosis code for heart failure
(Table PQI08-A, available at https://www.medicaid.gov/licenseagreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adult-nonhedis-value-set-directory.zip).
Exclusions
Transfer from a hospital (different facility), a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF), or another health care facility (see Table PQI08-B
below for admission codes for transfers)
Admissions with missing age (AGE = missing),
year (YEAR = missing), or principal diagnosis (DX1 = missing)
Obstetric admissions (Note: By definition, admissions with a principal diagnosis of heart
failure are precluded from assignment of MDC 14 by grouper software. Thus, obstetric
admissions should not be considered in the PQI rate.)
With any listed ICD-10-PCS procedure codes for cardiac procedure (Table PQI08-C,
available at https://www.medicaid.gov/licenseagreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adultnon-hedis-value-set-directory.zip)
Table PQI08-B. Admission Codes for Transfers
SID ASOURCE Codes
2 – Another hospital
3 – Another facility, including long-term care
Point of Origin UB-04 Codes
4 – Transfer from a hospital
5 – Transfer from a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF)
6 – Transfer from another health care facility
http://www.qualityindicators.ahrq.gov/Modules/pqi_resources.aspx
B-34
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Metric AD_44: PQI 15: Asthma in Younger Adults Admission Rate
(PQI15-AD)
Measure Steward: Agency for Healthcare Research and Quality
A. DESCRIPTION
Number of inpatient hospital admissions for asthma per 100,000 beneficiary months for
beneficiaries enrolled in the demonstration ages 18 to 39.
Note: A lower rate indicates better performance.
Data Collection Method: Administrative
Guidance for Reporting:
States should report this measure as a rate per 100,000 beneficiary months as
opposed to per 100,000 beneficiaries enrolled in the demonstration.
A two-step process should be used to determine whether beneficiaries should be
counted in this measure:
- For each beneficiary month considered for the denominator, assess the
beneficiary’s age at either the 15th or 30th of the month (or the 28th of the
month in February). If the beneficiary was ages 18 to 39 on that date, the
beneficiary month should be counted in the denominator. A consistent
date should be used to assess age across all months. For example, if a
state counts enrollment as of the 30th of the month and a beneficiary is
over age 18 on the 30th but was disenrolled from the demonstration on
the 27th, that month would not count toward the denominator. However, if
a state counts enrollment as of the 15th, that month would count toward
the denominator.
- For each hospital admission representing a qualifying numerator event,
assess the beneficiary’s age on the date of admission. Only admissions
for beneficiaries ages 18 to 39 should be included in the numerator.
This measure is designed to exclude transfers from other institutions from the
numerator. However, the variables contained in the software to identify transfers,
shown in Table PQI15-B, may not exist in all data sources. If that is the case,
states should describe how transfers are identified and excluded in their
calculations.
Free software is available from the AHRQ Web site for calculation of this measure
at http://www.qualityindicators.ahrq.gov/Software/Default.aspx. Use of the AHRQ
software is optional for calculating the PQI measures.
Include paid claims only.
The following coding systems are used in this measure: ICD-10-CM and UB. Refer to the
Acknowledgments section at the beginning of the manual for copyright information.
http://www.qualityindicators.ahrq.gov/Modules/pqi_resources.aspx
B-35
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
B. ELIGIBLE POPULATION
Beneficiary months
All beneficiary months for beneficiaries ages 18 to 39 as of the
15th or the 30th day of the month and who are enrolled in the
demonstration that month. Date for counting beneficiary
months must be consistent across the reporting period.
Continuous enrollment
None.
Allowable gap
None.
Anchor date
None.
C. ADMINISTRATIVE SPECIFICATION
Denominator
Total number of months of demonstration enrollment for beneficiaries enrolled in the
demonstration ages 18 to 39 during the measurement period.
Numerator
All inpatient hospital admissions for beneficiaries ages 18 to 39 with an ICD-10-CM
principal diagnosis code of asthma (Table PQI15-A, available at
https://www.medicaid.gov/license-agreement.html?file=%2Fmedicaid%2Fquality-ofcare%2Fdownloads%2F2019-adult-non-hedis-value-set-directory.zip).
Exclusions
Transfer from a hospital (different facility), a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF), or another health care facility (see Table PQI15-B
below for admission codes for transfers)
Admissions with missing age (AGE = missing),
year (YEAR = missing), or principal diagnosis (DX1 = missing)
Obstetric admissions (Note: By definition, admissions with a principal diagnosis of
asthma are precluded from assignment of MDC 14 by grouper software. Thus, obstetric
admissions should not be considered in the PQI rate.)
With any listed ICD-10-CM diagnosis code for cystic fibrosis and anomalies of the
respiratory system (Table PQI15-C, available at https://www.medicaid.gov/licenseagreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adultnon-hedis-value-set-directory.zip)
Table PQI15-B. Admission Codes for Transfers
SID ASOURCE Codes
2 – Another hospital
.
3 – Another facility, including long-term care
Point of Origin UB-04 Codes
4 – Transfer from a hospital
.
5 – Transfer from a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF)
.
6 – Transfer from another health care facility
http://www.qualityindicators.ahrq.gov/Modules/pqi_resources.aspx
B-36
APPENDIX C
VALUE SETS REFERENCED IN METRIC SPECIFICATIONS
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TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table C.1. HEDIS value sets referenced in metric specifications
Value Set Name
Relevant Metrics
Ambulatory Visits
AD_33: Preventive care and office visit utilization
ED
AD_35: Emergency department utilization
AD_36: Emergency department utilization, non-emergency
ED Procedure Code
AD_35: Emergency department utilization
AD_36: Emergency department utilization, non-emergency
ED POS
AD_35: Emergency department utilization
AD_36: Emergency department utilization, non-emergency
Inpatient Stay
AD_36: Emergency department utilization, non-emergency
AD_37: Inpatient admissions
Other Ambulatory Visits
AD_33: Preventive care and office visit utilization
Well-Care
AD_33: Preventive care and office visit utilization
Instructions for accessing the supporting value sets
Step 1: Open “1115 EandC Monitoring Metrics HEDIS Value Set Directory v1.xls”
(available upon request by contacting [email protected]).
Step 2: Filter the “Value Sets to Codes” tab to select value set names (column A) identified
in metric specification
Step 3: Include listed codes (column D) when calculating metric
C-3
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APPENDIX D
REFERENCE LIST OF RELATIONSHIPS AMONG METRICS
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TECHNICAL SPECIFICATIONS MANUAL
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Table D.1. Reference list of relationships among metrics for any
demonstration with premiums, premium assistance, health behaviors,
community engagement requirements, or retroactive eligibility waivers
Metric
Number
Metric name
Relationship to other metrics
Enrollment
AD_1
Total enrollment in the demonstration
Not applicable
AD_2
Beneficiaries in suspension status for
noncompliance
Beneficiaries in this metric are not included in AD_1
AD_3
Beneficiaries in a non-eligibility period who are
prevented from re-enrolling for a defined period of
time
Not applicable
AD_4
New enrollees
Not applicable
AD_5
Re-enrollments or re-instatements using defined
pathways after disenrollment or suspension of
benefits for noncompliance with demonstration
policies
Not applicable
AD_6
Re-enrollments or re-instatements for beneficiaries
not using defined pathways after disenrollment or
suspension of benefits for noncompliance
Not applicable
Mid-year loss of demonstration eligibility
AD_7
Beneficiaries determined ineligible for Medicaid,
any reason, other than at renewal
Metric AD_7 is the sum of metrics AD_12, AD_13, and
AD_14
AD_8
Beneficiaries no longer eligible for Medicaid, failure
to provide timely change in circumstance
information
This metric is a subset of Metric AD_7
AD_9
Beneficiaries determined ineligible for Medicaid
after state processes a change in circumstance
reported by a beneficiary
This metric is a subset of Metric AD_7
AD_10
Beneficiaries no longer eligible for the
demonstration due to transfer to another Medicaid
eligibility group
Not applicable
AD_11
Beneficiaries no longer eligible for the
demonstration due to transfer to CHIP
This metric is a subset of Metric AD_7
Cumulative metrics: Enrollment duration at time of disenrollment
AD_12
Enrollment duration 0-3 months
This metric is a subset of Metric AD_7
AD_13
Enrollment duration 4-6 months
This metric is a subset of Metric AD_7
AD_14
Enrollment duration 6-12 months
This metric is a subset of Metric AD_7
AD_15
Beneficiaries due for renewal
This metric is equal to the sum of metrics AD_16, AD_17,
AD_18, AD_19, AD_20, AD_21, and AD_22
AD _16
Beneficiaries determined ineligible for the
demonstration at renewal, disenrolled from
Medicaid
This metric is a subset of metric AD_15
AD_17
Beneficiaries determined ineligible for the
demonstration at renewal, transfer to another
Medicaid eligibility category
This metric is a subset of metric AD_15
AD_18
Beneficiaries determined ineligible for the
demonstration at renewal, transferred to CHIP
This metric is a subset of metric AD_15
AD_19
Beneficiaries who did not complete renewal,
disenrolled from Medicaid
This metric is a subset of metric AD_15
AD_20
Beneficiaries who had pending/ uncompleted
renewals and were still enrolled
This metric is a subset of metric AD_15
Renewal
D-3
TECHNICAL SPECIFICATIONS MANUAL
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Table D.1 (continued)
Metric
Number
Metric name
Relationship to other metrics
AD_21
Beneficiaries who retained eligibility for the
demonstration after completing renewal forms
This metric is a subset of metric AD_15
AD_22
Beneficiaries who renewed ex parte
This metric is a subset of metric AD_15
Cost sharing limit
AD_23
Beneficiaries who reached 5% limit
Not applicable
Appeals and grievances
AD_24
Appeals, eligibility
Not applicable
AD_25
Appeals, denial of benefits
Not applicable
AD_26
Grievances, care quality
Not applicable
AD_27
Grievances, provider or managed care organization
(MCO)
Not applicable
AD_28
Grievances, other
Not applicable
AD_29
Primary care provider availability
Not applicable
AD_30
Primary care provider active participation
Not applicable
AD_31
Specialist provider availability
Not applicable
AD_32
Specialist provider active participation
Not applicable
AD_33
Preventive care and office visit utilization
Not applicable
AD_34
Prescription drug use
Not applicable
AD_35
Emergency department utilization, total
Not applicable
AD_36
Emergency department utilization, non-emergency
Not applicable
AD_37
Inpatient admissions
Not applicable
Access to care
Quality of care and health outcomes
AD_38A
Medical Assistance with Smoking and Tobacco Use
Cessation (MSC-AD)
Not applicable
AD_38B
Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention
Not applicable
AD_39-1
Follow-Up After Emergency Department Visit for
Alcohol and Other Drug Abuse or Dependence
(FUA -AD)
Not applicable
AD_39-2
Follow-Up After Emergency Department Visit for
Mental Illness (FUM-AD)
Not applicable
AD_40
Initiation and Engagement of Alcohol and Other
Drug Abuse or Dependence Treatment (IET-AD)
Not applicable
AD_41
PQI 01: Diabetes Short-Term Complications
Admission Rate (PQI01-AD)
Not applicable
AD_42
PQI 05: Chronic Obstructive Pulmonary Disease
(COPD) or Asthma in Older Adults Admission Rate
(PQI05-AD)
Not applicable
AD_43
PQI 08: Heart Failure Admission Rate (PQI08-AD)
Not applicable
AD_44
PQI 15: Asthma in Younger Adults Admission Rate
(PQI15-AD)
Not applicable
Administrative cost
AD_45
Administrative cost of demonstration operation
D-4
Not applicable
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table D.2. Reference list of relationships among metrics for demonstrations
that require premiums or account payments
Metric
Metric name
Relationship to other metrics
Enrollment by premium payment status
PR_1
Beneficiaries subject to premium policy (or account
contribution) during the month, not exempt
This metric is equal to the sum of metrics PR_3, PR_4,
PR_5, and PR_6
PR_2
Beneficiaries who were exempt from premiums for
that month
Not applicable
PR_3
Beneficiaries who paid a premium during the month
This metric is a subset of metric PR_1
PR_4
Beneficiaries who were subject to premium policy
but declare hardship for that month
This metric is a subset of metric PR_1
PR_5
Beneficiaries in short-term arrears (grace period)
This metric is a subset of metric PR_1
PR_6
Beneficiaries in long-term arrears
This metric is a subset of metric PR_1
PR_7
Beneficiaries with collectible debt
This metric is a subset of metric PR_1.
This metric could include beneficiaries who are counted in
metrics PR_2, PR_3, PR_4, PR_5, or PR_6, depending on
state debt and enrollment policies.
Cumulative enrollment duration in states with time-variant premium policies
PR_8
Beneficiaries in enrollment duration tier 1
Not applicable
PR_9
Beneficiaries in enrollment duration tier 2
Not applicable
PR_10
Beneficiaries in enrollment duration tiers 3+
Not applicable
Mid-year change in circumstance by premium amount
PR_11
Beneficiaries for whom the state processed a midyear change in circumstance in household or
income information and who remained enrolled in
the demonstration
This metric is equal to the sum of metrics PR_12, PR_13,
and PR_14.
PR_12
No premium change following mid-year processing
of a change in household or income information
This metric is a subset of metric PR_11.
PR_13
Premium increase following mid-year processing of
change in household or income information
This metric is a subset of metric PR_11.
PR_14
Premium decrease following mid-year processing of
change in household or income information
This metric is a subset of metric PR_11.
Disenrollment or suspension for failure to pay
PR_15
Beneficiaries disenrolled from the demonstration for
failure to pay and therefore disenrolled from
Medicaid
This metric is a subset of metric AD_7, relevant only for
demonstrations with monthly payment requirements.
PR_16
Beneficiaries in a non-eligibility period who were
disenrolled for failure to pay and are prevented
from re-enrolling for a defined period of time
Not applicable
PR_17
Beneficiaries whose benefits are suspended for
failure to pay
This metric is a subset of metric AD_2
PR_18
No premium change
The sum of metrics PR_18, PR_19, and PR_20 should
equal the sum of metrics AD_21 and AD_22 among
beneficiaries required to pay premiums
PR_19
Premium increase
The sum of metrics PR_18, PR_19, and PR_20 should
equal the sum of metrics AD_21 and AD_22 among
beneficiaries required to pay premiums
PR_20
Premium decrease
The sum of metrics PR_18, PR_19, and PR_20 should
equal the sum of metrics AD_21 and AD_22 among
beneficiaries required to pay premiums
Renewal
Third party premium payment
PR_21
Third-party premium payment
Not applicable
D-5
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table D.3. Reference list of relationships among metrics for demonstrations
with Marketplace-focused premium assistance programs
Metric
Metric name
Relationship to other metrics
Enrollment by premium payment status
PA_1
Beneficiaries who lost Medicaid eligibility due to
mid-year change in circumstance, and transitioned
to a qualified health plan offered in the
Marketplace
This metric is a subset of metric AD_9
PA_2
Beneficiaries who lost Medicaid eligibility at
renewal, and transitioned to a qualified health plan
offered in the Marketplace
This metric is a subset of metric AD_16
Wraparound service utilization, by service
Not applicable
Access to care
PA_3
D-6
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table D.4. Reference list of relationships among metrics for demonstrations
with health behavior incentives
Metric
Metric name
Relationship to other metrics
Enrollment
HB_1
Total enrollment among beneficiaries subject to
health behavior incentives
This metric serves as a denominator to pair with metrics
HB_2, HB_3, and HB_4 to create rates
Use of incentivized services: claims-based analysis
HB_2
Beneficiaries using incentivized services that can
be documented through claims, by service
Not applicable
Other incentivized behaviors not documented through claims-based analysis
HB_3
Completion of incentivized health behavior(s) not
documented through claims analysis (i.e. health
risk assessments), by health behavior
Not applicable
HB_4
Completion of all incentivized health behaviors
(both claims-based and other), if there are multiple
Not applicable
Rewards granted for completion of incentivized health behaviors
HB_5
Beneficiaries granted a premium reduction for
completion of incentivized health behaviors
This metric can be compared to numbers in metrics HB_2,
HB_3, and/or HB_4, to understand whether behavior
completions are resulting in accrual of rewards, depending
on state policy
HB_6
Beneficiaries granted a financial reward other than
a premium reduction for completion of incentivized
health behaviors
This metric can be compared to numbers in metrics HB_2,
HB_3, and/or HB_4 to understand whether behavior
completions are resulting in accrual of rewards, depending
on state policy
HB_7
Beneficiaries granted a reward in the form of
additional covered benefits for completion of
incentivized health behaviors
This metric can be compared to numbers in metrics HB_2,
HB_3, and/or HB_4, to understand whether behavior
completions are resulting in accrual of rewards, depending
on state policy
D-7
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table D.5. Reference list of relationships among metrics relevant for
demonstrations with community engagement requirements
Metric
Metric name
Relationship to other metrics
Community engagement enrollment counts
CE_1
Total beneficiaries subject to the community
engagement requirement, not exempt
Metrics CE_1, CE_2, and CE_3 should sum to the total
number of enrolled beneficiaries in income and eligibility
groups subject to community engagement requirements
CE_2
Total beneficiaries who were exempt from
community engagement requirements in the month
Metrics CE_1, CE_2, and CE_3 should sum to the total
number of enrolled beneficiaries in income and eligibility
groups subject to community engagement requirements
CE_3
Beneficiaries with approved good cause
circumstances
Metrics CE_1, CE_2, and CE_3 should sum to the total
number of enrolled beneficiaries in income and eligibility
groups subject to community engagement requirements
CE_4
Beneficiaries subject to community engagement
requirement and in suspension status due to failure
to meet requirement
This metric is a subset of metric AD_2
CE_5
Beneficiaries subject to the community engagement
requirement and receiving benefits who met the
requirement for qualifying activities
This metric is a subset of metric CE_1
CE_6
Beneficiaries subject to the community engagement
requirement and receiving benefits but in a grace
period or allowable month of noncompliance
This metric is a subset of metric CE_1
CE_7
Beneficiaries who successfully completed make-up
hours or other activities to retain active benefit status
after failing to meet community engagement
requirements in a previous month
This metric is a subset of metric CE_1 for states with an
“opportunity to cure” policy
CE_8
Beneficiaries in a non-eligibility period who were
disenrolled for noncompliance with community
engagement requirement and are prevented from reenrolling for a defined period of time
Not applicable
Community engagement requirement qualifying activities
CE_9
Beneficiaries who met the community engagement
requirement by satisfying requirements of other
programs
This metric is a subset of metric CE_5
CE_10
Beneficiaries who met the community engagement
requirement through employment for the majority of
their required hours
This metric is a subset of metric CE_5
CE_11
Beneficiaries who met the community engagement
requirement through job training or job search for the
majority of their required hours
This metric is a subset of metric CE_5
CE_12
Beneficiaries who met the community engagement
requirement through educational activity for the
majority of their required hours
This metric is a subset of metric CE_5
CE_13
Beneficiaries who met the community engagement
requirement who were engaged in other qualifying
activity for the majority of their required hours
This metric is a subset of metric CE_5
CE_14
Beneficiaries who met the community engagement
requirement by combining two or more activities
This metric is a subset of metric CE_5
Basis of beneficiary exemptions from community engagement requirement
CE_15
Beneficiaries exempt from Medicaid community
engagement requirements because they were
exempt from requirements of SNAP and/or TANF
This metric is a subset of metric CE_2
CE_16
Beneficiaries exempt from Medicaid community
engagement requirements on the basis of pregnancy
This metric is a subset of metric CE_2
D-8
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table D.5 (continued)
Metric
Metric name
Relationship to other metrics
CE_17
Beneficiaries exempt from community engagement
requirements due to former foster youth status
This metric is a subset of metric CE_2
CE_18
Beneficiaries exempt from Medicaid community
engagement requirements due to medical frailty
This metric is a subset of metric CE_2
CE_19
Beneficiaries exempt from Medicaid community
engagement requirements on the basis of caretaker
status
This metric is a subset of metric CE_2
CE_20
Beneficiaries exempt from Medicaid community
engagement requirements due to unemployment
insurance compensation
This metric is a subset of metric CE_2
CE_21
Beneficiaries exempt from Medicaid community
engagement requirements due to substance abuse
treatment status
This metric is a subset of metric CE_2
CE_22
Beneficiaries exempt from Medicaid community
engagement requirements due to student status
This metric is a subset of metric CE_2
CE_23
Beneficiaries exempt from community engagement
requirements because they were excused by a
medical professional
This metric is a subset of metric CE_2
CE_24
Beneficiaries exempt from Medicaid community
engagement requirements, other
This metric is a subset of metric CE_2
Supports and assistance
CE_25
Beneficiaries receiving supports to participate and
placement assistance
This metric includes individuals counted in metrics CE_26
through CE_30. Beneficiaries may be counted more in
more than one of metrics CE_26 through CE_30, but
should only be counted once in metric CE_25, regardless
of the number of different types of supports received.
CE_26
Beneficiaries provided with transportation assistance
This metric is a subset of metric CE_25
CE_27
Beneficiaries provided with childcare assistance
This metric is a subset of metric CE_25
CE_28
Beneficiaries provided with language supports
This metric is a subset of metric CE_25
CE_29
Beneficiaries assisted with placement in community
engagement activities
This metric is a subset of metric CE_25
CE_30
Beneficiaries provided with other non-Medicaid
assistance
This metric is a subset of metric CE_25
Reasonable modifications for beneficiaries with disabilities
CE_31
Beneficiaries who requested reasonable
modifications to community engagement processes
or requirements due to disability
Not applicable
CE_32
Beneficiaries granted reasonable modifications to
community engagement processes or requirements
due to disability
Not applicable
New suspensions and disenrollments during the measurement period
CE_33
Beneficiaries newly suspended for failure to
complete community engagement requirements
This metric is a subset of metric CE_4
CE_34
Beneficiaries newly disenrolled for noncompliance
with community engagement requirement
Not applicable
Reinstatement of benefits after suspension
CE_35
Total beneficiaries whose benefits were reinstated
after being in suspended status for noncompliance
This metric is equal to the sum of metrics CE_36, CE_37,
CE_38, CE_39, and CE_40
CE_36
Beneficiaries whose benefits were reinstated
because their time-limited suspension period ended
This metric is a subset of metric CE_35
CE_37
Beneficiaries whose benefits were reinstated
because they completed required community
engagement activities
This metric is a subset of metric CE_35
D-9
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table D.5 (continued)
Metric
Metric name
Relationship to other metrics
CE_38
Beneficiaries whose benefits were reinstated
because they completed “on-ramp” activities other
than qualifying community engagement activities
This metric is a subset of metric CE_35
CE_39
Beneficiaries whose benefits were reinstated
because they newly meet community engagement
exemption criteria or had a good cause circumstance
This metric is a subset of metric CE_35
CE_40
Beneficiaries whose benefits were reinstated after
successful appeal of suspension for noncompliance
This metric is a subset of metric CE_35
Re-entry after disenrollment
CE_41
Total beneficiaries re-enrolling after disenrollment for
noncompliance
This metric is equal to the sum of metrics CE_42, CE_43,
CE_44, CE_45, and CE_46
CE_42
Beneficiaries re-enrolling after completing required
community engagement activities
This metric is a subset of metric CE_41
CE_43
Beneficiaries re-enrolling after completing “on-ramp”
activities other than qualifying community
engagement activities
This metric is a subset of metric CE_41
CE_44
Beneficiaries re-enrolling after re-applying,
subsequent to being disenrolled for noncompliance
with community engagement requirements
This metric is a subset of metric CE_41
CE_45
Beneficiaries re-enrolling because they newly met
community engagement exemption criteria or had a
good cause circumstance
This metric is a subset of metric CE_41
CE_46
Beneficiaries re-enrolling after successful appeal of
disenrollment for noncompliance
This metric is a subset of metric CE_41
D-10
TECHNICAL SPECIFICATIONS MANUAL
MATHEMATICA POLICY RESEARCH
Table D.6. Reference list of relationships among metrics relevant for
demonstrations with retroactive eligibility waivers
Metric
Metric name
Relationship to other metrics
At application
RW_1
Beneficiaries who indicated that they had unpaid
medical bills at the time of application
Not applicable
RW_2
Beneficiaries who had a coverage gap at renewal
Not applicable
RW_3
Beneficiaries who had a coverage gap at renewal
and had claims denied
This metric is a subset of metric RW_2
At renewal
D-11
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| File Type | application/pdf |
| Author | Roger Young |
| File Modified | 2019-09-20 |
| File Created | 2019-06-27 |