GenIC # 59 (Revision) - Medicaid Section 1115 Severe Mental Illness and Children with Serious Emotional Disturbance Demonstrations

Medicaid Section 1115 Serious
Mental Illness and Serious Emotional
Disturbance Demonstrations:
Technical Specifications for
Monitoring Metrics
Version 2.0
August 2020

Section 1115 Serious Mental Illness and Serious Emotional Disturbance Demonstrations:
Technical Specifications for Monitoring Metrics

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

MATHEMATICA

CONTENTS
ACRONYMS ............................................................................................................................................... VII
LICENSE AGREEMENTS AND ACKNOWLEDGEMENTS......................................................................... XI
I.

BACKGROUND AND INTRODUCTION .......................................................................................... 1
A. Overview of section 1115 SMI/SED demonstration monitoring metrics .................................... 1
B. Reporting guidance for section 1115 SMI/SED monitoring metrics ........................................ 10
C. Using technical specifications.................................................................................................. 17

II.

METRIC SPECIFICATIONS .......................................................................................................... 19

APPENDIX A ESTABLISHED MEASURES AND MEASURE SETS REFERENCED IN
TECHNICAL SPECIFICATIONS .................................................................................. A.1
APPENDIX B VALUE SETS REFERENCED IN METRIC SPECIFICATIONS......................................... B.1
APPENDIX C HOW TO USE SUPPORTING MEASURE SPECIFICATIONS, VALUE SETS,
AND CODE LISTS TO CALCULATE METRICS ..........................................................C.1
APPENDIX D TECHNICAL SPECIFICATIONS FOR ESTABLISHED QUALITY MEASURES
ADAPTED FROM FFY 2020 CHILD AND ADULT CORE SET MEASURE
SPECIFICATIONS ........................................................................................................D.1
APPENDIX E STANDARDIZED DEFINITION OF SMI ............................................................................ E.1
APPENDIX F AVERAGE LENGHTH OF STAY (ALOS) STANDARD DEVIATIONS............................... F.4

TABLES
Table 1. Summary of section 1115 SMI/SED monitoring metrics ................................................................. 2
Table 2. Measurement period of section 1115 SMI/SED demonstration metrics by
domain/milestone ............................................................................................................................. 2
Table 3. Subpopulation reporting for section 1115 SMI/SED demonstrations ............................................. 4
Table 4. Overview of section 1115 SMI/SED demonstration monitoring metrics, by measurement
domain.............................................................................................................................................. 6
Table 5. Example of alignment between section 1115 SMI/SED demonstration years and
measurement periods .................................................................................................................... 13
Table 6. Reporting in quarterly and annual section 1115 SMI/SED monitoring reports ............................. 14
Table 7. Metric elements included in the technical specifications .............................................................. 18

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Table A.1. Established measures and measure sets referenced in metric specifications ......................... A.3
Table B.1. HEDIS and other value sets and code lists referenced in metric specifications ...................... B.3
Table C.1. How to use supporting measure specifications, value sets, and code lists to calculate
metrics ...........................................................................................................................................C.3
Table D.1. Measurement Period for Denominators and Numerators for the section 1115 SMI/SED
Monitoring Metrics Adapted from FFY 2020 Adult and Child Core Sets Measures......................D.5
Table F.1. Data distribution and transformation methods .......................................................................... F.3
Table F.2. State data for average length of stay and standard deviation .................................................. F.3

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METRICS
Metric #1: SUD Screening of Beneficiaries Admitted to Psychiatric Hospitals or Residential
Treatment Settings (SUB-2) ........................................................................................................... 19
Metric #2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
(APP-CH) ....................................................................................................................................... 20
Metric #3: All-Cause Emergency Department (ED) Utilization Rate for Medicaid Beneficiaries who
may Benefit From Integrated Physical and Behavioral Health Care (PMH-20) ............................. 21
Metric #4: 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an
Inpatient Psychiatric Facility (IPF) .................................................................................................. 22
Metric #5: Medication Reconciliation Upon Admission ............................................................................... 24
Metric #6: Medication Continuation Following Inpatient Psychiatric Discharge.......................................... 25
Metric #7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH) .................................. 26
Metric #8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD) ....................... 27
Metric #9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD) .................................................................................................................. 28
Metric #10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD) ............................ 29
Metric #11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient
Facility or Residential Treatment for Mental Health Among Beneficiaries With SMI or SED
(count) ............................................................................................................................................ 30
Metric #12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient
Facility or Residential Treatment for Mental Health Among Beneficiaries With SMI or SED
(rate) ............................................................................................................................................... 32
Metric #13: Mental Health Services Utilization - Inpatient .......................................................................... 34
Metric #14: Mental Health Services Utilization – Intensive Outpatient and Partial Hospitalization ............ 36
Metric #15: Mental Health Services Utilization - Outpatient........................................................................ 38
Metric #16: Mental Health Services Utilization - ED ................................................................................... 40
Metric #17: Mental Health Services Utilization - Telehealth ....................................................................... 42
Metric #18: Mental Health Services Utilization - Any Services ................................................................... 44
Metric #19a: Average Length of Stay in IMDs ............................................................................................ 47
Metric #19b: Average Length of Stay in IMDs (IMDs receiving FFP only) ................................................. 50
Metric #20: Beneficiaries With SMI/SED Treated in an IMD for Mental Health .......................................... 53
Metric #21: Count of Beneficiaries With SMI/SED (monthly) ...................................................................... 55
Metric #22: Count of Beneficiaries With SMI/SED (annually) ..................................................................... 56
Metric #23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD) ................................................................................................ 57
Metric #24: Screening for Depression and Follow-up Plan: Age 18 and Older (CDF-AD) ......................... 58

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Metric #25: Screening for Depression and Follow-up Plan: Ages 12–17 (CDF-CH)` ................................. 59
Metric #26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With
SMI ................................................................................................................................................. 60
Metric #27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or
Alcohol or Other Drug Dependence ............................................................................................... 61
Metric #28: Alcohol Screening and Follow-up for People with Serious Mental Illness ............................... 62
Metric #29: Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH) .................. 63
Metric #30: Follow-up Care for Adult Medicaid Beneficiaries Who are Newly Prescribed an
Antipsychotic Medication................................................................................................................ 64
Metric #32: Total Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED – Not Inpatient or Residential ......................................................................................... 66
Metric #33: Total Costs Associated with Mental Health Services Among Beneficiaries with
SMI/SED –Inpatient or Residential ................................................................................................ 70
Metric #34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential......................................................................................... 73
Metric #35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries with
SMI/SED - Inpatient or Residential ............................................................................................... 74
Metric #36: Grievances Related to services for SMI/SED .......................................................................... 75
Metric #37: Appeals Related to Services for SMI/SED ............................................................................... 76
Metric #38: Critical Incidents Related to Services for SMI/SED ................................................................. 77
Metric #39: Total Costs Associated With Treatment for Mental Health in an IMD Among
Beneficiaries with SMI/SED ........................................................................................................... 78
Metric #40: Per Capita Costs Associated With Treatment for Mental Health in an IMD Among
Beneficiaries With SMI/SED .......................................................................................................... 81

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ACRONYMS

AAP

Adults’ Access to Preventive/Ambulatory Health Services (measure)

AHA

American Hospital Association

AHRQ

Agency for Healthcare Research and Quality

ALOS

Average Length of Stay

AD

Adult Core Set

AMA

American Medical Association

AOD

Alcohol or Other Drug Dependence

APC

Use of Multiple Concurrent Antipsychotics in Children and Adolescents
(measure)

APM

Metabolic Monitoring for Children and Adolescents on Antipsychotics
(measure)

APP

Use of first-line psychosocial care for children and adolescents on
antipsychotics (measure)

BDI or BDI-II Beck Depression Inventory
BDI-PC

Beck Depression Inventory-Primary Care Version

BH

Behavioral Health

CAH

Critical Access Hospital

CCBHC

Certified Community Behavioral Health Clinics Demonstration

CCS

Clinical Classification Software

CDF

Screening for Depression and Follow-up Plan

CES-D

Center for Epidemiologic Studies Depression Scale

CH

Child Core Set

CHIP

Children’s Health Insurance Program

CMCS

Center for Medicaid & CHIP Services

CMS

Centers for Medicare & Medicaid Services

CPT

Current Procedural Terminology

CQM

Clinical Quality Measure

CSDD

Cornell Scale for Depression in Dementia

DADS

Duke Anxiety- Depression Scale

DEPS

Depression Scale

DNI

Do Not Intubate

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DNR

Do Not Resuscitate

DO

Doctor of Osteopathy

DY

Demonstration Year

ED

Emergency Department

EHR

Electronic Health Record

FFP

Federal Financial Participation

FFS

Fee for Service

FFY

Federal Fiscal Year

FUA

Follow-up After Emergency Department Visit for Alcohol and Other Drug
Abuse Dependence (measure)

FUH

Follow-up After Hospitalization for Mental Illness (measure)

FUM

Follow-up After Emergency Department Visit for Mental Illness (measure)

GDS

Geriatric Depression Scale

HAM-D

Hamilton Rating Scale for Depression

HCPCS

Healthcare Common Procedure Coding System

HEDIS

Healthcare Effectiveness Data and Information Set

HPCMI

Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c
(HbA1c) Poor Control (>9.0%) (measure)

HWR

Hospital-Wide Readmission (HWR)

ICD

International Classification of Diseases

IET

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence
Treatment (measure)

IMD

Institution for Mental Diseases

IOP/PH

Intensive Outpatient Care/Partial Hospitalization

IPF

Inpatient Psychiatric Facility

IPFQR

Inpatient Psychiatric Facility Quality Reporting Program

IPSD

Index Prescription Start Date

LDL

Low-Density Lipoprotein

LOINC

Logical Observation Identifiers Names and Codes

MC

Managed Care

MCO

Managed Care Organization

MD

Doctor of Medicine

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MDD

Major Depressive Disorder

MLD

Medication List Directory

MPT

Mental Health Utilization measure

MSIS

Medicaid Statistical Information System

NBCC

National Board for Certified Counselors

NCQA

National Committee for Quality Assurance

NDC

National Drug Code

NEC

Not Elsewhere Classified

NQF

National Quality Forum

NPI

National Provider Identifier

PHQ-9

Patient Health Questionnaire

PMDA

Performance Metrics Database and Analytics

PMH-20

All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries
Who May Benefit from Integrated Physical and Behavioral Health Care
(measure)

POS

Place of Service

PTA

Prior To Admission

QDWI

Qualified Disabled and Working Individuals

QI

Qualified Individuals

QID-SR

Quick Inventory of Depressive Symptomatology Self-Report

QMB

Qualified Medicare Beneficiary

QPP

Quality Payment Program

RN

Registered Nurse

SAMHSA

Substance Abuse and Mental Health Services Administration

SED

Serious Emotional Disturbance

SLMB

Specified Low-Income Medicare Beneficiary

SMDL

State Medicaid Director Letter

SMI

Serious Mental Illness

SNOMED

SNOMED Clinical Terms®

STC

Special Terms and Conditions

SUB-2

Alcohol Use Brief Intervention Provided or Offered (measure)

SUD

Substance Use Disorder

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TJC

The Joint Commission

T-MSIS

Transformed Medicaid Statistical Information System

UB

Uniform Bill Codes

VS

Value Set

WHO

World Health Organization

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LICENSE AGREEMENTS AND ACKNOWLEDGEMENTS

Use of the Resource Medicaid Section 1115 Serious Mental Illness and Serious Emotional
Disturbance Demonstrations: Technical Specifications for Monitoring Metrics indicates
acceptance of the following license agreements.
The American Medical Association (AMA) and the American Hospital Association (AHA)
permit the use of Current Procedural Terminology (CPT) and National Uniform Billing
Committee (NUBC) UB-04 codes solely for the purpose of reporting state data on Medicaid and
Children’s Health Insurance Program (CHIP) measures to the Centers for Medicare & Medicaid
Services (CMS).
The National Committee for Quality Assurance (NCQA) and The Joint Commission (TJC)
permit the use of their technical specifications solely for the purpose of reporting state data on
Medicaid and CHIP measures to the Centers for Medicare & Medicaid Services (CMS).
For Proprietary Codes in the Technical Specifications:

CPT® codes copyright 2019 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 American Hospital Association (AHA) holds a copyright to the Uniform Billing Codes
(“UB”). The UB Codes in the technical specifications are included with the permission of the
AHA. The UB Codes contained in the technical specifications may be used only to report state
measure results or to use state measure results for internal, noncommercial 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].
SNOMED CLINICAL TERMS® (SNOMED CT®) copyright 2004-2019 The International
Health Terminology Standards Development Organisation. All Rights Reserved.
For Codes in the Public Domain:

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.

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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: http://opendata
commons.org/licenses/odbl/1.0/. Any rights on individual contents of the database are licensed
under the Database Contents License: http://opendatacommons.org/licenses/dbcl/1.0/.
For National Committee for Quality Assurance (NCQA) measures in the technical
specifications for 1115 SMI/SED demonstration monitoring metrics:
Content reproduced with permission from HEDIS 2016 and 2020 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 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 "Adjusted, Uncertified, Unaudited HEDIS rates."
Certain non-NCQA measures in the CMS 1115 SMI/SED technical specifications contain
HEDIS VS developed by and included with the permission of the NCQA. NCQA disclaims all
liability for use or accuracy of the HEDIS VS within the non-NCQA measures.
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 HEDIS VS.
The American Medical Association holds a copyright to the CPT® codes contained in the
measure specifications and HEDIS VS.
The American Hospital Association holds a copyright to the Uniform Billing Codes
("UB") contained in the measure specifications and HEDIS 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, contact [email protected].

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MEASURE RATE NOTICE
The state must prominently display the following notice on any display of measure rates based
on NCQA technical specifications for 1115 SMI/SED demonstration monitoring metrics:
The MPT, FUH-CH, FUH-AD, FUA-AD, FUM-AD, AAP, APM, and APC measures (Metrics
#13, 14, 15, 16, 17, 18, 7, 8, 9, 10, 26, 29) are Healthcare Effectiveness Data and Information
Set (HEDIS®) measures that are owned and copyrighted by the National Committee for Quality
Assurance (NCQA). HEDIS measures and specifications are not clinical guidelines, do not
establish a standard of medical care and have not been tested for all potential applications. The
measures and specifications are provided “as is” without warranty of any kind. NCQA makes no
representations, warranties or endorsements about the quality of any product, test or protocol
identified as numerator compliant or otherwise identified as meeting the requirements of a
HEDIS measure or specification. NCQA makes no representations, warranties, or endorsement
about the quality of any organization or clinician who uses or reports performance measures
and NCQA has no liability to anyone who relies on HEDIS measures or specifications or data
reflective of performance under such measures and specifications.
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. A calculated measure result (a “rate”) from a HEDIS measure that has not been certified
via NCQA’s Measure Certification Program, and is based on adjusted HEDIS specifications,
may not be called a “HEDIS rate” until it is audited and designated reportable by an NCQACertified HEDIS Compliance Auditor. Until such time, such measure rates shall be designated
or referred to as “Adjusted, Uncertified, Unaudited HEDIS rates.”
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 HEDIS VS.
The American Medical Association holds a copyright to the CPT® codes contained in the
measure specifications and HEDIS VS.
The American Hospital Association holds a copyright to the Uniform Billing Codes
("UB") contained in the measure specifications and HEDIS 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, contact [email protected].
For the Joint Commission measure in the technical specifications for 1115 SMI/SED
demonstration monitoring metrics:
The Specifications Manual for National Quality Measures [Version 5.6, 2019] is
periodically updated by The Joint Commission. Users of the Specifications Manual for Joint
Commission National Quality Measures must update their software and associated
documentation based on the published manual production timelines.

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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MATHEMATICA

BACKGROUND AND INTRODUCTION

This document provides instructions on how to calculate and report monitoring metrics for a
state with Medicaid section 1115 demonstrations that focus on serious mental illness (SMI) and
serious emotional disturbance (SED). 1
Center for Medicaid and CHIP Services (CMCS) selected section 1115 SMI/SED
demonstration monitoring metrics (hereafter referred to as “metrics”) with input from subject
matter experts and members of the state advisory group for Medicaid monitoring and evaluation.
These metrics consist of (1) established quality measures endorsed by the National Quality
Forum (NQF) or included in other Medicaid Quality Measures measure sets and (2) CMSconstructed implementation performance metrics to track the goals and milestones presented in
the State Medicaid Director Letter (SMDL) dated November 13, 2018 (SMDL #18-011). The
CMS-constructed metrics often refer to definitions included in established quality measures, but
they did not go through the measure endorsement process and are intended only for monitoring
progress of section 1115 SMI/SED demonstrations (hereafter referred to as “SMI/SED
demonstrations”).
An important goal of monitoring SMI/SED demonstrations is to identify trends that suggest
the need for adjustment to improve demonstration performance. These metrics are designed to
monitor demonstration performance while minimizing state reporting burden.
This technical specifications manual is organized as follows: Section A of this chapter
provides an overview of the metrics, Section B provides reporting instructions that apply to the
metrics, and Section C defines the elements included in each specification table. Chapter II
presents technical specifications for each metric followed by appendices with supporting
information for metric specifications. Appendix A lists the established measures and measure
sets references in the technical specifications manual. Appendix B provides a list of value sets
that are references throughout the technical specifications. Appendix C includes instructions on
how to use supporting measure specifications, value sets, and code lists to calculate metrics.
Appendix D provides the technical specifications for the adapted FFY 2020 Child and Adult
Core Set measures. Appendix E provides the serious mental illness definition from National
Committee for Quality Assurance (NCQA). Appendix F includes additional guidance for
calculating standard deviations for Metric #19 Average Length of Stay (ALOS).
A. Overview of section 1115 SMI/SED demonstration monitoring metrics

There are 39 metrics representing several demonstration milestones (Table 1). This set of
metrics could change over time, including adding or removing metrics. CMS may select new
established quality measures based on measure steward testing results and/or NQF endorsement.
The following describes important parameters for SMI/SED demonstration metrics reporting:

1

See the acronyms list on page vii for definitions of all acronyms in this document.

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Required or recommended. Metrics are either required or recommended.
•

Required metrics provide information that is critical for monitoring the success of SMI/SED
demonstrations and could be constructed with data that are readily available to the state.

•

Recommended metrics might be more difficult to report than required metrics, but still
provide important information on the operation of a demonstration.

Table 1. Summary of section 1115 SMI/SED monitoring metrics
Number of metricsb
Demonstration milestonesa

Total

Required

Milestone 1: Ensuring Quality of Care in Psychiatric Hospitals and Residential Settings

2

1

Milestone 2: Improving Care Coordination and Transitions to Community-Based Care

10

7

Milestone 3: Increasing Access to Continuum of Care including Crisis Stabilization
Services

8

8

Milestone 4: Earlier Identification and Engagement in Treatment including through
Increased Integration

10

6

Other SMI/SED Metrics

9

9

Total

39

31

Milestones included in this table are from the State Medicaid Director Letter #18-011 which can be accessed at
https://www.medicaid.gov/sites/default/files/federal-policy-guidance/downloads/smd18011.pdf.
b Each metric is listed under a primary milestone above. However, some metrics may address multiple milestones.
a

Measurement period. This parameter identifies the measurement period (the data collection
time frame) for each metric. The measurement period may be a month, quarter, or demonstration
year. Table 2 lists the number of metrics by milestone for each measurement period. The state
should use the measurement period for established quality measures that are provided in the
specifications for those measures. Section B provides detailed guidance and reporting
instructions for measurement period.
Table 2. Measurement period of section 1115 SMI/SED demonstration metrics by
domain/milestone
Number of metrics
Demonstration milestones

Annual

Quarterly

Monthly

Milestone 1: Ensuring Quality of Care in Psychiatric Hospitals and Residential
Settings

2

0

0

Milestone 2: Improving Care Coordination and Transitions to CommunityBased Care

10

0

0

Milestone 3: Increasing Access to Continuum of Care including Crisis
Stabilization Services

2

0

6

Milestone 4: Earlier Identification and Engagement in Treatment including
through Increased Integration

9

0

1

Other SMI/SED Metrics

6

3

0

Total

29

3

7

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Data source. This parameter identifies the likely data source(s) that should be used to report
each metric. Data sources include claims data, medical and administrative records, provider
enrollment databases, and other state-specific databases.
Demonstration reporting. The state should report on each metric for its SMI/SED
demonstration. Note that for most metrics, demonstration reporting focuses on the subset of
Medicaid beneficiaries targeted by the SMI/SED demonstration—that is, Medicaid beneficiaries
with SMI/SED. However, some metrics focus more broadly on the Medicaid population (for
example, metrics measuring hospitalization after mental illness or antipsychotic medication use).
Additional details are available for each metric in Chapter II.
Subpopulation categories. Some subpopulations have unique treatment needs with respect to
SMI/SED. Table 3 describes subpopulation categories on which the state can report for CMSconstructed metrics, including:
• CMS-provided subpopulation categories. CMS has identified common subpopulation
categories applicable to all SMI/SED demonstrations, including five recommended and two
required reporting categories (“CMS-provided” in Table 3). For each CMS-provided
subpopulation category, CMS provides guidance on how to define the subpopulations within
each category, as well as examples of how the state may identify the subpopulations. The
state may propose alternate approaches to calculating these subpopulations in its monitoring
protocol. The metric specifications (Chapter II) of this manual list the subpopulations for
which the metric should be calculated in addition to the full SMI/SED demonstration
population. CMS provides guidance on which of the CMS-provided subpopulations are
relevant for each metric.
•

State-specific subpopulation categories. There is one state-specific subpopulation category
that is required: the state-specific definition of SMI. The state may identify additional
subpopulation categories specific to its demonstration (“state-specific” in Table 3). For
example, if a state implements its demonstration differently within different geographic areas
or models of care, CMS recommends that the state report metrics separately for each area or
model. Under those circumstances, reporting metrics only at the demonstration level could
obscure important differences across areas or models. Because state-specific subpopulation
categories are unique to the state’s context and demonstration, the state has greater flexibility
in proposing definitions and approaches for identifying these categories in its monitoring
protocol. For each state-specific metric, the state should also identify subpopulation
categories, if applicable.

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Table 3. Subpopulation reporting for section 1115 SMI/SED demonstrations
Subpopulation
Categories

Required or
Recommended

Description

CMS-provided
Standardized definition
of SMI

Required

Age group

Required

Dual-eligible status

Required

Disability

Recommended

Criminal justice status

Recommended

Co-occurring
Substance Use
Disorder (SUD)

Recommended

We refer to the National Committee for Quality Assurance (NCQA)
definition of SMI as the standardized definition of SMI 2. NCQA defines
individuals with SMI as those who meet at least one of the following
criteria within the measurement period: (1) at least one acute inpatient
claim/encounter with any diagnosis of schizophrenia, schizoaffective
disorder,bipolar disorder, or major depression, OR; (2) at least two
visits in an outpatient, IOP, community mental health center visit,
electroconvulsive therapy, observation, ED, nonacute inpatient, or
telehealth setting, on different dates of service with a diagnosis of
schizophrenia or schizoaffective disorder OR; (3) at least two visits in
an outpatient, IOP, community mental health center visit,
electroconvulsive therapy, observation, ED, nonacute inpatient, or
telehealth setting on different dates of service with a diagnosis of
bipolar disorder. See Table B.1 for applicable value sets and Appendix
E: Standardized Definition of SMI for details.
Age groups defined as: children <16; transition-age youth 16-24; adults
25–64; and older adults 65+. Determine beneficiary age status as of the
first day of the measurement period.
Determine dual-eligible status (i.e., dual-eligible [Medicare-Medicaid
eligible], Medicaid only) as of the first day of the measurement period.
For example, in Transformed Medicaid Statistical Information System
(T-MSIS), dual-eligible status is determined by the eligibility file data
element, DUAL-ELIGIBLE-CODEa. Additional resources for defining
dual-eligible populations can be found on Medicaid.govb.
Determine eligibility for Medicaid on the basis of disability (yes or no)
based on ever qualifying for this subpopulation during the measurement
period. For reference, in T-MSIS, eligibility based on disability is
determined by the eligibility file data element, ELIGIBILITY-GROUP.
Determine criminal justice status (i.e., criminally involved, not criminally
involved) based on ever qualifying for this subpopulation during the
measurement period. There is no standard methodology for identifying
criminal justice status; the state will need to identify a method for
flagging criminal involvement (such as by matching Medicaid
beneficiaries to data from state law enforcement agencies).
Determine co-occurring SUD (yes or no) for this subpopulation during
the measurement period. The state can identify beneficiaries with cooccurring SUD by identifying beneficiaries with a SUD diagnosis and a
SUD-related service during the measurement period and/or in the 11
months before the measurement period.

2

The version of the NCQA definition of SMI in Appendix E: Standardized Definition of SMI is based on the
technical specification of Metric #23 (Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c
(HbA1c) Poor Control (>9.0%) (HPCMI-AD)) from the FFY 2020 Adult Core Set. CMS acknowledges that the
NCQA definition is somewhat narrowly targeted to three conditions (schizophrenia, bipolar I disorder, and major
depression) and may not capture the full range of individuals with SMI targeted by a state. CMS is using the NCQA
definition as method to gather relatively standardized data from the state.

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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Subpopulation
Categories

Required or
Recommended

Co-occurring physical
health conditions

Recommended

Determine co-occurring physical health conditions for this
subpopulation during the measurement period. The state may use the
definitions and ICD-10 codes in the CMS Chronic Conditions Data
Warehouse
(https://www.ccwdata.org/documents/10280/19139421/ccw-chroniccondition-algorithms.pdf) to identify co-occurring physical health
conditions.

State-specific definition
of SMI

Required

Delivery system

Recommended

Geographic area

Recommended

Model of care

Recommended

Other subpopulation

Recommended

The state may have their own distinct definition of SMI and report
according to the definition it provides in its monitoring protocols,
specifically within the document: 1115 SMI Monitoring Protocol
Workbook.xlsx on the “Protocol-SMI & SED definitions” tab.
If the state’s SMI/SED demonstration services are provided through
managed care (MC) for some beneficiaries and fee-for-service (FFS)
for others, the state can report metrics separately for MC and FFS
populations.
If the state’s SMI/SED demonstration operates differently within
different geographic areas within the state, the state can report metrics
by geographic area (e.g., by county).
If the state’s SMI/SED demonstration operates differently within
different models of care, the state can report metrics by model of care
(e.g., by individual managed care organization or accountable care
organization).
If the state’s section SMI/SED demonstration includes programs or
services that target other subpopulations within its overall
demonstration population, the state can report metrics for these
subpopulations (e.g., Medicaid beneficiaries with SMI or SED who are
experiencing homelessness).

Description

State-specific

The T-MSIS data dictionary can be accessed at https://www.medicaid.gov/medicaid/data-and-systems/macbis/
tmsis/index.html. Additional resources for reporting on dually eligible beneficiaries are available on Medicaid.gov.
See, for example, https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iapdownloads/functional-areas/integrated-medicare-medicaid-data.pdf, and https://www.medicaid.gov/state-resourcecenter/innovation-accelerator-program/iap-functional-areas/data-analytics/index.html.
b Additional information on defining dual-eligible populations are available on Medicaid.gov. See, for example,
https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-downloads/functionalareas/integrated-medicare-medicaid-data.pdf, and https://www.medicaid.gov/state-resource-center/innovationaccelerator-program/iap-functional-areas/data-analytics/index.html.
IOP = intensive outpatient care; PH = partial hospitalization; ED = emergency department
a

Table 4 lists metrics by measurement domain and provides key reporting parameters, including
the measurement period, data source, and CMS-provided subpopulation categories for each
metric.

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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Table 4. Overview of section 1115 SMI/SED demonstration monitoring metrics, by measurement domain

1
2

3

4
5
6
7
8
9
10

Milestone 1 a
SUD Screening of Beneficiaries Admitted to
Psychiatric Hospitals or Residential Treatment
Settings (SUB-2)
Use of First-Line Psychosocial Care for Children
and Adolescents on Antipsychotics (APP-CH)
Milestone 2 a
All-Cause Emergency Department Utilization
Rate for Medicaid Beneficiaries who may
Benefit From Integrated Physical and
Behavioral Health Care (PMH-20)
30-Day All-Cause Unplanned Readmission
Following Psychiatric Hospitalization in an
Inpatient Psychiatric Facility (IPF)
Medication Reconciliation Upon Admission
Medication Continuation Following Inpatient
Psychiatric Discharge
Follow-up After Hospitalization for Mental
Illness: Ages 6-17 (FUH-CH)
Follow-up After Hospitalization for Mental
Illness: Age 18 and Older (FUH-AD)
Follow-up After Emergency Department Visit for
Alcohol and Other Drug Abuse (FUA-AD)
Follow-up After Emergency Department Visit for
Mental Illness (FUM-AD)

Medical record
review or claims

X

NCQA

Required

Year

Claims

X

CMS

Required

Year

Claims

X

CMS

Required

Year

Claims

X

CMS

Recommended

Year

X

CMS

Required

Year

Electronic/paper
medical records
Claims

NCQA

Required

Year

Claims

X

NCQA

Required

Year

Claims

X

NCQA

Required

Year

Claims

X

NCQA

Required

Year

Claims

X

6

X

State-specific definition of SMI

Year

Co-occurring physical health
conditions (Recommended)

Recommended

Co-occurring SUD
(Recommended)

TJC

Criminal Justice Status
(Recommended)

Measurement
Period
Data source

Disability (Recommended)

Required or
recommended

Dual-eligible status

Measure
Steward

Age Group

Metric name

Standardized Definition of SMI

Metric

Demonstration Reporting

Subpopulation Categories b

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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20

21
22
23

Recommended

Year

State data on
cause of death,
linked to claims

X

X

None

Recommended

Year

State data on
cause of death,
linked to claims

X

X

None
None

Required
Required

Month
Month

Claims
Claims

X
X

X
X

X
X

X
X

X
X

X
X

X
X

X
X

X
X

None
None
None
None

Required
Required
Required
Required

Month
Month
Month
Month

Claims
Claims
Claims
Claims

X
X
X
X

X
X
X
X

X
X
X
X

X
X
X
X

X
X
X
X

X
X
X
X

X
X
X
X

X
X
X
X

X
X
X
X

None
None

Required
Required

Year
Year

Claims
Claims

X
X

None

Required

Year

Claims

X

None
None
NCQA

Required
Required
Required

Month
Year
Year

Claims
Claims
Claims, Medical
Records

X
X
X

X
X

X
X

X
X

X
X

X
X

X
X

X
X

X
X

7

Age Group

None

Measurement
Period
Data source

Standardized Definition of SMI

State-specific definition of SMI

19a
19b

Co-occurring physical health
conditions (Recommended)

15
16
17
18

Co-occurring SUD
(Recommended)

13
14

Required or
recommended

Criminal Justice Status
(Recommended)

12

Suicide or Overdose Death Within 7 and 30
Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among
Beneficiaries With SMI or SED (count)
Suicide or Overdose Death Within 7 and 30
Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among
Beneficiaries With SMI or SED (rate)
Milestone 3 a
Mental Health Services Utilization - Inpatient
Mental Health Services Utilization - Intensive
Outpatient and Partial Hospitalization
Mental Health Services Utilization - Outpatient
Mental Health Services Utilization - ED
Mental Health Services Utilization - Telehealth
Mental Health Services Utilization - Any
Services
Average Length of Stay in IMDs
Average Length of Stay in IMDs (IMDs receiving
FFP only)
Beneficiaries With SMI/SED Treated in an IMD
for Mental Health
Milestone 4 a
Count of Beneficiaries With SMI/SED (monthly)
Count of Beneficiaries With SMI/SED (annually)
Diabetes Care for Patients with Serious Mental
Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)

Measure
Steward

Disability (Recommended)

11

Metric name

Demonstration Reporting

Metric

Dual-eligible status

Subpopulation Categories b

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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24

Screening for Depression and Follow-up Plan:
Age 18 and Older (CDF-AD)

NCQA

Recommended

Year

25

Screening for Depression and Follow-up Plan:
Ages 12–17 (CDF-CH)

NCQA

Recommended

Year

26c

Access to Preventive/Ambulatory Health
Services for Medicaid Beneficiaries With SMI
Tobacco Use Screening and Follow-up for
People with Serious Mental Illness or Alcohol or
Other Drug Dependence
Alcohol Screening and Follow-up for People
with Serious Mental Illness
Metabolic Monitoring for Children and
Adolescents on Antipsychotics (APM-CH)
Follow-up Care for Adult Medicaid Beneficiaries
Who are Newly Prescribed an Antipsychotic
Medication
Other SMI/SED Metrics
Total Costs Associated With Mental Health
Services Among Beneficiaries With SMI/SED Not Inpatient or Residential
Total Costs Associated With Mental Health
Services Among Beneficiaries With SMI/SED Inpatient or Residential
Per Capita Costs Associated With Mental
Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential

NCQA

Required

NCQA

27
28
29
30

32d
33
34

X

Year

Claims or
electronic
medical records
Claims or
electronic
medical records
Claims

Recommended

Year

Claims

X

NCQA

Recommended

Year

Claims

X

NCQA

Required

Year

Claims

X

CMS

Required

Year

Claims

X

None

Required

Year

Claims

X

None

Required

Year

Claims

X

None

Required

Year

Claims

X

8

X

X

State-specific definition of SMI

Co-occurring physical health
conditions (Recommended)

Co-occurring SUD
(Recommended)

Criminal Justice Status
(Recommended)

Measurement
Period
Data source

Disability (Recommended)

Required or
recommended

Dual-eligible status

Measure
Steward

Age Group

Metric name

Standardized Definition of SMI

Metric

Demonstration Reporting

Subpopulation Categories b

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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37

Appeals Related to Services for SMI/SED

None

Required

Quarter

38

Critical Incidents Related to Services for
None
SMI/SED
None
Total Costs Associated With Treatment for
Mental Health in an IMD Among Beneficiaries
With SMI/SED
Per Capita Costs Associated With Treatment for None
Mental Health in an IMD Among Beneficiaries
With SMI/SED

Required

Quarter

Required
Required

39
40

X

Year

Administrative
records
Administrative
records
Administrative
records
Claims

Year

Claims

X

X
X
X

Milestones included in this table are from the State Medicaid Director Letter #18-011.
A state must report the state-specific definition of SMI for the metrics noted in the table. For CMS-constructed metrics, the state can identify additional
subpopulations categories specific to their demonstration.
c Metric #26 is an adjusted HEDIS measure: Access to Preventative/Ambulatory Health Services for Adult Medicaid Beneficiaries with SMI. Although the technical
specifications provided by the measure steward describe how to report the metric by age group, the state is not expected to report this subpopulation category for
this metric.
d Metric #31 was removed from the 1115 SMI/SED monitoring metrics in Version 2.0 Medicaid Section 1115 Serious Mental Illness and Serious Emotional
Disturbance Demonstrations: Technical Specifications for Monitoring Metrics
IMD = Institution for Mental Diseases; NCQA = National Committee for Quality Assurance; SMI/SED = Serious Mental Illness/Serious Emotional Disturbance; TJC
= The Joint Commission
a

b

9

State-specific definition of SMI

Quarter

Co-occurring physical health
conditions (Recommended)

Required

X

Co-occurring SUD
(Recommended)

None

Claims

Criminal Justice Status
(Recommended)

Year

Disability (Recommended)

Required

Dual-eligible status

None

36

Per Capita Costs Associated With Mental
Health Services Among Beneficiaries With
SMI/SED - Inpatient or Residential
Grievances Related to Services for SMI/SED

35

Measurement
Period
Data source

Age Group

Required or
recommended

Metric name

Standardized Definition of SMI

Measure
Steward

Metric

Demonstration Reporting

Subpopulation Categories b

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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B. Reporting guidance for section 1115 SMI/SED monitoring metrics

This section provides reporting guidance applicable to section 1115 SMI/SED
demonstration monitoring metrics. The technical specifications for calculating each metric can
be found in Chapter II.
Technical assistance. CMS offers technical assistance to help a state collect, report, and use the
metrics. For technical assistance, contact the section 1115 demonstration monitoring and
evaluation mailbox ([email protected]), copying the state’s CMS
demonstration team on the message.
Supplemental materials. Technical specifications for some established quality measures as
well as established value sets and other resource materials are provided in the 1115 SMI
Monitoring Metrics Supporting Information v2.zip file accompanying this manual, and also
accessible to the state through Performance Metrics Database and Analytics (PMDA) in the
Reference Materials section. To access the .zip file, the state should go to the Reference
Materials section of PMDA and complete the National Measure Stewards Terms and Conditions
‘Point and Click’ Agreement. This agreement should automatically appear when a state
downloads the technical specifications manual or supporting information .zip file.
Metric type. This document describes three types of SMI/SED metrics:
•

CMS-constructed metrics. Many of the metrics were constructed by CMS. The technical
specifications for these metrics are included in this document (Chapter II). Many of these
metrics reference HEDIS 2020 value sets or other lists that contain complete sets of codes
used to identify a treatment service or diagnosis. When referenced, use these value sets to
calculate a metric. Established value sets are provided in the 1115 SMI Monitoring Metrics
Supporting Information v2.zip file accompanying this manual, and are also accessible to the
state through PMDA in the Reference Materials section.

•

Established quality measures. Some metrics are established quality measures available from
a Quality Measures measure set such as (the Core Set of Children’s Health Care Quality
Measures for Medicaid and CHIP [Child Core Set], the Core Set of Adult Health Care
Quality Measures for Medicaid [Adult Core Set], or measure steward (NCQA or the Joint
Commission), as specified. 3 To help the state calculate these metrics, this document
references the original measure specifications and associated value sets, provided in the 1115
SMI Monitoring Metrics Supporting Information v2.zip file accompanying this manual.
These materials are also accessible to the state through PMDA in the Reference Materials
section.

•

State-specific metrics. In addition to the metrics provided by CMS, a state can propose
metrics specific to its demonstration. These metrics are referred to as “state-specific metrics”
within this document.

3

Established quality measures include: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 23, 24, 25, 26, 27, 28, 29, and 30.

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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Determining measurement periods. To determine measurement periods, the state must first
identify the start date of its SMI/SED demonstration. For monitoring purposes, CMS defines the
start date of the demonstration as the effective date in the state’s special terms and conditions
(STCs). For example, if the state’s STCs at the time of SMI/SED demonstration approval note
that the SMI/SED demonstration is effective January 1, 2020 – December 31, 2025, the state
should consider January 1, 2020 to be the start date of the SMI/SED demonstration for purposes
of monitoring. 4
When reporting metrics, the state should use the following guidance for determining the
measurement period:
•

•

CMS-constructed and state-specific metrics:
-

Monthly metrics. For metrics where the measurement period is a month, the first
measurement period is the first month in which the demonstration started (as defined
by the start date of the demonstration’s approval period), irrespective of the day of the
month the demonstration started. For example, if the SMI/SED demonstration began
on March 1 or on any other day in March (e.g., March 15), the first measurement
period is March 1 through March 31. The second measurement period is April 1
through April 30. For each quarterly report, the state should submit data pertaining to
the three months within the quarter.

-

Quarterly metrics. For metrics where the measurement period is a quarter, the first
measurement period spans the first three months of the SMI/SED demonstration’s
approval period. For example, if the SMI/SED demonstration began March 1 or on any
other day in March (e.g., March 15), the first quarterly measurement period is March 1
through May 31. The second quarterly measurement period is June 1 through August
31.

-

Annual metrics. For metrics where the measurement period is a year, the measurement
period should align with the SMI/SED demonstration year schedule. For example, if
the SMI/SED demonstration began on March 1 or on any other day in March (e.g.,
March 15), the first measurement period is March 1 of the year in which the
demonstration started through February 28 of the following calendar year.

Established quality measures. For metrics that are established quality measures, the annual
measurement period should align with a calendar year, with the first measurement period
aligned with the calendar year in which the SMI/SED demonstration started. For example, if
the SMI/SED demonstration began March 1, 2019, the first measurement period should be
the 2019 calendar year (January 1, 2019 through December 31, 2019) to align with the
measurement period for these measures in other quality reporting programs.

4

The effective date is defined as the first day the state may begin its SMI/SED demonstration, as indicated in the
state’s STCs. Note that in many cases, the effective date is distinct from the approval date of a demonstration; that
is, in certain cases, CMS may approve a section 1115 demonstration with an effective date that is in the future. For
example, CMS may approve an extension request on 12/15/2020, with an effective date of 1/1/2021 for the new
demonstration period. In many cases, the effective date also differs from the date a state begins implementing its
demonstration.

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Determining baseline reporting periods. To determine baseline reporting periods, the state
must first identify the start date of its SMI/SED demonstration. For monitoring purposes, CMS
defines the start date of the demonstration as the effective date in the state’s STCs. For example,
if the state’s STCs at the time of SMI/SED demonstration approval note that the SMI/SED
demonstration is effective January 1, 2020 – December 31, 2025, the state should consider
January 1, 2020 to be the start date of the SMI/SED demonstration for purposes of monitoring.
•

•

CMS-constructed and state-specific metrics: For CMS-constructed and state-specific
metrics where the measurement period is a month, quarter, or year, the baseline reporting
period is the first SMI/SED demonstration year (SMI/SED DY1). For example, if the state’s
SMI/SED demonstration began on March 1, 2019, the baseline reporting period is March 1,
2019 – February 29, 2020.
-

If the state’s SMI/SED demonstration began on any day other than the first day of the
month, the state should still start its baseline reporting period on the first day of the
month for monitoring purposes. This applies to all baseline reporting periods (month,
quarter, and year). For example, if a state’s demonstration began on March 15, 2019
the state should consider March 1 as the beginning of its baseline period.

-

For a state where the first SMI/SED DY is less than 12 months, the state should report
the 12 months preceding the end of SMI/SED DY1 as its baseline reporting period
(including months before the start of the SMI/SED demonstration). For example, if the
state has a 10-month SMI/SED DY1 that began March 1, 2019 and ended December
31, 2019, the baseline reporting period should be January 1, 2019 –
December 31, 2019.

Established quality measures: For metrics that are established quality measures, the calendar
year in which the demonstration started is the baseline reporting period. For example, if the
state’s SMI/SED demonstration began on March 1, 2019, the baseline reporting period is
January 1, 2019 through December 21, 2019.
-

For measures calculated over a 2-year period (Metric #6: Medication Continuation
Following Inpatient Psychiatric Discharge), the baseline reporting period is the
calendar year in which the SMI/SED demonstration started and the prior year. For
each subsequent reporting period, shift the period for the denominator forward by one
year.

-

For a state where the SMI/SED DY1 is less than 12 months, the state should use the
last day of SMI/SED DY1 to identify the appropriate calendar year for reporting. If the
last day of SMI/SED DY1 is December 31, the baseline reporting period would be the
same calendar year. For example, if a state has a 10-month SMI/SED DY1 starting
March 1, 2020 and ending on December 31, 2020, the baseline reporting period is
January 1, 2020 – December 31, 2020 (calendar year 2020). If the last day of
SMI/SED DY1 is any other date, the baseline reporting period should be the prior
calendar year. For example, if a state has a 10-month SMI/SED DY1 that started on
September 1, 2019 and ended June 30, 2020, the baseline period is January 1, 2019 –
December 31, 2019 (calendar year 2019).

To confirm the measurement and baseline reporting periods, contact the section 1115
demonstration monitoring and evaluation mailbox

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

MATHEMATICA

([email protected]), copying the state’s CMS demonstration team on
the message.
Table 5 below illustrates these guidelines, using an SMI/SED demonstration that begins
March 1, 2019 as an example.
Table 5. Example of alignment between section 1115 SMI/SED demonstration years and
measurement periods
SMI/SED Measurement Period
Month
Section 1115
SMI/SED
Demonstration Start
Date:
March 1, 2019

Start Date

Quarter
End Date

Yeara
End
Date

Start Date

Mar 1
Apr 1
May 1
June 1
…
Feb 1

Mar 31
Apr 30
May 31
June 30
…
Feb 29

Mar 1
June 1
Sep 1
Dec 1

May 31
Aug 31
Nov 30
Feb 29

SMI/SED DY2
March 1, 2020 –
Feb 28, 2021

Month as defined in the Baseline year row

Month as defined in the Baseline year row

Quarter as defined in the Baseline
year row

SMI/SED DY3
March 1, 2021 –
Feb 28, 2022

Month as
defined in the
baseline
reporting period
row

Month as
defined in the
baseline
reporting period
row

SMI/SED DY4
March 1, 2022 –
Feb 28, 2023

Month as defined in the Baseline year row

Month as defined in the Baseline year row

End
Date

Established quality
measures

CMS-constructed and state-specific metrics

SMI/SED DY1
March 1, 2019 –
Feb 29, 2020
(baseline reporting
period)

SMI/SED DY5
March 1, 2023 –
Feb 29, 2024

Start Date

Jan 1, 2019

Dec 31, 2019

Quarter as
defined in the
Baseline year
row

Jan 1, 2020

Dec 31, 2020

Quarter as
defined in
the baseline
reporting
period row

Quarter as
defined in the
baseline
reporting
period row

Jan 1, 2021

Dec 31, 2021

Dec 31, 2022

Quarter as defined in the Baseline
year row

Quarter as
defined in the
Baseline year
row

Jan 1, 2022

Month as defined in the Baseline year row

Dec 31, 2023

Quarter as defined in the Baseline
year row

Quarter as
defined in the
Baseline year
row

Jan 1, 2023

Month as defined in the Baseline year row

a This

example does not apply to Metric #6, which is calculated over a two-year time period.
DY = Demonstration year

Metric calculation and reporting. The state should report data to CMS in accordance with the
schedule and format agreed upon in the approved monitoring protocol. Because of the dynamic
nature of Medicaid data, metrics should be produced at the same time in each measurement
period throughout the SMI/SED demonstration. This applies even if data are not shared with
CMS until a later date. For example, if a state submits data quarterly, the submission should
contain three monthly values for each monthly metric, each produced at the same time relative to
its measurement period.
Guidelines for including metrics and narrative information in monitoring reports are as follows:
•

Each quarterly monitoring report should contain (1) narrative information on implementation
for the most recent demonstration quarter, (2) grievances and appeals metrics for the most
recent demonstration quarter, and (3) all other monthly and quarterly metrics for the prior

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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quarter (which allows at least 90 days for claims run-out and other considerations for data
completeness).
•

•

To allow for adequate time to implement annual specification updates from measure
stewards, annual metrics that are established quality measures should be reported:
-

For a state with an SMI/SED demonstration year that ends January 31 or February 28:
in the first quarterly monitoring report of the next SMI/SED demonstration year

-

For a state with an SMI/SED demonstration year that ends March 31 through
November 30: in the annual monitoring report

-

For a state with an SMI/SED demonstration year that ends December 31: in the second
quarterly monitoring report of the next SMI/SED demonstration year

All other annual metrics should be reported in the first quarterly monitoring report of the next
SMI/SED demonstration year, rather than in the annual monitoring report. This allows at
least 90 days for claims run-out and other considerations for data completeness.

Table 6 illustrates these guidelines, which apply to both CMS-constructed and state-specific
metrics.
Table 6. Reporting in quarterly and annual section 1115 SMI/SED monitoring reports

Report name:

DY1Q1
report

DY1Q2
report

DY1Q3
report

DY1Q4
(annual)
report**

DY2Q1
report

DY2Q2
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

Report due date:
Measurement periods,
by reporting category
Narrative information on
implementation
Grievances and appeals
Other monthly and
quarterly metrics
Annual metrics that are
established quality
measures*

DY1Q1

DY1Q2

DY1Q3

DY1Q4

DY2Q1

DY2Q2

DY1Q1

DY1Q2

DY1Q3

DY1Q4

DY2Q1

DY2Q2

n.a.

DY1Q1

DY1Q2

DY1Q3

DY1Q4

DY2Q1

n.a.

n.a.

n.a.

A state with
a DY ending
3/31 –
11/30: CY1

A state with a
DY ending
on 12/31:
CY1

Other annual metrics

n.a.

n.a.

n.a.

n.a.

A state with
a DY
ending on
1/31 or
2/28: CY1
DY1

n.a.

Note: The state is expected to submit retrospective data in the second monitoring report submission after monitoring
protocol approval
* Metrics that are established quality measures should be calculated for the calendar year. Note that one established
quality measure (Metric #6) should be calculated over a 2-year period (starting with the calendar year in which the
demonstration began and the calendar year prior). All other metrics should be calculated for the SMI/SED
demonstration year.
**Per the STCs, the state’s fourth quarterly monitoring report (Q4) is also considered to be its annual monitoring
report for the previous demonstration year. If the state’s SMI/SED demonstration is part of a broader section 1115
demonstration, the state should consider its broader section 1115 demonstration Q4 monitoring report to be the
state’s annual monitoring report.
CY = calendar year; CY1 = the calendar year in which the demonstration began; DY = Demonstration year; Q =
Quarter; n.a. = not applicable (information not expected to be included in the monitoring report)

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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Manual version. CMS will release an annual update of this technical specifications manual to
incorporate updated specifications and/or value sets from national measure stewards of
established quality measures included in the SMI/SED demonstration metrics. Additionally, the
annual update to this manual may include clarifications and improvements to specifications for
CMS-constructed metrics and to metrics reporting guidance. The state should use the manual
versions as follows:
•

CMS-constructed metrics. The state should use the latest version of the manual available (as
identified by the version number) to calculate these metrics.

•

Established quality measures. For measurement periods that occur within calendar year
2019, the state should use Version 2.0 of this manual (this version, August 2020). For later
years, the state should use the version of the manual associated with the calendar year (for
example, use Version 3.0 – the next annual update – to calculate established quality
measures for calendar year 2020).

General guidance. When reporting SMI/SED demonstration monitoring metrics, please follow
these guidelines for all metrics:
•

Supporting measure specifications, value sets, and code lists. Many monitoring metrics
reference value sets, code lists, or full specifications for established quality measures. See
Appendix C: How to Use Supporting Measure Specifications, Value Sets, and Code
Lists to Calculate Metrics for instructions on how to access and use these supporting
materials to calculate monitoring metrics.

•

Eligible population. The eligible population for each metric will vary based on whether
the metric is a CMS-constructed metric or an established quality measure.
-

All CMS-constructed metrics. CMS-constructed metrics should include full benefit
enrollees, including individuals entitled to the full scope of Medicaid benefits, enrolled
in an alternative benchmark-equivalent plan, eligible for only pregnancy-related
services, or otherwise eligible for full coverage of Medicaid SMI or SED services.
Beneficiaries with partial benefits are only eligible for inclusion in metric calculations
(using the same enrollment criteria as beneficiaries with full benefits) if they are
eligible to receive services described in the metric numerator.
The metrics should exclude beneficiaries who are: (1) only entitled to restricted
benefits based on alien status, (2) only entitled to restricted benefits based on Medicare
dual-eligibility status including QMB, SLMB, QDWI and QI; (3) have a first source of
payment other than Medicaid or Medicare for substance use disorder treatment
services (for example private insurance or eligibility for Medicaid only after
spenddown); (4) only eligible for family planning services; or (5) inmates in a facility
by operation of criminal law.
The exclusion criteria should only apply to the metric measurement period and not to
the look back period for any CMS-constructed metrics. That is, beneficiaries who
would not meet the inclusion criteria during a look back period, but who meet the
criteria during the measurement period, should still be included.

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The following additional criteria apply based on the measurement period of the CMSconstructed metric:
o For annual metrics, beneficiaries with full benefits enrolled in Medicaid for at
least one month (30 consecutive days) during the measurement period are
eligible for inclusion in CMS-constructed annual metric calculations, unless
otherwise specified in the “population of interest” or “denominator” rows of
the metric’s technical specification.
o For monthly and quarterly metrics, beneficiaries with full benefits enrolled in
Medicaid for any amount of time during the measurement period are eligible
for inclusion in CMS-constructed monthly or quarterly metric calculations,
unless otherwise specified in the “population of interest” or “denominator”
rows of the metric’s technical specification
For each CMS-constructed metric, the state should review the associated specification
table in Chapter II to determine additional metric-specific eligibility criteria.
-

Established quality measures. For metrics that are established quality measures, the state
should use the technical specifications from the measure steward to determine eligibility
criteria. For measures in the Medicaid Child and Adult Core Sets, refer to the technical
specifications included in Appendix D: Technical Specifications for Established
Quality Measures Adapted from FFY 2020 Child and Adult Core Set Measure
Specifications. For all other established quality measures, refer to the original measure
specifications, provided in the 1115 SMI Monitoring Metrics Supporting Information
v2.zip file accompanying this manual. These materials are also accessible through
PMDA in the Reference Materials section.
Note that for some metrics that are established quality measures, Chapter II provides
additional criteria beyond those specified by the respective measure steward that should
be applied when calculating the metric. This information can be found under the
“population of interest” and “metric calculation” rows in the technical specifications
tables in Chapter II.

•

Claim type. For CMS-constructed metrics, use only paid claims to identify whether a
treatment service was provided to Medicaid beneficiaries. For established quality measures,
follow guidance from the measure steward. For example, some HEDIS measures use paid,
suspended, pending and denied claims.

•

State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or
other types of codes. When applicable, the state should supplement the codes referenced in
metric specifications with state-specific codes that are not included in the value sets. Statespecific codes must be for services specific to mental health treatment. If the service code can
be for either mental health or SUD services, then a mental health diagnosis code must be
included on the claim. The state should describe these state-specific codes in the
“Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. If the state would
like to provide this information in an attachment, the state should enter “See attachment” in
this column in Part A. See the latest Section 1115 SMI/SED Monitoring Protocol Instructions
for further guidance.

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

•

MATHEMATICA

Telehealth and state-specific service codes. In response to the 2019 Coronavirus (COVID19) pandemic, CMS recognizes that many providers and facilities have shifted from inperson visits to telehealth or other service delivery models. To account for these changes in
service delivery, the state should review its telehealth codes, as well as relevant statespecific service codes, to ensure these codes will accurately capture use of telehealth
services or alternative service delivery models. The state may refer to the Telemedicine page
on Medicaid.gov 5 for additional information regarding telehealth coding and policy
considerations related to COVID-19.
-

CMS-constructed metrics. CMS-constructed metrics include telehealth HEDIS value
sets (Online assessments, Telehealth Modifier, Telehealth POS, or Telephone Visits)
where applicable. The state may wish to supplement the telehealth codes referenced in
the metric specifications with state-specific codes that are not included in these value
sets. The state should review the codes in the telehealth-related HEDIS value sets 6 and
determine if additional codes are necessary to capture services performed via
telehealth or other new service delivery models in response to COVID-19. The state
should describe these state-specific telehealth and service codes in the “Explanation of
any deviations from the CMS-provided specifications” column in Part A (monitoring
protocol workbook) of its monitoring protocol submission. See the latest Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance.

-

Established quality measures. For metrics that are established quality measures, the
state should use the technical specifications and value sets from the measure steward
as specified in this manual. The state should not supplement telehealth or other service
coding with state-specific codes for these metrics. As established quality measures
within this manual are to be reported for calendar year 2019, a future update of this
manual and supporting materials will capture any changes to established quality
measure technical specifications or value sets related to COVID-19 that are deemed
necessary by the measure steward.

C. Using technical specifications

Table 7 defines the elements included in specifications for metrics in Chapter II. The
description column explains each metric element.

5

Telemedicine guidance is available on Medicaid.gov at:
https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html.
6

Detailed instructions for accessing the HEDIS value sets can be found in Appendix C: How to Use Supporting
Measure Specifications, Value Sets, and Code Lists to Calculate Metrics.

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Table 7. Metric elements included in the technical specifications
Metric #: Metric Name
Metric element

Description

Measure
sets/endorsements

Describes whether the metric is included in other Medicaid Quality Measures measure
sets (such as Core Set) and is endorsed by NQF. When applicable, this element also
names the measure steward.

Description

Brief measure description.

Population of interest

Criteria for determining the population that should be included in each metric.

Numerator

When the metric is a rate, this element describes the numerator in the rate. When the
metric is a count, this element describes the counted variable.
This element is not used in metrics that reference established quality measures.

Denominator

When the metric is a rate, this element describes the denominator in the rate. This
element is not used in metrics that are counts or that reference established quality
measures.

Metric calculation

When the metric is a rate, this element provides instructions for calculating the metric.
This element is not used when the metric is a count.

Additional guidance

Any additional guidance required to calculate and report this metric.

Measurement period
(Metric type)

Measurement period describes whether the measurement period is a month, quarter,
or year. Metric type describes whether the metric is CMS-constructed or an established
quality measure.

Reporting category

Reporting category describes the category associated with reporting guidelines for
including metrics in monitoring reports (see Table 6 above). Categories include
grievances and appeals and qualitative information on referral into treatment, other
monthly and quarterly metrics, annual metrics that are established quality measures,
and other annual metrics.

Subpopulation
categories

Describes the subpopulations that the state should report separately. Required
subpopulations are identified with the notation (required).

Relationship to other
metrics

Describes components of a metric that are used in other metrics.

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.

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II. METRIC SPECIFICATIONS

This chapter presents technical specifications for each of the SMI/SED demonstration
monitoring metrics. Reporting guidance that applies to all metrics can be found in Chapter I.
Metric #1: SUD Screening of Beneficiaries Admitted to Psychiatric Hospitals or Residential Treatment
Settings (SUB-2)
Metric element
Measure
sets/endorsements
Description

Population of interest

Metric calculation

Additional guidance

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
Hospital Inpatient Quality Reporting Program
Measure steward: The Joint Commission
Two rates will be reported for this measure:
1. SUB-2: Patients who screened positive for unhealthy alcohol use who
received or refused a brief intervention during the hospital stay.
2. SUB-2a: Patients who received the brief intervention during the hospital stay.
The measure is reported as an overall rate which includes all patients to whom a brief
intervention was provided, or offered and refused, and a second rate, a subset of the
first, which includes only those patients who received a brief intervention. The Provided
or Offered rate (SUB-2), describes patients who screened positive for unhealthy
alcohol use who received or refused a brief intervention during the hospital stay. The
Alcohol Use Brief Intervention (SUB-2a) rate describes only those who received the
brief intervention during the hospital stay. Those who refused are not included.
All Medicaid beneficiaries within the denominator defined in the measure steward's
specifications. The denominator includes all beneficiaries discharged from acute
inpatient care with Length of Stay (Discharge Date minus Admission Date) less than or
equal to 120 days.
Calculation instructions are located in The Specifications Manual for National Hospital
Inpatient Quality Measures v5.6; see measure SUB-2, Alcohol Use Brief Intervention
Provided or Offered, and measure SUB-2a, Alcohol Use Brief Intervention.
The specification is located in “2l-SUB2.pdf” and references ICD-10 codes in
“Appendix -A1.xls.” See also the Data Dictionary for the measure data elements in “1bAlphaDD.pdf”.
The Specifications Manual for National Hospital Inpatient Quality Measures v5.6 is
available at https://www.qualitynet.org/files/5d0d3931764be766b0103221?filename=26-2-SUB-v5-6.pdf.
Detailed instructions for accessing the measure specification and code set can be
found in Appendix C: How to Use Supporting Measure Specifications, Value Sets,
and Code Lists to Calculate Metrics.
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Medical record review or claims
Not specified

Version of Specification: Joint Commission National Hospital Inpatient Quality Measures version 5.6a.
Specifications come from the greater IQR program manual.

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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Metric #2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
Metric element
Measure
sets/endorsements

Description
Population of interest
Metric calculation
Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
FFY 2020 Core Set of Child Health Care Quality Measures for Medicaid (Child Core
Set), based on HEDIS specifications
NQF #2801
Measure steward: NCQA
Percentage of children and adolescents ages 1 to 17 who had a new prescription for
an antipsychotic medication and had documentation of psychosocial care as first-line
treatment
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2020 Child
and Adult Core Sets Measure Specifications
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Include paid, suspended, pending, and denied claims

Version of Specification: Child Core Set Technical Specifications and Resource Manual for Federal Fiscal
Year 2020 Reporting, March 2020

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Metric #3: All-Cause Emergency Department (ED) Utilization Rate for Medicaid Beneficiaries who may
Benefit From Integrated Physical and Behavioral Health Care (PMH-20)
Metric element
Measure
sets/endorsements
Description
Population of interest
Metric calculation

Additional guidance

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
Measure steward: CMS
Number of all-cause ED visits per 1,000 beneficiary months among adult Medicaid
beneficiaries age 18 and older who meet the eligibility criteria of beneficiaries with SMI
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Note that the measure steward’s specifications refer to multiple denominators. For the
purpose of SMI/SED demonstration monitoring, the state should calculate this metric
for the Medicaid beneficiaries with SMI (denominator #4).
Instructions for calculating this metric are provided in the full measure specification
(pmh-20-ed-tech-specs-manual) provided to the state in the 1115 SMI Monitoring
Metrics Supporting Information v2.zip file accompanying this manual and the
Reference Materials section on PMDA.
Calculation instructions are also located in Technical Specifications and Resource
Manual for “All-cause emergency department utilization rate for Medicaid beneficiaries
who may benefit from integrated physical and behavioral health care.”
Detailed instructions for accessing the value sets required for this metric are provided
in Appendix C: How to Use Supporting Measure Specifications, Value Sets, and
Code Lists to Calculate Metrics.
The Technical Specifications and Resource Manual is available at
https://www.medicaid.gov/resources-for-states/innovation-acceleratorprogram/functional-areas/quality-measurement/physical-and-mental-health-integrationquality-measures/index.html.
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

Version of Specification: Technical Specifications and Resource Manual, April 2019

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Metric #4: 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an Inpatient
Psychiatric Facility (IPF)
Metric element
Measure sets/
endorsements
Description

Population of interest

Numerator

Denominator
Metric calculation

Description
Medicare Inpatient Psychiatric Facility Quality Reporting Program (IPFQR)
Based on NQF #2860
Measure steward: CMS
The rate of unplanned, 30-day, readmission for demonstration beneficiaries with a
primary discharge diagnosis of a psychiatric disorder or dementia/Alzheimer’s disease.
The measurement period used to identify cases in the measure population is 12 months
from January 1 through December 31.
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for at least one month (30 consecutive days) during the measurement period.
The SMI/SED demonstration population is defined as any beneficiary with an SMI/SED
diagnosis in the measurement period and/or in the 12 months before the measurement
period. Additional guidance on identifying the eligible population is provided in Chapter I.
The count of 30-day readmissions. A readmission is defined as any admission, for any
reason, to an IPF or a short-stay acute care hospital (including critical access hospitals
(CAHs)) that occurs within 30 days after the discharge date from an eligible index
admission to an IPF, except those considered planned. The measure uses the CMS 30day Hospital-Wide Readmission (HWR) Measure Planned Readmission Algorithm,
Version 4.0.
The count of index hospital admissions to IPFs
The measure population consists of eligible index admissions to IPFs. A readmission
within 30-days will also be eligible as an index admission, if it meets all other eligibility
criteria. Patients may have more than one index admission within the measurement
period.
Step 1. Identify the Eligible population:
Identify beneficiaries who meet the following criteria:
•
Age 18 or older at admission
•
Discharged alive
•
Enrolled in Medicaid during the month of, and at least one month after the
admission date
Step 2. Exclude beneficiaries who are:
•
Discharged against medical advice because the IPF may have limited
opportunity to complete treatment and prepare for discharge
•
With unreliable demographic and vital status data defined as the following:
­ Age greater than 115 years
­ Missing gender
­ Discharge status of “dead” but with subsequent admissions
­ Death date prior to admission date
­ Death date within the admission and discharge dates but the discharge status
was not “dead”
•
With readmissions on the day of discharge or day following discharge because
those readmissions are likely transfers to another inpatient facility. The hospital
that discharges the patient to home or a non-acute care setting is accountable
for subsequent readmissions.
•
With readmissions two days following discharge because readmissions to the
same IPF within two days of discharge are combined into the same claim as the
index admission and do not appear as readmissions due to the interrupted stay
billing policy. Therefore, complete data on readmissions within two days of
discharge are not available.
Step 3. Calculate the Denominator: count of index admissions with discharge dates
between January 1 and December 31

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Metric #4: 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an Inpatient
Psychiatric Facility (IPF)
Metric element
Metric calculation
(continued)

Additional guidance

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
To identify index admissions, identify discharges with a psychiatric primary diagnosis
included in one of the Agency for Healthcare Research and Quality (AHRQ) Clinical
Classification Software (CCS) ICD groupings below. (More information on grouping ICD
codes into clinically coherent groups is available at the following link: https://www.hcupus.ahrq.gov/toolssoftware/ccs/ccs.jsp.).
•
Primary discharge diagnosis clinical categories designating psychiatric illness
for measure cohort
­ 650 – Adjustment disorders
­ 651 – Anxiety disorders
­ 652 – Attention-deficit, conduct, and disruptive behavior disorders
­ 653 – Delirium, dementia, and amnestic and other cognitive disorders
­ 654 – Developmental disorders
­ 655 – Disorders usually diagnosed in infancy, childhood, or adolescence
­ 656 – Impulse control disorders, NEC
­ 657 – Mood disorders
­ 658 – Personality disorders
­ 659 – Schizophrenia and other psychotic disorders
­ 660 – Alcohol-related disorders
­ 661 – Substance-related disorders
­ 662 – Suicide and intentional self-inflicted injury
­ 663 – Screening and history of mental health and substance abuse codes
­ 670 – Miscellaneous disorders
Step 4. Calculate the Numerator: Count of 30-day Readmissions
Among index admissions identified in Step 3, identify the readmissions to an IPF or a
short-stay acute care hospital (including CAHs) that occurs within 30 days after the
discharge date from an eligible index admission to an IPF.
Step 5. Exclude admissions considered planned
Of the readmissions identified in Step 4, identify and exclude admissions considered
planned as determined by the CMS 30-day Hospital-Wide Readmission (HWR) Measure
Planned Readmission Algorithm, Version 4.0 available at:
https://qualitynet.org/files/5d0d374b764be766b0101361?filename=2019HWRReport.pdf.
Step 6. Calculate the rate of readmissions: number readmissions (Step 5) / number of
index admissions (Step 3).
This measure is based on the 30-Day All-Cause Unplanned Readmission Following
Psychiatric Hospitalization in an Inpatient Psychiatric Facility (IPF) in the IPFQR
program. The program manual for IPFQR is available at:
https://qualitynet.org/files/5df7a5ca62faad001ffd7a87?filename=FY20_IPFQR_CBM_Sp
ecs.pdf. For the purpose of SMI/SED demonstration monitoring, the state should use
measure calculation instructions in this manual.
Note that the measure steward’s specifications refer to Medicare beneficiaries. For
purpose of SMI/SED demonstration monitoring, the state should calculate this metric for
the Medicaid beneficiaries described in the population of interest.
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Only use paid claims. (Do not use suspended, pending, and denied claims.)

Version of Specification: Inpatient Psychiatric Facility Quality Reporting Program Claims-Based Measure
Specifications, November 2019)

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Metric #5: Medication Reconciliation Upon Admission
Metric element
Measure
sets/endorsements
Description

Population of interest
Numerator

Denominator
Metric calculation

Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation categories
Relationship to other
metrics
Data source
Claim type

Description
NQF #3317
Measure steward: CMS
Percentage of patients for whom a designated prior to admission (PTA) medication
list was generated by referencing one or more external sources of PTA medications
and for which all PTA medications have a documented reconciliation action by the
end of Day 2 of the hospitalization
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Number of admissions with a designated PTA medication list generated by
referencing one or more external sources of medications for which all PTA
medications have a documented reconciliation action by the end of Day 2 of the
hospitalization
Admissions to an inpatient facility from home or a non-acute setting
Instructions for calculating this metric are located in the full measure specification
(IPQFR_Medication Rec on Admsn_specs) provided to the state in the 1115 SMI
Monitoring Metrics Supporting Information v2.zip file accompanying this manual
and the Reference Materials section on PMDA
Detailed instructions for accessing the specifications can be found in Appendix C:
How to Use Supporting Measure Specifications, Value Sets, and Code Lists to
Calculate Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Electronic/paper medical records
Not applicable

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Metric #6: Medication Continuation Following Inpatient Psychiatric Discharge
Metric element
Measure
sets/endorsements
Description

Population of interest
Metric calculation

Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation categories
Relationship to other
metrics
Data source
Claim type

Description
Based on NQF# 3205
Measure steward: CMS
This measure assesses whether psychiatric patients admitted to an inpatient
psychiatric facility (IPF) for major depressive disorder (MDD), schizophrenia, or
bipolar disorder filled a prescription for evidence-based medication within 2 days
prior to discharge and 30 days post-discharge
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric are located in the full measure specification
(IPQFR_Medication Continuation_specs) and data dictionary (IPQFR_Medication
Continuation_Data Dictionary) provided to the state in the 1115 SMI Monitoring
Metrics Supporting Information v2.zip file accompanying this manual and the
Reference Materials section on PMDA.
Detailed instructions for accessing the specifications and data dictionary can be
found in Appendix C: How to Use Supporting Measure Specifications, Value
Sets, and Code Lists to Calculate Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

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Metric #7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
Metric element
Measure
sets/endorsements

Description

Population of interest
Metric calculation

Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
FFY 2020 Core Set of Child Health Care Quality Measures for Medicaid (Child Core
Set), based on HEDIS specifications
NQF #0576
Measure steward: NCQA
Percentage of discharges for children ages 6 to 17 who were hospitalized for treatment
of selected mental illness or intentional self-harm diagnoses and who had a follow-up
visit with a mental health practitioner. Two rates are reported:
•
Percentage of discharges for which the child received follow-up within 30
days after discharge
•
Percentage of discharges for which the child received follow-up within 7 days
after discharge
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2020 Child
and Adult Core Sets Measure Specifications
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Include paid, suspended, pending, and denied claims

Version of Specification: Child Core Set Technical Specifications and Resource Manual for Federal Fiscal
Year 2020 Reporting, March 2020

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Metric #8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)
Metric element
Measure
sets/endorsements

Description

Population of interest
Metric calculation
Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
FFY 2020 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core
Set)
NQF #0576
Measure steward: NCQA
Percentage of discharges for beneficiaries age 18 years and older who were
hospitalized for treatment of selected mental illness diagnoses or intentional self-harm
and who had a follow-up visit with a mental health practitioner. Two rates are reported:
•
Percentage of discharges for which the beneficiary received follow-up within
30 days after discharge
•
Percentage of discharges for which the beneficiary received follow-up within
7 days after discharge
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2020 Child
and Adult Core Sets Measure Specifications
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Include paid, suspended, pending, and denied claims

Version of Specification: Adult Core Set Technical Specifications and Resource Manual for Federal Fiscal
Year 2020 Reporting, March 2020

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Metric #9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence
(FUA-AD)
Metric element
Measure
sets/endorsements

Description

Description
FFY 2020 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core
Set), based on HEDIS specifications
NQF #3488
Measure steward: NCQA
Percentage of emergency department (ED) visits for beneficiaries age 18 and older
with a primary diagnosis of alcohol or other drug (AOD) abuse dependence who
had a follow-up visit for AOD abuse or dependence. Two rates are reported:

•

Population of interest
Metric calculation
Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation categories
Relationship to other
metrics
Data source
Claim type
Note:

Percentage of ED visits for which the beneficiary received follow-up within
30 days of the ED visit (31 total days)
•
Percentage of ED visits for which the beneficiary received follow-up within
7 days of the ED visit (8 total days)
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2020
Child and Adult Core Sets Measure Specifications
Instructions for accessing HEDIS value sets are provided in Appendix C: How to
Use Supporting Measure Specifications, Value Sets, and Code Lists to
Calculate Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Include paid, suspended, pending, and denied claims

Version of Specification: Adult Core Set Technical Specifications and Resource Manual for Federal Fiscal
Year 2020 Reporting, March 2020

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Metric #10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
Metric element
Measure
sets/endorsements

Description

Description
FFY 2020 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core
Set), based on HEDIS specifications
NQF #3489
Measure steward: NCQA
Percentage of emergency department (ED) visits for beneficiaries age 18 and older
with a primary diagnosis of mental illness or intentional self-harm and who had a
follow-up visit for mental illness. Two rates are reported:

•

Population of interest
Metric calculation
Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Percentage of ED visits for mental illness for which the beneficiary received
follow-up within 30 days of the ED visit (31 total days)
•
Percentage of ED visits for mental illness for which the beneficiary received
follow-up within 7 days of the ED visit (8 days)
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2020 Child
and Adult Core Sets Measure Specifications
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Include paid, suspended, pending, and denied claims

Version of Specification: Adult Core Set Technical Specifications and Resource Manual for Federal Fiscal
Year 2020 Reporting, March 2020

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Metric #11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
Metric element
Measure
sets/endorsements
Description
Population of Interest

Numerator

Description
None
Number of suicide or overdose deaths among Medicaid beneficiaries with SMI or SED
within 7 and 30 days of discharge from an inpatient facility or residential stay for mental
health
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for at least one month (30 consecutive days) during the measurement period.
The SMI/SED demonstration population is defined as any beneficiary with an SMI/SED
diagnosis in the measurement period and/or in the 12 months before the measurement
period. Additional guidance on identifying the eligible population is provided in Chapter I.
Count of the number of suicide or overdose deaths among the population of interest
within 7 and 30 days of a mental health discharge date.
Step 1a. Identify claims with a place of service or UB Revenue code listed below:
Place of Service Codes:
•
51 –Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
•
From the 2016 HEDIS BH Stand Alone Acute Inpatient Value Set
•
From the 2016 HEDIS BH Acute Inpatient Value Set
•
From the 2016 HEDIS BH Nonacute Inpatient Value Set
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2016 BH Stand Alone Nonacute Inpatient Value Set
•
From the HEDIS 2020 Inpatient Stay Value Set
Step 1b. Identify claims with a primary mental health diagnosis from the HEDIS 2020
Mental Health Diagnosis Value Set.
Step 2. Among claims identified in Steps 1a and 1b, retain claims for residential or
inpatient treatment.
Step 3. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1 and 2.
Step 4. Using the beneficiaries from step 3, retain only inpatient or residential treatment
stays for mental health with discharge dates that fall within the measurement period.
Step 5. Using state data (e.g. medical examiner data or death records) identify
beneficiaries with the following ICD-10 codes for underlying cause of death in the
measurement period:
•
U03 (other means)
•
X40 – X44 (unintentional drug poisonings)
•
X60- X64 (suicidal drug poisonings)
•
X70 – X84 (intentional self-harm)
•
X85 (homicide drug poisoning)
•
Y10-Y19 (drug poisoning of undetermined intent)
•
Y20-Y34 (other events of undetermined intent)
•
Y87 (other means)
Step 6. Subtract the date of death from the death record from the discharge date for any
inpatient or residential treatment stay for mental health for the same beneficiary and
calculate the number of beneficiaries with a date of death within 7 and within 30 days of a
mental health stay discharge date.

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Metric #11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
Metric element
Additional guidance

Description
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
Data sources for suicide deaths may vary by state. For example, a state may have
access to a centralized state medical examiner system, whereas another state may have
decentralized systems containing death records. When suicide deaths occur, coroners
and medical examiners are instructed to record the cause of death on the death
certificate using ICD-10 codes. A state may also have more detailed information on cause
of death. If available, state-specific data sources may be used to identify suicide deaths.

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Use the discharge date to identify claims in the measurement period. Do not count
beneficiaries for an ongoing stay during the measurement period if the patient is not
discharged in that period. If a discharge date is not explicitly reported, identify all claims
associated with a single stay and use the latest end date of service on the claims. Use
one of the following approaches to combine claims for the same stay:
•
combine claims for the same beneficiary, provider, and admission date; or
•
If an admission date is not reported on all claims, then combine claims for the
same patient and provider that have less than a one day break between the end
date of the first claim and the start date of the next claim. For example, if the end
date of the first claim is December 18 and the start date of the next claim is
December 19, then combine the claims as a single stay. However, if the second
claim has a start date of December 20 or later, then do not combine the claims.
Year (CMS-constructed)
Other annual metrics
Age groups (required)
State-specific subpopulations
Beneficiaries counted in this metric are the same as those counted in Metric #12. Metric
#11 calculates a count, whereas Metric #12 expresses that count as a rate.
State data on cause of death
Not applicable

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
Metric element
Measure
sets/endorsements
Description
Population of
interest

Numerator

Denominator

Description
None
Rate of suicide or overdose deaths among Medicaid beneficiaries with SMI or SED within 7
and 30 days of discharge from an inpatient facility or residential stay for mental health
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for at least one month (30 consecutive days) during the measurement period. The
SMI/SED demonstration population is defined as any beneficiary with an SMI/SED
diagnosis in the measurement period and/or in the 12 months before the measurement
period. Additional guidance on identifying the eligible population is provided in Chapter I.
The number of suicide or overdose deaths among beneficiaries in the population of
interest.
Step 1. Use the beneficiaries identified in the Denominator. Retain only stays with
discharge dates that fall within the measurement period.
Step 2. Using state data (e.g. medical examiner data or death records) identify
beneficiaries with the following ICD-10 codes for underlying cause of death in the
measurement period:
•
U03 (other means)
•
X40 – X44 (unintentional drug poisonings)
•
X60- X64 (suicidal drug poisonings)
•
X70 – X84 (intentional self-harm)
•
X85 (homicide drug poisoning)
•
Y10-Y19 (drug poisoning of undetermined intent)
•
Y20-Y34 (other events of undetermined intent)
•
Y87 (other means)
Step 3. Subtract the date of death from the death record from the discharge date for any
inpatient or residential treatment stay for mental health for the same beneficiary and
calculate the number of beneficiaries with a date of death within 7 and within 30 days of a
mental health stay discharge date.
Step 1a. Identify claims for inpatient or residential stays using the place of service or UB
Revenue codes listed below:
Place of Service Codes:
•
51 – Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
•
From the 2016 HEDIS BH Stand Alone Acute Inpatient Value Set
•
From the 2016 HEDIS BH Acute Inpatient Value Set
•
From the 2016 HEDIS BH Nonacute Inpatient Value Set
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2016 BH Stand Alone Nonacute Inpatient Value Set
•
From the HEDIS 2020 Inpatient Stay Value Set
Step 1b. Identify claims with a primary mental health diagnosis from the HEDIS 2020
Mental Health Diagnosis Value Set.
Step 2. Among claims identified in Steps 1a and 2b, retain claims for residential or inpatient
treatment.
Step 3. Determine the total number of unique beneficiaries (de-duplicated) with claims that
meet the criteria in Steps 1 and 2.

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Metric #12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
Metric element

Description

Metric calculation

Calculate the rate of suicide or overdose deaths among Medicaid beneficiaries with SMI or
SED within 7 and 30 days of discharge from an inpatient facility or residential stay for
mental health by dividing the total number of beneficiaries in the numerator by the number
of beneficiaries in the denominator, as follows:
•
Rate for 7 days: Total number of beneficiaries with a date of death within 7 days of
a mental health stay discharge date / Total number of beneficiaries with a primary
mental health diagnosis and an inpatient or residential stay.
•
Rate for 30 days: Total number of beneficiaries with a date of death within 30 days
of a mental health stay discharge date / Total number of beneficiaries with a
primary mental health diagnosis and an inpatient or residential stay.

Additional guidance

Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate Metrics.
Data sources for suicide deaths may vary by state. For example, a state may have access
to a centralized state medical examiner system, whereas another state may have
decentralized systems containing death records. When suicide deaths occur, coroners and
medical examiners are instructed to record the cause of death on the death certificate using
ICD-10 codes. The state may also have more detailed information on cause of death. If
available, state-specific data sources may be used to identify suicide deaths.

Measurement
period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to
other metrics
Data source
Claim type
Note:

Use the discharge date to identify claims in the measurement period. Do not count
beneficiaries for an ongoing stay during the measurement period if the patient is not
discharged in that period. If a discharge date is not explicitly reported, identify all claims
associated with a single stay and use the latest end date of service on the claims. Use one
of the following approaches to combine claims for the same stay:
•
combine claims for the same beneficiary, provider and admission date; or
•
If an admission date is not reported on all claims, then combine claims for the
same patient and provider that have less than a one day break between the end
date of the first claim and the start date of the next claim. For example, if the end
date of the first claim is December 18 and the start date of the next claim is
December 19, then combine the claims as a single stay. However, if the second
claim has a start date of December 20 or later, then do not combine the claims.
Year (CMS-constructed)

Other annual metrics
Age groups (required)
State-specific subpopulations
Beneficiaries counted in this metric are the same as those counted in Metric #11. Metric
#11 calculates a count, whereas Metric #12 expresses that count as a rate.
State data on cause of death
Not applicable

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

33

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

MATHEMATICA

Metric #13: Mental Health Services Utilization - Inpatient
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Additional guidance

Description
None
Number of beneficiaries in the demonstration population who use inpatient services
related to mental health during the measurement period
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for any amount of time during the measurement period. The SMI/SED
demonstration population is defined as any beneficiary with an SMI/SED diagnosis in
the measurement period. Additional guidance on identifying the eligible population is
provided in Chapter I.
The total number of unique beneficiaries (de-duplicated total) who have a claim for
inpatient services related to mental health during the measurement period.
Step 1. Identify all acute and nonacute inpatient stay claims that have a revenue code
from the HEDIS 2020 Inpatient Stay Value Set and have a primary diagnosis code in
the HEDIS 2020 Mental Health Diagnosis Value Set on the discharge claim.
Step 2. Identify the discharge date for the stay.
Step 3. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1 and 2.
Instructions for identifying beneficiaries with the standardized definition of SMI can be
found in Appendix E: Standardized Definition of SMI.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
Use the discharge date to identify claims in the measurement period. Do not count
beneficiaries for an ongoing stay during the measurement period if the patient is not
discharged in that period. If a discharge date is not explicitly reported, identify all
claims associated with a single stay and use the latest end date of service on the
claims. Use one of the following approaches to combine claims for the same stay:
•
combine claims for the same beneficiary, provider and admission date; or
•
If an admission date is not reported on all claims, then combine claims for the
same patient and provider that have less than a one day break between the
end date of the first claim and the start date of the next claim. For example, if
the end date of the first claim is December 18 and the start date of the next
claim is December 19, then combine the claims as a single stay. However, if
the second claim has a start date of December 20 or later, then do not
combine the claims.
This measure is based on an NCQA HEDIS measure (MPT). Instructions for
calculating the HEDIS version of this measure are provided for reference in the full
measure specification (NCQA Measure Specifications_v2, Measure: Mental Health
Utilization [MPT]) in the 1115 SMI Monitoring Metrics Supporting Information v2.zip file
accompanying this manual and the Reference Materials section on PMDA.

Measurement period
(Metric type)

Month (CMS-constructed)

Reporting category
Subpopulation
categories

Other monthly and quarterly metrics
Standardized definition of SMI (required)
State-specific definition of SMI (required)
Age groups (required)
Dual-eligible status (required)
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring physical health conditions

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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Metric #13: Mental Health Services Utilization - Inpatient
Metric element
Subpopulation
categories (continued)
Relationship to other
metrics
Data source
Claim type
Note:

Description
State-specific subpopulations
The approach to identify mental health diagnoses in this metric also applies to Metrics
#14 - #19, #32 - #33, and #39 - #40. Beneficiaries identified for this metric are a
subset of the beneficiaries for Metric #18.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

35

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

MATHEMATICA

Metric #14: Mental Health Services Utilization – Intensive Outpatient and Partial Hospitalization
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Additional guidance

Description
None
Number of beneficiaries in the demonstration population who used intensive
outpatient and/or partial hospitalization services related to mental health during the
measurement period
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for any amount of time during the measurement period. The SMI/SED
demonstration population is defined as any beneficiary with an SMI/SED diagnosis in
the measurement period. Additional guidance on identifying the eligible population is
provided in Chapter I.
The total number of unique beneficiaries (de-duplicated total) who have a claim for
intensive outpatient and/or partial hospitalization services related to mental health
during the measurement period.
Step 1. Identify claims with a primary mental health diagnosis from the HEDIS 2020
Mental Health Diagnosis Value Set.
Step 2. Among claims identified in Step 1, retain claims with a code from any of the
following HEDIS 2020 Value Sets:
•
Partial Hospitalization or Intensive Outpatient
•
(MPT IOP/PH Group 1; Electroconvulsive Therapy; or Transcranial Magnetic
Stimulation) with a corresponding code in Partial Hospitalization POS
•
(MPT IOP/PH Group 1; Electroconvulsive Therapy; or Transcranial Magnetic
Stimulation) with a corresponding code in Community Mental Health Center
POS
­ The state should ensure that the visit was in an intensive outpatient or
partial hospitalization setting (the community mental health POS code
can be used in settings other than intensive outpatient and partial
hospitalizations)
•
MPT IOP/PH Group 2 with a corresponding code in Partial Hospitalization
POS
­ The state should ensure that the visit was billed by a mental health
practitioner using the Mental Health Practitioner Value Set
•
MPT IOP/PH Group 2 with a corresponding code in Community Mental
Health Center POS
­ The state should ensure that the visit was in an intensive outpatient or
partial hospitalization setting (the community mental health center POS
code can be used in settings other than intensive outpatient and partial
hospitalizations)
­ The state should ensure that the visit was billed by a mental health
practitioner using the Mental Health Practitioner Value Set
Step 3. Exclude any claims from Step 2 with a code in the Telehealth Modifier or
Telehealth POS value sets.
Step 4. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1, 2, and 3.
Instructions for identifying beneficiaries with the standardized definition of SMI can be
found in Appendix E: Standardized Definition of SMI.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
This measure is based on an NCQA HEDIS measure (MPT). Instructions for
calculating the HEDIS version of this measure are for reference provided in the full
measure specification (NCQA Measure Specifications_v2, Measure: Mental Health
Utilization [MPT]) in the 1115 SMI Monitoring Metrics Supporting Information v2.zip file
accompanying this manual, and the Reference Materials section on PMDA.

36

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

MATHEMATICA

Metric #14: Mental Health Services Utilization – Intensive Outpatient and Partial Hospitalization
Metric element
Measurement period
(Metric type)
Reporting category
Subpopulation categories

Relationship to other
metrics
Data source
Claim type
Note:

Description
Month (CMS-constructed)
Other monthly and quarterly metrics
Standardized definition of SMI (required)
State-specific definition of SMI (required)
Age groups (required)
Dual-eligible status (required)
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring or physical health condition
State-specific subpopulations
The approach to identify mental health diagnoses in this metric also applies to Metrics
#13 - #19, #32 - #33, and #39 - #40. Beneficiaries identified for this metric are a
subset of the beneficiaries for Metric #18.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

37

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

MATHEMATICA

Metric #15: Mental Health Services Utilization - Outpatient
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Additional guidance

Description
None
Number of beneficiaries in the demonstration population who used outpatient services
related to mental health during the measurement period
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for any amount of time during the measurement period. The SMI/SED
demonstration population is defined as any beneficiary with an SMI/SED diagnosis in
the measurement period. Additional guidance on identifying the eligible population is
provided in Chapter I.
The number of unique beneficiaries (de-duplicated total) with an outpatient service
related to mental health during the measurement period.
Step 1. Identify claims with a primary mental health diagnosis from the HEDIS 2020
Mental Health Diagnosis Value Set.
Step 2. Among claims identified in Step 1, retain claims with a code from any of the
following HEDIS 2020 Value Sets:
•
MPT Stand Alone Outpatient Group 1
•
MPT Stand Alone Outpatient Group 2
­ The state should ensure the visit was billed by a mental health
practitioner using the Mental Health Practitioner Value Set
•
Observation
­ The state should ensure the visit was billed by a mental health
practitioner using the Mental Health Practitioner Value Set
•
(Visit Setting Unspecified; Electroconvulsive Therapy; or Transcranial
Magnetic Stimulation) with a corresponding code from Outpatient POS
•
(Visit Setting Unspecified; Electroconvulsive Therapy; or Transcranial
Magnetic Stimulation) with a corresponding code from Community Mental
Health Center POS
­ The state should ensure that the visit was in an outpatient setting (this
POS code can be used in settings other than outpatient)
•
(Electroconvulsive Therapy; or Transcranial Magnetic Stimulation) with a
corresponding code from Ambulatory Surgical Center POS
Step 3. Exclude any claims from Step 2 with a code in the Inpatient Stay, Telehealth
Modifier, or Telehealth POS value sets.
Step 4. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1, 2, and 3.
Instructions for identifying beneficiaries with the standardized definition of SMI can be
found in Appendix E: Standardized Definition of SMI.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.

Measurement period
(Metric type)
Reporting category

This measure is based on an NCQA HEDIS measure (MPT). Instructions for
calculating the HEDIS version of this measure are provided for reference in the full
measure specification (NCQA Measure Specifications_v2, Measure: Mental Health
Utilization [MPT]) in the 1115 SMI Monitoring Metrics Supporting Information v2.zip file
accompanying this manual, and the Reference Materials section on PMDA.
Month (CMS-constructed)
Other monthly and quarterly metrics

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

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Metric #15: Mental Health Services Utilization - Outpatient
Metric element
Subpopulation
categories

Relationship to other
metrics
Data source
Claim type
Note:

Description
Standardized definition of SMI (required)
State-specific definition of SMI (required)
Age groups (required)
Dual-eligible status (required)
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring physical health conditions
State-specific subpopulations
The approach to identify mental health diagnoses in this metric also applies to Metrics
#13 - #19, #32 - #33, and #39 - #40. Beneficiaries identified for this metric are a subset
of the beneficiaries for Metric #18.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

39

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Metric #16: Mental Health Services Utilization - ED
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Additional guidance

Description
None
Number of beneficiaries in the demonstration population who use emergency department
services for mental health during the measurement period
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for any amount of time during the measurement period. The SMI/SED
demonstration population is defined as any beneficiary with an SMI/SED diagnosis in the
measurement period. Additional guidance on identifying the eligible population is
provided in Chapter I.
The total number of unique beneficiaries (de-duplicated total) who have a claim for
emergency services for mental health during the measurement period.
Step 1. Identify claims with a primary mental health diagnosis from the HEDIS 2020
Mental Health Diagnosis Value Set.
Step 2. Among claims identified in Step 1, retain claims with a code from any of the
following HEDIS 2020 Value Sets:
•
ED
­ The state should ensure the visit was billed by a mental health practitioner
using the Mental Health Practitioner Value Set
•
Visit Setting Unspecified with a corresponding code from ED POS
•
Visit Setting Unspecified with a corresponding code from Community Mental
Health Center POS
­ The state should ensure that the visit was in an ED setting (this POS code
can be used in settings other than the ED)
Step 3. Exclude any claims from Step 2 with a code in the Inpatient Stay, Telehealth
Modifier, or Telehealth POS value sets.
Step 4. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1, 2, and 3.
Instructions for identifying beneficiaries with the standardized definition of SMI can be
found in Appendix E: Standardized Definition of SMI.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.

Measurement period
(Metric type)
Reporting category
Subpopulation
categories

This measure is based on an NCQA HEDIS measure (MPT). Instructions for calculating
the HEDIS version of this measure are provided for reference in the full measure
specification (NCQA Measure Specifications_v2, Measure: Mental Health Utilization
[MPT]) in the 1115 SMI Monitoring Metrics Supporting Information v2.zip file
accompanying this manual, and the Reference Materials section on PMDA.
Month (CMS-constructed)
Other monthly and quarterly metrics
Standardized definition of SMI (required)
State-specific definition of SMI (required)
Age groups (required)
Dual-eligible status (required)
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring physical health conditions
State-specific subpopulations

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Metric #16: Mental Health Services Utilization - ED
Metric element
Relationship to other
metrics
Data source
Claim type
Note:

Description
The approach to identify mental health diagnoses in this metric also applies to Metrics
#13 - #19, #32 - #33, and #39 - #40. Beneficiaries identified for this metric are a subset
of the beneficiaries for Metric #18.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #17: Mental Health Services Utilization - Telehealth
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Description
None
Number of beneficiaries in the demonstration population who used telehealth services
related to mental health during the measurement period
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for any amount of time during the measurement period. The SMI/SED
demonstration population is defined as any beneficiary with an SMI/SED diagnosis in the
measurement period. Additional guidance on identifying the eligible population is
provided in Chapter I.
The number of unique beneficiaries (de-duplicated total) in the demonstration population
with a service claim for telehealth services related to mental health during the
measurement period.
Step 1. Identify claims with a primary mental health diagnosis from the HEDIS 2020
Mental Health Diagnosis Value Set.
Step 2. Among claims identified in Step 1, retain claims with a code from any of the
following HEDIS 2020 Value Sets or another online assessment CPT code:
HEDIS 2020 Value Sets
•
Telephone Visits
•
Online Assessments
•
Visit Setting Unspecified with a corresponding code from (Telehealth Modifier or
Telehealth POS)
•
MPT IOP/PH Group 1 with a corresponding code from (Telehealth Modifier or
Telehealth POS)
•
MPT IOP/PH Group 2 with a corresponding code from (Telehealth Modifier or
Telehealth POS)
The state should ensure the visit was billed by a mental health practitioner
using the Mental Health Practitioner Value Set
Online assessment CPT codes:
•
•
•
•
•
•

98970: Qualified nonphysician health care professional online digital evaluation
and management service, for an established patient, for up to 7 days,
cumulative time during the 7 days; 5-10 minutes
98971: 11—20 minutes
98972: 21 or more minutes
99421: Online digital evaluation and management service, for an established
patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes
99422: 11—20 minutes
99423: 21 or more minutes

Step 3. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1 and 2.
Additional guidance

Instructions for identifying beneficiaries with the standardized definition of SMI can be
found in Appendix E: Standardized Definition of SMI.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.

Measurement period
(Metric type)

This measure is based on an NCQA HEDIS measure (MPT). Instructions for calculating
the HEDIS version of this measure are provided for reference in the full measure
specification (NCQA Measure Specifications_v2, Measure: Mental Health Utilization
[MPT]) in the 1115 SMI Monitoring Metrics Supporting Information v2.zip file
accompanying this manual, and the Reference Materials section on PMDA.
Month (CMS-constructed)

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Metric #17: Mental Health Services Utilization - Telehealth
Metric element
Reporting category
Subpopulation
categories

Description

Data source

Other monthly and quarterly metrics
Standardized definition of SMI (required)
State-specific definition of SMI (required)
Age groups (required)
Dual-eligible status (required)
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring physical health conditions
State-specific subpopulations
The approach to identify mental health diagnoses in this metric also applies to Metrics
#13 - #19, #32 - #33, and #39 - #40. Beneficiaries identified for this metric are a subset
of the beneficiaries for Metric #18.
Claims

Claim type

Only use paid claims. (Do not use suspended, pending, or denied claims.)

Relationship to other
metrics

Note:

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #18: Mental Health Services Utilization - Any Services
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Description
None
Number of beneficiaries in the demonstration population who used any services related
to mental health during the measurement period
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for any amount of time during the measurement period. The SMI/SED
demonstration population is defined as any beneficiary with an SMI/SED diagnosis in the
measurement period. Additional guidance on identifying the eligible population is
provided in Chapter I.
The number of unique beneficiaries (de-duplicated total) with a service claim for any
services related to mental health during the measurement period.
Step 1. Identify claims with a primary mental health diagnosis from the HEDIS 2020
Mental Health Diagnosis Value Set.
Step 2. Among claims identified in Step 1, retain claims with a code from any of the
following HEDIS 2020 Value Sets or another online assessment CPT code:
HEDIS 2020 Value Sets
•
•
•

•

•

•

•

•
•

•

•

Inpatient Stay
Partial Hospitalization or Intensive Outpatient
MPT IOP/PH Group 1 with a corresponding code from Partial Hospitalization
POS or Community Mental Health Center POS
­ The state should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
Electroconvulsive Therapy with a corresponding code from Partial
Hospitalization POS or Community Mental Health Center POS
­ The state should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
Transcranial Magnetic Stimulation with a corresponding code from Partial
Hospitalization POS or Community Mental Health Center POS
­ The state should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
MPT IOP/PH Group 2 with a corresponding code from Partial Hospitalization
POS
­ The state should ensure that the visit was billed by a mental health
practitioner using the Mental Health Practitioner
MPT IOP/PH Group 2 with a corresponding code from Community Mental
Health Center POS
­ The state should ensure that the visit was in an intensive outpatient or
partial hospitalization setting
­ The state should ensure that the visit was billed by a mental health
practitioner using the Mental Health Practitioner
MPT Stand Alone Outpatient Group 1
MPT Stand Alone Outpatient Group 2
­ The state should ensure the visit was billed by a mental health practitioner
using the Mental Health Practitioner
Observation
­ The state should ensure the visit was billed by a mental health practitioner
using the Mental Health Practitioner
Visit Setting Unspecified with a corresponding code from Outpatient POS or ED
POS or (Telehealth Modifier or Telehealth POS)

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Metric #18: Mental Health Services Utilization - Any Services
Metric element
Numerator (continued)

Description
•
•
•

•

•

•
•
•

•
•

Electroconvulsive Therapy with a corresponding code from Outpatient POS or
Ambulatory Surgical Center POS
Transcranial Magnetic Stimulation with a corresponding code from Outpatient
POS or Ambulatory Surgical Center POS
Visit Setting Unspecified with a corresponding code from Community Mental
Health Center POS
­ The state should ensure that the visit was in an outpatient setting or where
the organization can confirm that the visit was in an ED setting
Electroconvulsive Therapy with a corresponding code from Community Mental
Health Center POS
­ The state should ensure that the visit was in an outpatient setting
Transcranial Magnetic Stimulation with a corresponding code from Community
Mental Health Center POS
­ The state should ensure that the visit was in an outpatient setting
ED Value Set
MPT IOP/PH Group 1 with a corresponding code from (Telehealth Modifier or
Telehealth POS)
MPT IOP/PH Group 2 with a corresponding code from (Telehealth Modifier or
Telehealth POS)
­ The state should ensure the visit was billed by a mental health practitioner
using the Mental Health Practitioner
Telephone Visits
Online Assessments

Online assessment CPT codes:
•
•
•
•
•
•

98970: Qualified nonphysician health care professional online digital evaluation
and management service, for an established patient, for up to 7 days,
cumulative time during the 7 days; 5-10 minutes
98971: 11—20 minutes
98972: 21 or more minutes
99421: Online digital evaluation and management service, for an established
patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes
99422: 11—20 minutes
99423: 21 or more minutes

Step 3. Determine the total number of unique beneficiaries (de-duplicated) with claims
that meet the criteria in Steps 1 and 2.
Additional guidance

Instructions for identifying beneficiaries with the standardized definition of SMI can be
found in Appendix E: Standardized Definition of SMI.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.

Measurement period
(Metric type)
Reporting category

This measure is based on an NCQA HEDIS measure (MPT). Instructions for calculating
the HEDIS version of this measure are provided for reference in the full measure
specification (NCQA Measure Specifications_v2, Measure: Mental Health Utilization
[MPT]) in the 1115 SMI Monitoring Metrics Supporting Information v2.zip file
accompanying this manual, and the Reference Materials section on PMDA.
Month (CMS-constructed)
Other monthly and quarterly metrics

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Metric #18: Mental Health Services Utilization - Any Services
Metric element
Subpopulation
categories

Relationship to other
metrics
Data source
Claim type
Note:

Description
Standardized definition of SMI (required)
State-specific definition of SMI (required)
Age groups (required)
Dual-eligible status (required)
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring physical health conditions
State-specific subpopulations
The approach to identify mental health diagnoses in this metric also applies to Metrics
#13 - #19, #32 - #33, and #39 - #40. Beneficiaries identified for this metric are a deduplicated combination of the beneficiaries from Metrics #13-17.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.

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Metric #19a: Average Length of Stay in IMDs
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Denominator

Description
None
Average length of stay (ALOS) for beneficiaries in the demonstration discharged from
an inpatient or residential stay in an IMD
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for at least one month (30 consecutive days) during the measurement
period. The SMI/SED demonstration population is defined as any beneficiary with an
SMI/SED diagnosis in the measurement period and/or in the 12 months before the
measurement period. Additional guidance on identifying the eligible population is
provided in Chapter I.
CMS will ask the state to report three rates for this metric:
1. ALOS for all IMDs and populations
2. ALOS among short-term stays (less than or equal to 60 days)
3. ALOS among long-term stays (greater than 60 days)
For each rate (total population, short-term, and long-term stays):
Step 1. Determine length of stay for each discharge identified in the denominator.
Length of stay is calculated based on the number of days between a beneficiary’s
admission date and discharge date from an IMD. A beneficiary admitted and
discharged on the same day is treated as a one-day stay.
If a claim does not have a discharge date explicitly reported, the latest end date of
service on a claim for the stay should be used as the discharge date. Only include
stays for a given measurement period if the reported discharge date or proxy
discharge date falls within the measurement period. Days should be counted as part of
the length of the stay even if they are prior to the measurement period. If an admission
date is not reported on the claim with the discharge date, look back 12 months from
the beginning of the measurement period to identify claims associated with the same
stay. If no admission date is reported on any of these claims, use the earliest date of
service as the admission date.
Step 2. Sum the total number of days in an IMD by summing the lengths of stay from
the denominator.
Separately for short-term, long-term, and all stays, identify the total number of inpatient
and residential discharges from an IMD for mental health treatment.
Step 1. Identify qualifying IMD discharges during the measurement period. This
method may be specific to each state; a state may a maintain centralized database of
IMD stays. Alternatively, a state may be able to identify IMD stays in T-MSIS data or
through other methods.
Step 1a. Identify claims for inpatient or residential stays using the place of service or
UB Revenue codes listed below:
Place of Service Codes:
•
51 – Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
HCPCS Codes:
•
H0017 – Behavioral health; residential
•
H0018 – Behavioral health; short-term residential
•
H0019 – Behavioral health; long-term residential
•
T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2020 Inpatient Stay Value Set
Step 1b. Among the claims identified in Step 1a, retain claims with a primary mental
health diagnosis from the HEDIS 2020 Mental Health Diagnosis Value Set.

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Metric #19a: Average Length of Stay in IMDs
Metric element
Denominator (continued)

Metric calculation

Additional guidance

Description
Step 2. Among claims identified in Step 1 (1a and 1b), retain claims for residential or
inpatient treatment in an IMD. (See the additional guidance section for a definition of
IMDs).
Step 3. De-duplicate and sum the discharges from Step 2 to identify the total number
of discharges from an IMD for beneficiaries with a mental health diagnosis.
Step 4. Stratify IMD discharges during the measurement period into short-term, longterm, and all stays.
For each rate, calculate the mean length of stay by dividing the total number of days in
an IMD for all discharges in the numerator by the number of discharges in the
denominator, as follows:
Total number of days in an IMD / Number of discharges
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
Use the discharge date to identify claims in the measurement period for residential
and inpatient services. Do not count beneficiaries for an ongoing stay during the
measurement period if the patient is not discharged in that period. If a discharge date
is not explicitly reported, identify all claims associated with a single stay and use the
latest end date of service on the claims. Use one of the following approaches to
combine claims for the same stay:
•
Combine claims for the same beneficiary, provider and admission date; or
•
If an admission date is not reported on all claims, combine claims for the
same patient and provider that have less than a one day break between the
end date of the first claim and the start date of the next claim. For example, if
the end date of the first claim is December 18 and the start date of the next
claim is December 19, then combine the claims as a single stay. However, if
the second claim has a start date of December 20 or later, then do not
combine the claims.
An IMD is defined as a hospital, nursing facility, or other institution that has more than
16 beds and is primarily engaged in providing diagnosis, treatment, or care for people
with mental diseases.
A state may have a published list of IMDs in which the designation is made by the
state. If available, the state can use that list to identify facilities; obtain the associated
billing provider IDs and identify claims in Steps 1a or 1b associated with those provider
IDs. Otherwise, refer to the State Medicaid Manual for additional regulatory guidance.
Per the guidance in Section 4390 of the State Medicaid Manual, the following five
criteria should be used to evaluate whether the overall character of a facility is that of
an IMD:
1. The facility is licensed as a psychiatric facility.
2. The facility is accredited as a psychiatric facility.
3. The facility is under the jurisdiction of the state’s mental health authority.
(This criterion does not apply to facilities under the state’s mental health
authority that are not providing services to mentally ill persons.).
4. The facility specializes in providing psychiatric/psychological care and
treatment. This may be ascertained through review of patients’ records. It
may also be indicated by the fact that an unusually large proportion of the
staff has specialized psychiatric/psychological training or that a large
proportion of the patients are receiving psychopharmacological drugs.
5. The current need for institutionalization for more than 50 percent of all the
patients in the facility results from mental diseases.
­ When applying the 50 percent guideline determine whether each patient’s
current need for institutionalization results from a mental disease. It is not
necessary to determine whether any mental health care is being provided in
applying this guideline.

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Metric #19a: Average Length of Stay in IMDs
Metric element
Additional guidance
(continued)
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
If more than 50 percent of the patients are residing in the institution because
of implications of mental health or substance use diagnoses, then the facility
may be determined to be an IMD.
Year (CMS-constructed)
­

Other annual metrics
State-specific subpopulations
The definition of an IMD should be the same in Metrics #19a, #19b and #20. The
approach to identify mental health diagnoses in this metric also applies to Metrics #13
- #19, #32 - #33, and #39 - #40. The group of IMDs in Metric #19b is a subgroup of
this metric.
Claims
State-specific IMD database
If using claims, only use paid claims. (Do not use suspended, pending, or denied
claims.)

A state may be asked to provide CMS with the standard deviation based on the mean calculated in this
metric as part of the midpoint assessment. For details, see Appendix F: Average Length of Stay (ALOS)
Standard Deviations.
The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #19b: Average Length of Stay in IMDs (IMDs receiving FFP only)
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Denominator

Description
None
Average length of stay (ALOS) for beneficiaries with SMI discharged from an inpatient
or residential stay in an IMD receiving federal financial participation (FFP)
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for at least one month (30 consecutive days) during the measurement
period. The SMI/SED demonstration population is defined as any beneficiary with an
SMI/SED diagnosis in the measurement period and/or in the 12 months before the
measurement period. Additional guidance on identifying the eligible population is
provided in Chapter I.
CMS will ask the state to report three rates for this metric:
1. ALOS for all IMDs and populations
2. ALOS among short-term stays (less than or equal to 60 days)
3. ALOS among long-term stays (greater than 60 days)
For each rate (total population, short-term, and long-term stays):
Step 1. Determine length of stay for each discharge identified in the denominator.
Length of stay is calculated based on the number of days between a beneficiary’s
admission date and discharge date from an IMD receiving FFP. A beneficiary admitted
and discharged on the same day is treated as a one-day stay.
If a claim does not have a discharge date explicitly reported, the latest end date of
service on a claim for the stay should be used as the discharge date. Only include
stays for a given measurement period if the reported discharge date or proxy
discharge date falls within the measurement period. Days should be counted as part of
the length of the stay even if they are prior to the measurement period. If an admission
date is not reported on the claim with the discharge date, look back 12 months from
the beginning of the measurement period to identify claims associated with the same
stay. If no admission date is reported on any of these claims, use the earliest date of
service as the admission date.
Step 2. Sum the total number of days in an IMD receiving FFP by summing the lengths
of stay from the denominator.
Separately for short-term, long-term and all stays, identify the total number of inpatient
and residential discharges from an IMD for mental health treatment. Limit to IMDs
receiving FFP.
Step 1. Identify qualifying IMD discharges for inpatient or residential treatment for
mental health during the measurement period. This method may be specific to each
state; a state may maintain a centralized database of IMD stays. Alternatively, a state
may be able to identify IMD stays in T-MSIS data or through other methods.
Step 1a. Identify claims for inpatient or residential stays using the place of service or
UB Revenue codes listed below:
Place of Service Codes:
•
51 – Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
HCPCS Codes:
•
H0017 – Behavioral health; residential
•
H0018 – Behavioral health; short-term residential
•
H0019 – Behavioral health; long-term residential
•
T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2020 Inpatient Stay Value Set
Step 1b. Among the claims identified in Step 1a, retain claims with a primary mental
health diagnosis from the HEDIS 2020 Mental Health Diagnosis Value Set.

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Metric #19b: Average Length of Stay in IMDs (IMDs receiving FFP only)
Metric element
Denominator (continued)

Metric calculation

Additional guidance

Description
Step 2. Among claims identified in Step 1 (1a and 1b), retain claims for residential or
inpatient treatment in an IMD. (See the additional guidance section for a definition of
IMDs).
Step 3. Limit the claims identified in Step 2 to claims for treatment in IMDs receiving
federal financial participation. De-duplicate and sum the discharges from Step 2 to
identify the total number of discharges from an IMD for beneficiaries with a mental
health diagnosis.
Step 4. Stratify IMD discharges during the measurement period into short-term, longterm, and all stays.
For each rate, calculate the mean length of stay by dividing the total number of days in
an IMD for all discharges in the numerator by the number of discharges in the
denominator, as follows:
Total number of days in an IMD / Number of discharges
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
Use the discharge date to identify claims in the measurement period for residential and
inpatient services. Do not count beneficiaries for an ongoing stay during the
measurement period if the patient is not discharged in that period. If a discharge date
is not explicitly reported, identify all claims associated with a single stay and use the
latest end date of service on the claims. Use one of the following approaches to
combine claims for the same stay:
•
Combine claims for the same beneficiary, provider and admission date; or
•
If an admission date is not reported on all claims, combine claims for the
same patient and provider that have less than a one day break between the
end date of the first claim and the start date of the next claim. For example, if
the end date of the first claim is December 18 and the start date of the next
claim is December 19, then combine the claims as a single stay. However, if
the second claim has a start date of December 20 or later, then do not
combine the claims.
An IMD is defined as a hospital, nursing facility, or other institution that has more than
16 beds and is primarily engaged in providing diagnosis, treatment, or care for people
with mental diseases. The state should limit to IMDs receiving federal financial
participation (FFP).
A state may have a published list of IMDs in which the designation is made by the
state. If available, a state can use that list to identify facilities; obtain the associated
billing provider IDs and identify claims in Steps 1a or 1b associated with those provider
IDs. Otherwise, refer to the State Medicaid Manual for additional regulatory guidance.

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Metric #19b: Average Length of Stay in IMDs (IMDs receiving FFP only)
Metric element
Additional guidance
(continued)

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
Per the guidance in Section 4390 of the State Medicaid Manual, the following five
criteria should be used to evaluate whether the overall character of a facility is that of
an IMD:
1. The facility is licensed as a psychiatric facility.
2. The facility is accredited as a psychiatric facility.
3. The facility is under the jurisdiction of the state’s mental health authority.
(This criterion does not apply to facilities under the state’s mental health
authority that are not providing services to mentally ill persons.).
4. The facility specializes in providing psychiatric/psychological care and
treatment. This may be ascertained through review of patients’ records. It
may also be indicated by the fact that an unusually large proportion of the
staff has specialized psychiatric/psychological training or that a large
proportion of the patients are receiving psychopharmacological drugs.
5. The current need for institutionalization for more than 50 percent of all the
patients in the facility results from mental diseases.
When applying the 50 percent guideline determine whether each patient’s current
need for institutionalization results from a mental disease. It is not necessary to
determine whether any mental health care is being provided in applying this guideline.
If more than 50 percent of the patients are residing in the institution because of
implications of mental health or substance use diagnoses, then the facility may be
determined to be an IMD.
Year (CMS-constructed)
Other annual metrics
State-specific subpopulations
The definition of an IMD should be the same in Metrics #19a, #19b, and #20. The
approach to identify mental health diagnoses in this metric also applies to Metrics #13
- #19, #32 - #33, and #39 - #40. The IMDs included in Metric #19b are a subset of the
IMDs in Metric #19a.
Claims
State-specific IMD database
If using claims, only use paid claims. (Do not use suspended, pending, or denied
claims.)

A state may be asked to provide CMS with the standard deviation based on the mean calculated in this
metric as part of the midpoint assessment. For details, see Appendix F: Average Length of Stay (ALOS)
Standard Deviations.
The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #20: Beneficiaries With SMI/SED Treated in an IMD for Mental Health
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Additional guidance

Description
None
Number of beneficiaries in the demonstration population who have a claim for
inpatient or residential treatment for mental health in an IMD during the reporting
year
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled
in Medicaid for at least one month (30 consecutive days) during the measurement
period. The SMI/SED demonstration population is defined as any beneficiary with
an SMI/SED diagnosis in the measurement period and/or in the 12 months before
the measurement period. Additional guidance on identifying the eligible population
is provided in Chapter I.
The number of unique beneficiaries (de-duplicated total) enrolled in the
measurement period who have a service claim with a mental health diagnosis and
who received inpatient/residential treatment in an IMD within the measurement
period.
Step 1. Identify qualifying IMD discharges for inpatient or residential treatment for
mental health during the measurement period. This method may be specific to each
state; a state may maintain centralized databases of IMD stays. Alternatively, a
state may be able to identify IMD stays in T-MSIS data or through other methods.
Only include IMDs receiving Federal Financial Participation under the
demonstration.
Step 1a. Identify claims with a place of service, HCPCS, or UB Revenue code
listed below:
Place of Service Codes:
•
51 – Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
HCPCS Codes:
•
H0017 – Behavioral health; residential
•
H0018 – Behavioral health; short-term residential
•
H0019 – Behavioral health; long-term residential
•
T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
HEDIS 2020 Inpatient Stay Value Set
Step 1b. Among the claims identified in Step 1a, retain claims with a primary
mental health diagnosis from the HEDIS 2020 Mental Health Diagnosis Value Set.
Step 2. Among the claims identified in Step 1 (1a and 1b), retain claims for
inpatient/residential treatment in an IMD. (See the additional guidance section for a
definition of IMDs.) Only include IMDs receiving Federal Financial Participation
under the demonstration.
Step 3. Determine the total number of unique beneficiaries (de-duplicated) with
claims that meet the criteria in Steps 1 and 2.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to
Use Supporting Measure Specifications, Value Sets, and Code Lists to
Calculate Metrics.
An IMD is defined as a hospital, nursing facility, or other institution that has more
than 16 beds and is primarily engaged in providing diagnosis, treatment, or care for
people with mental diseases. Only include IMDs receiving Federal Financial
Participation under the demonstration.
A state may have a published list of IMDs in which the designation is made by the
state. If available, use that list to identify facilities; obtain the associated billing
provider IDs, and identify claims in Steps 1a or 1b associated with those provider
IDs. Otherwise, refer to the State Medicaid Manual for additional regulatory
guidance.

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Metric #20: Beneficiaries With SMI/SED Treated in an IMD for Mental Health
Metric element
Additional guidance
(continued)

Measurement period
Reporting category
Subpopulation categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
Per the guidance in Section 4390 of the State Medicaid Manual, the following five
criteria should be used to evaluate whether the overall character of a facility is that
of an IMD:
1. The facility is licensed as a psychiatric facility.
2. The facility is accredited as a psychiatric facility.
3. The facility is under the jurisdiction of the state’s mental health authority.
(This criterion does not apply to facilities under the state’s mental health
authority that are not providing services to mentally ill persons.).
4. The facility specializes in providing psychiatric/psychological care and
treatment. This may be ascertained through review of patients’ records. It
may also be indicated by the fact that an unusually large proportion of the
staff has specialized psychiatric/psychological training or that a large
proportion of the patients are receiving psychopharmacological drugs.
5. The current need for institutionalization for more than 50 percent of all the
patients in the facility results from mental diseases.
a. When applying the 50 percent guideline determine whether each
patient’s current need for institutionalization results from a mental
disease. It is not necessary to determine whether any mental health
care is being provided in applying this guideline.
b. If more than 50 percent of the patients are residing in the institution
because of implications of mental health or substance use diagnoses,
then the facility may be determined to be an IMD.
Year (CMS-constructed)
Other annual metrics
State-specific subpopulations
The definition of an IMD should be the same in Metrics #19a, #19b and #20. The
approach to identify mental health diagnoses in this metric also applies to Metrics
#13 - #19, #32 - #33, and #39 - #40. The IMDs included in Metric #19b are the
same IMDs in Metric #20.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.

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Metric #21: Count of Beneficiaries With SMI/SED (monthly)
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Additional guidance

Measurement period
(Metric Type)
Reporting Category
Subpopulation categories

Relationship to other
metrics
Data source
Claim type
Note:

Description
None
Number of beneficiaries in the demonstration population during the measurement
period and/or in the 11 months before the measurement period
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled
in Medicaid for any amount of time during the measurement period. The SMI/SED
demonstration population is defined as any beneficiary with an SMI/SED diagnosis
in the measurement period. Additional guidance on identifying the eligible population
is provided in Chapter I.
Count the number of unique beneficiaries (de-duplicated total) enrolled in the
measurement period who have SMI/SED-related treatment during the measurement
period and/or in the 11 months before the measurement period as determined by a
qualifying facility or provider claims
Instructions for identifying beneficiaries with the standardized definition of SMI can
be found in Appendix E: Standardized Definition of SMI.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to
use Supporting Measure Specifications, Value Sets, and Code Lists to
Calculate Metrics.
Month (CMS-constructed)
Other monthly and quarterly metrics
Standardized definition of SMI (required)
State-specific definition of SMI (required)
Age groups (required)
Dual-eligible status (required)
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring physical health conditions
State-specific subpopulations
The approach to identify SMI/SED beneficiaries also applies to Metric #22, which is
an annual count
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #22: Count of Beneficiaries With SMI/SED (annually)
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Additional guidance

Measurement period
(Metric Type)
Reporting category
Subpopulation
categories

Relationship to other
metrics
Data source
Claim type
Note:

Description
None
Number of beneficiaries in the demonstration population during the measurement
period and/or in the 12 months before the measurement period
All beneficiaries in the SMI/SED demonstration population with full benefits enrolled in
Medicaid for at least one month (30 consecutive days) during the measurement
period. The SMI/SED demonstration population is defined as any beneficiary with an
SMI/SED diagnosis in the measurement period and/or in the 12 months before the
measurement period. Additional guidance on identifying the eligible population is
provided in Chapter I.
Count the number of unique beneficiaries (de-duplicated total) enrolled in the
measurement period who have SMI/SED-related treatment during the measurement
period and/or in the 12 months before the measurement period as determined by a
qualifying facility or provider claims
Instructions for identifying beneficiaries with the standardized definition of SMI can be
found in Appendix E: Standardized Definition of SMI.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
Year (CMS-constructed)
Other annual metrics
Standardized definition of SMI (required)
State-specific definition of SMI (required)
Age groups (required)
Dual-eligible status (required)
Eligible for Medicaid on the basis of disability
Criminal justice status
Co-occurring SUD
Co-occurring physical health conditions
State-specific subpopulations
The approach to identify SMI/SED beneficiaries also applies to Metric #21, which is a
monthly count
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
Metric element
Measure
sets/endorsements

Description
Population of interest
Metric calculation
Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Notes:

Description
FFY 2020 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core
Set)
NQF #2607
Measure steward: NCQA
Percentage of beneficiaries ages 18 to 75 with a serious mental illness and diabetes
(type 1 and type 2) whose most recent Hemoglobin A1c (HbA1c) level during the
measurement year is >9.0%
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2020 Child
and Adult Core Sets Measure Specifications
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims, Medical Records
Include paid, suspended, pending, and denied claims

Version of Specification: Adult Core Set Technical Specifications and Resource Manual for Federal Fiscal
Year 2020 Reporting, March 2020

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Metric #24: Screening for Depression and Follow-up Plan: Age 18 and Older (CDF-AD)
Metric element
Measure
sets/endorsements

Description
Population of interest
Metric calculation
Additional guidance

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
FFY 2020 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core
Set)
NQF #0418/0418e
Measure steward: CMS
Percentage of beneficiaries age 18 and older screened for depression on the date of
the encounter using an age appropriate standardized depression screening tool, and if
positive, a follow-up plan is documented on the date of the positive screen
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2020 Child
and Adult Core Sets Measure Specifications
Instructions for accessing HEDIS value sets are provided in Appendix C: How to use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims or electronic medical records
Include paid, suspended, pending, and denied claims

Version of Specification: Adult Core Set Technical Specifications and Resource Manual for Federal Fiscal
Year 2020 Reporting, March 2020

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Metric #25: Screening for Depression and Follow-up Plan: Ages 12–17 (CDF-CH)`
Metric element
Measure
sets/endorsements

Description
Population of interest
Metric calculation
Additional guidance

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
FFY 2020 Core Set of Child Health Care Quality Measures for Medicaid (Child Core
Set)
NQF #0418/0418e
Measure steward: CMS
Percentage of beneficiaries ages 12 to 17 screened for depression on the date of the
encounter using an age appropriate standardized depression screening tool, and if
positive, a follow-up plan is documented on the date of the positive screen
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2020 Child
and Adult Core Sets Measure Specifications
Instructions for accessing HEDIS value sets are provided in Appendix C: How to use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims or electronic medical records
Include paid, suspended, pending, and denied claims

Version of Specification: Child Core Set Technical Specifications and Resource Manual for Federal Fiscal
Year 2020 Reporting, March 2020

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Metric #26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With SMI
Metric element
Measure
sets/endorsements
Description
Population of interest
Metric calculation

Additional guidance

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
Adjusted, HEDIS measure
Measure steward: NCQA
The percentage of Medicaid beneficiaries age 18 years or older with SMI who had an
ambulatory or preventive care visit during the measurement period
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications.
Step 1. Identify claims during the measurement period with a diagnosis code (any
diagnosis code on the claim) from the HEDIS 2020 Mental Health Diagnosis Value
Set.
Step 2. Using the claims in step 1 as the denominator population, follow instructions
for calculating this metric found in the original HEDIS measure specifications (AAP
Adults’ Access to Preventive/Ambulatory Health Services [AAP] measure in the NCQA
Measure Specifications_v2.pdf and the HEDIS General Guideline 17_Hospice.pdf)
provided in the 1115 SMI Monitoring Metrics Supporting Information v2.zip file
accompanying this manual and the Reference Materials section on PMDA.
Note that the measure steward’s specifications refer to multiple types of payers. For
purpose of SMI/SED demonstration monitoring, the state should calculate this metric
for the Medicaid population.
Instructions for accessing the specifications and value sets are provided in Appendix
C: How to Use Supporting Measure Specifications, Value Sets, and Code Lists
to Calculate Metrics.
This metric is an adjusted version of a HEDIS measure called Adults’ Access to
Preventive/Ambulatory Health Services (AAP). The state should use the HEDIS
specification to calculate this metric among beneficiaries in the demonstration
population identified in Steps 1 and 2 of the metric calculation section in this table.
Year (Established quality measure)
Annual metrics that are established quality measures
Nonea
None
Claims
Include paid, suspended, pending, and denied claims

Although the measure steward’s specifications include instructions for reporting the metric by age group,
the state is not expected to report the age subpopulation category for this metric.
Version of Specification: HEDIS 2020 Technical Specifications for Health Plans, Measure AAP: Adults’
Access to Preventive/Ambulatory Health Services

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Metric #27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or
Other Drug Dependence
Metric element
Measure
sets/endorsements
Description

Population of interest
Metric calculation

Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
NQF #2600
Measure steward: NCQA
The percentage of patients 18 years and older with a serious mental illness or alcohol
or other drug dependence who received a screening for tobacco use and follow-up for
those identified as a current tobacco user. Two rates are reported, one for adults with
SMI and the other for adults with AOD.
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric are located in the full measure specification
(NCQA Measure Specifications_v2, Measure: NQF #2600) provided to the state in the
1115 SMI Monitoring Metrics Supporting Information v2.zip file accompanying this
manual a and the Reference Materials section on PMDA.
Instructions for accessing the specifications can be found in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.

Measure specification and value set information shown was last updated in 2014. The state should use
their discretion on including state-specific codes to supplement the applicable value sets.

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Metric #28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Metric element
Measure
sets/endorsements
Description
Population of interest
Metric calculation

Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
NQF #2599
Measure steward: NCQA
The percentage of patients 18 years and older with a serious mental illness, who were
screened for unhealthy alcohol use and received brief counseling or other follow-up
care if identified as an unhealthy alcohol user
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric are located in the full measure specification
(NCQA Measure Specifications_v2, Measure: NQF #2599), provided to the state in the
1115 SMI Monitoring Metrics Supporting Information v2.zip file accompanying this
manual and the Reference Materials section on PMDA
Instructions for accessing the specifications can be found in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

Measure specification and value set information shown was last updated in 2014. The state should use
their discretion on including state-specific codes to supplement the applicable value sets.

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Metric #29: Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)
Metric element
Measure
sets/endorsements

Description

Population of interest
Metric calculation
Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
FFY 2020 Core Set of Child Health Care Quality Measures for Medicaid (Child Core
Set), based on HEDIS specifications
NQF #2800
Measure steward: NCQA
The percentage of children and adolescents ages 1 to 17 who had two or more
antipsychotic prescriptions and had metabolic testing. Three rates are reported:
•
Percentage of children and adolescents on antipsychotics who received
blood glucose testing
•
Percentage of children and adolescents on antipsychotics who received
cholesterol testing
•
Percentage of children and adolescents on antipsychotics who received
blood glucose and cholesterol testing
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric can be found in Appendix D: Technical
Specifications for Established Quality Measures Adapted from FFY 2020 Child
and Adult Core Sets Measure Specifications
Instructions for accessing the specifications and value sets are provided in Appendix
C: How to Use Supporting Measure Specifications, Value Sets, and Code Lists
to Calculate Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Use suspended, pending, and denied claims

Version of Specification: Child Core Set Technical Specifications and Resource Manual for Federal Fiscal
Year 2020 Reporting, March 2020

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Metric #30: Follow-up Care for Adult Medicaid Beneficiaries Who are Newly Prescribed an Antipsychotic
Medication
Metric element
Measure
sets/endorsements
Description
Population of interest
Metric calculation

Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
NQF #3313
Measure steward: CMS
Percentage of Medicaid beneficiaries age 18 years and older with new antipsychotic
prescriptions who have completed a follow-up visit with a provider with prescribing
authority within four weeks (28 days) of prescription of an antipsychotic medication
All Medicaid beneficiaries within the eligible population defined in the measure
steward's specifications
Instructions for calculating this metric are located in the full measure specification
(NQF-3313 Specs) and value sets (NQF-3313 Value Set) provided to the state in the
1115 SMI Monitoring Metrics Supporting Information v2.zip file accompanying this
manual and the Reference Materials section on PMDA
Instructions for accessing the specifications and value sets are provided in Appendix
C: How to Use Supporting Measure Specifications, Value Sets, and Code Lists
to Calculate Metrics
Year (Established quality measure)
Annual metrics that are established quality measures
None
None
Claims
Use paid, suspended, pending, and denied claims

Version of Specification: Follow-up Care for Adult Medicaid Beneficiaries Who are Newly Prescribed an
Antipsychotic Medication Measure (NQF 3313) Technical Specifications and Resource Manual, April 2019.

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Metric #31: Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC-CH)
CMCS removed Use of Multiple Concurrent Antipsychotics in Children and Adolescents
(APC-CH) from the Adult Core Set because it is retired by the measure steward (NCQA) and is
no longer available for use. Starting with Version 2.0 of this manual, CMS has removed
Metric #31 for the purpose of SMI/SED demonstration monitoring.

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Metric #32: Total Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED –
Not Inpatient or Residential
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Description
None
The sum of all Medicaid spending for mental health services not in inpatient or
residential settings during the measurement period
Medicaid mental health services costs among all beneficiaries in the SMI/SED
demonstration population with full benefits enrolled in Medicaid for at least one month
(30 consecutive days) during the measurement period. The SMI/SED demonstration
population is defined as any beneficiary with an SMI/SED diagnosis in the
measurement period and/or in the 12 months before the measurement period.
Additional guidance on identifying the eligible population is provided in Chapter I.
Step 1. Identify claims with a primary mental health diagnosis from the HEDIS 2020
Mental Health Diagnosis Value Set.
Step 2. Among the claims identified in Step 1, retain claims with a code from any of
the following HEDIS 2020 Value Sets or another online assessment CPT code:
HEDIS 2020 Value Sets
•
MPT Stand Alone Outpatient Group 1
•
MPT Stand Alone Outpatient Group 2
The state should ensure the visit was billed by a mental health practitioner
using the Mental Health Practitioner Value Set
•
Observation
The state should ensure the visit was billed by a mental health practitioner
using the Mental Health Practitioner Value Set
•
(Visit Setting Unspecified; Electroconvulsive Therapy; or Transcranial
Magnetic Stimulation) with a corresponding code from Outpatient POS
•
(Visit Setting Unspecified; Electroconvulsive Therapy; or Transcranial
Magnetic Stimulation) with a corresponding code from Community Mental
Health Center POS
The state should ensure that the visit was in an outpatient setting (this POS
code can be used in settings other than outpatient)
•
(Electroconvulsive Therapy; or Transcranial Magnetic Stimulation) with a
corresponding code from Ambulatory Surgical Center POS
•
Partial Hospitalization or Intensive Outpatient
•
(MPT IOP/PH Group 1; Electroconvulsive Therapy; or Transcranial Magnetic
Stimulation) with a corresponding code in Partial Hospitalization POS
•
(MPT IOP/PH Group 1; Electroconvulsive Therapy; or Transcranial Magnetic
Stimulation) with a corresponding code in Community Mental Health Center
POS
­ The state should ensure that the visit was in an intensive outpatient or
partial hospitalization setting (the community mental health POS code
can be used in settings other than intensive outpatient and partial
hospitalizations)

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Metric #32: Total Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED –
Not Inpatient or Residential
Metric element
Numerator (continued)

Description
•

•

•
•
•

•
•
•

•
•

MPT IOP/PH Group 2 with a corresponding code in Partial Hospitalization
POS
­ The state should ensure that the visit was billed by a mental health
practitioner using the Mental Health Practitioner Value Set
MPT IOP/PH Group 2 with a corresponding code in Community Mental
Health Center POS
­ The state should ensure that the visit was in an intensive outpatient or
partial hospitalization setting (the Community Mental Health Center POS
code can be used in settings other than intensive outpatient and partial
hospitalizations)
­ The state should ensure that the visit was billed by a mental health
practitioner using the Mental Health Practitioner Value Set
ED
­ The state should ensure the visit was billed by a mental health
practitioner using the Mental Health Practitioner Value Set
Visit Setting Unspecified with a corresponding code from ED POS
Visit Setting Unspecified with a corresponding code from Community Mental
Health Center POS
­ The state should ensure that the visit was in an ED setting (this POS
code can be used in settings other than the ED)
Visit Setting Unspecified with a corresponding code from (Telehealth Modifier
or Telehealth POS)
MPT IOP/PH Group 1 with a corresponding code from (Telehealth Modifier or
Telehealth POS)
MPT IOP/PH Group 2 with a corresponding code from (Telehealth Modifier or
Telehealth POS)
­ The state should ensure the visit was billed by a mental health
practitioner using the Mental Health Practitioner Value Set
Telephone Visits
Online Assessments

Online assessment CPT codes:
98970: Qualified nonphysician health care professional online digital
evaluation and management service, for an established patient, for up to 7
days, cumulative time during the 7 days; 5-10 minutes
­ 98971: 11—20 minutes
­ 98972: 21 or more minutes
­ 99421: Online digital evaluation and management service, for an established
patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes
­ 99422: 11—20 minutes
99423: 21 or more minutes
­

Step 3. Among the claims identified in Step 2, exclude any claims with a code in the
Inpatient Stay Value Set. Retain the remaining claims to calculate the cost.
Step 4. Sum the total amount paid by Medicaid on the claims identified in Step 3. If
using T-MSIS data to calculate this metric, this data element is named TOTMEDICAID-PAID-AMT.

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Metric #32: Total Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED –
Not Inpatient or Residential
Metric element

Description

Numerator (continued)

Step 5. Identify the managed care mental health encounter records and sum the
amount paid by Medicaid for these encounters. There are several ways to estimate the
amount paid by Medicaid on encounter claims:
•
If available, the state should use payment rates reported by managed care
organizations to identify costs for mental health encounters.
•
Determine the FFS cost to Medicaid for a service (such as by using an FFS
Medicaid physician fee schedule) and apply that figure to encounter claims
for the same service. This method may not be appropriate if there are no FFS
claims for the same service types to use as a reference. A state may
maintain the FFS fee schedules and frequently make them publicly available.
•
Use a Medicaid-to-Medicare Fee Index. These indices enable researchers to
assume that Medicaid rates for a given service are set at a certain
percentage of Medicare rates. In other words, they estimate the Medicaid
fees for each state relative to the Medicare fees and provide a conversion
factor. For each service, apply the conversion factor to the Medicare fee
schedule to estimate the cost to Medicaid.
­ An example of Medicaid-to-Medicare fee comparisons is MACPAC’s
comparison of medical hospital payments between Medicaid and
Medicare, available at https://www.macpac.gov/wp-content/uploads/
2017/04/Medicaid-Hospital-Payment-A-Comparison-across-States-andto-Medicare.pdf.
­ The Medicare fee schedule is available at https://www.cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/FeeSchedule
GenInfo/index.html. CMS’s searchable Medicare Physician Fee
schedule contains Medicare payment information for more than 10,000
services and can be found at https://www.cms.gov/apps/physician-feeschedule/search/search-criteria.aspx.
•
Use Medicaid FFS equivalent amounts for encounter records reported in TMSIS.
Step 6. Sum the amount paid by Medicaid from Step 4 and Step 5 to determine total
Medicaid spending associated with services for mental health during the measurement
period.

Additional guidance

A state that uses fee schedules to calculate this metric should update them each year
to reflect changes in payment rates over time. However, to ensure consistency, the
method used to calculate this metric should stay the same across measurement
periods. For example, a state should not calculate managed care costs using a
Medicaid-to-Medicare Fee Index in one year and the MEDICAID-FFS-EQUIVALENTAMT field in other years.

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics

Data source
Claim type

Instructions for accessing HEDIS value sets is provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
Year (CMS-constructed)
Other annual metrics
State-specific subpopulations
The approach to identify mental health diagnoses in this metric also applies to Metrics
#13 - #19, #33, and #39 - #40. The total spending identified in this metric is used to
calculate Metric #34, Per Capita Associated With Mental Health Services Among
Beneficiaries with SMI/SED - Not Inpatient or Residential. Claims for services in
Metrics #32 and #33 are mutually exclusive.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

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MATHEMATICA

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #33: Total Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED –
Inpatient or Residential
Metric element
Measure
sets/endorsements
Description
Population of Interest

Numerator

Description
None
The sum of all Medicaid costs for mental health services in inpatient or residential
settings during the measurement period.
Medicaid mental health services costs among all beneficiaries in the SMI/SED
demonstration population with full benefits enrolled in Medicaid for at least one month
(30 consecutive days) during the measurement period. The SMI/SED demonstration
population is defined as any beneficiary with an SMI/SED diagnosis in the
measurement period and/or in the 12 months before the measurement period.
Additional guidance on identifying the eligible population is provided in Chapter I.
Step 1. Identify beneficiaries with a primary mental health diagnosis from the HEDIS
2020 Mental Health Diagnosis Value Set.
Step 2. Among claims identified in Step 1, retain claims with a place of service,
HCPCS, or UB Revenue code listed below claims with a code from any of the
following:
Place of Service Codes:
•
51 – Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
•
HEDIS 2016 BH Stand Alone Acute Inpatient Value Set
•
HEDIS 2016 HEDIS BH Acute Inpatient Value Set
•
HEDIS 2016 HEDIS BH Nonacute inpatient Value Set
HCPCS Codes:
•
H0017 – Behavioral health; residential
•
H0018 – Behavioral health; short-term residential
•
H0019 – Behavioral health; long-term residential
•
T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
HEDIS 2016 BH Stand Alone Nonacute Inpatient Value Set
•
HEDIS 2020 Inpatient Stay Value Set
Step 3. Among the claims identified in Step 2, exclude any claims with a code from the
Telehealth Modifier, Telehealth POS, MPT Stand Alone Outpatient Group 1, MPT
Stand Alone Outpatient Group 2, Observation, Outpatient POS, Community Mental
Health Center POS, Ambulatory Surgical Center POS, or Partial Hospitalization POS
Value Sets. Retain remaining claims to calculate costs.
Step 4. Sum the total amount paid by Medicaid on the claims from Step 3. If using TMSIS data to calculate this metric, this data element is named TOT-MEDICAID-PAIDAMT.

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Metric #33: Total Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED –
Inpatient or Residential
Metric element
Numerator (continued)

Additional guidance

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics

Data source
Claim type
Note:

Description
Step 5. Identify the managed care mental health encounter records and sum the
amount paid by Medicaid for these encounters. There are several ways to estimate the
amount paid by Medicaid on encounter claims:
•
If available, a state should use payment rates reported by managed care
organizations to identify costs for mental health encounters.
•
Determine the FFS cost to Medicaid for a service (such as by using an FFS
Medicaid physician fee schedule) and apply that figure to encounter claims for the
same service. This method may not be appropriate if there are no FFS claims for
the same service types to use as a reference. A state may maintain the FFS fee
schedules and frequently make them publicly available.
•
Use a Medicaid-to-Medicare Fee Index. These indices enable researchers to
assume that Medicaid rates for a given service are set at a certain percentage of
Medicare rates. In other words, they estimate the Medicaid fees for each state
relative to the Medicare fees and provide a conversion factor. For each service,
apply the conversion factor to the Medicare fee schedule to estimate the cost to
Medicaid.
­ An example of Medicaid-to-Medicare fee comparisons is MACPAC’s
comparison of medical hospital payments between Medicaid and Medicare,
available at https://www.macpac.gov/wp-content/uploads/
2017/04/Medicaid-Hospital-Payment-A-Comparison-across-States-and-toMedicare.pdf.
­ The Medicare fee schedule is available at https://www.cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/FeeSchedule
GenInfo/index.html. CMS’s searchable Medicare Physician Fee schedule
contains Medicare payment information for more than 10,000 services and
can be found at https://www.cms.gov/apps/physician-feeschedule/search/search-criteria.aspx.
•
Use Medicaid FFS equivalent amounts for encounter records reported in T-MSIS.
Step 6. Sum the amount paid by Medicaid from Step 4 and Step 5 to determine total
Medicaid spending associated with mental health during the measurement period.
A state that uses fee schedules to calculate this metric should update them each year
to reflect changes in payment rates over time. However, to ensure consistency, the
method used to calculate this metric should stay the same across measurement
periods. For example, a state should not calculate managed care costs using a
Medicaid-to-Medicare Fee Index in one year and the MEDICAID-FFS-EQUIVALENTAMT field in other years.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
Year (CMS constructed)
Other annual metrics
State-specific subpopulations
The approach to identify mental health diagnoses in this metric also applies to Metrics
#13 - #19, #32, and #39 - #40. The total spending identified in this metric is used to
calculate Metric #35, Per Capita Associated With Mental Health Services Among
Beneficiaries with SMI/SED - Not Inpatient or Residential. Claims for services in
Metrics #32 and #33 are mutually exclusive.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.

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State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries with SMI/SED Not Inpatient or Residential
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator
Denominator

Metric calculation
Additional guidance

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
None
Per capita costs for non-inpatient, non-residential services for mental health, among
beneficiaries in the demonstration population during the measurement period
Medicaid mental health services costs among all beneficiaries in the SMI/SED
demonstration population with full benefits enrolled in Medicaid for at least one month
(30 consecutive days) during the measurement period. The SMI/SED demonstration
population is defined as any beneficiary with an SMI/SED diagnosis in the
measurement period and/or in the 12 months before the measurement period.
Additional guidance on identifying the eligible population is provided in Chapter I.
The sum of all Medicaid spending for mental health services not in inpatient or
residential settings during the measurement period
Count the number of unique beneficiaries (de-duplicated total) enrolled in the
measurement period who have qualifying facility or provider claims to qualify as being
in the population of interest during the measurement period and/or in the 12 months
before the measurement period
Calculate per capita costs by dividing spending on mental health treatment in the
numerator by the number of beneficiaries in the denominator
A state that uses fee schedules to calculate this metric should update them each year
to reflect changes in payment rates over time. However, to ensure consistency, the
method used to calculate this metric should stay the same across measurement
periods. For example, a state should not calculate managed care costs using a
Medicaid-to-Medicare Fee Index in one year and the MEDICAID-FFS-EQUIVALENTAMT field in other years.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
Year (CMS-constructed)
Other annual metrics
State-specific subpopulations
The numerator for this metric is the same as total spending calculated in Metric #32.
The denominator is the same as the numerator in Metric #22, or the annual count of
unique enrolled beneficiaries that qualify as having SMI/SED-related treatment.
Claims for services in Metrics #34 and #35 are mutually exclusive.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries with SMI/SED Inpatient or Residential
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator
Denominator

Metric calculation
Additional guidance

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
None
Per capita costs for inpatient or residential services for mental health among
beneficiaries in the demonstration population during the measurement period
Medicaid mental health services costs among all beneficiaries in the SMI/SED
demonstration population with full benefits enrolled in Medicaid for at least one month
(30 consecutive days) during the measurement period. The SMI/SED demonstration
population is defined as any beneficiary with an SMI/SED diagnosis in the
measurement period and/or in the 12 months before the measurement period.
Additional guidance on identifying the eligible population is provided in Chapter I.
The sum of all Medicaid costs for mental health services in inpatient or residential
settings during the measurement period
Count the number of unique beneficiaries (de-duplicated total) enrolled in the
measurement period who have qualifying facility or provider claims that as being in the
population of interest during the measurement period and/or in the 12 months before
the measurement period
Calculate per capita spending by dividing spending on mental health treatment in the
numerator by the number of beneficiaries in the denominator
A state that uses fee schedules to calculate this metric should update them each year
to reflect changes in payment rates over time. However, to ensure consistency, the
method used to calculate this metric should stay the same across measurement
periods. For example, a state should not calculate managed care costs using a
Medicaid-to-Medicare Fee Index in one year and the MEDICAID-FFS-EQUIVALENTAMT field in other years.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
Year (CMS-constructed)
Other annual metrics
State-specific subpopulations
The numerator for this metrics is the same as total spending calculated in Metric #33.
The denominator is the same as the numerator in Metric #22, or the annual count of
unique enrolled beneficiaries that qualify as having SMI/SED-related treatment.
Claims for services in Metrics #34 and #35 are mutually exclusive.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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Metric #36: Grievances Related to services for SMI/SED
Metric element
Measure
sets/endorsements
Description
Population of interest
Numerator

Additional guidance
Measurement period
(Metric type)
Reporting Category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
None
Number of grievances filed during the measurement period that are related to services
for SMI/SED
Grievances filed during the measurement period
Number of grievances related to SMI/SED services by or on behalf of enrollees during
the measurement period. Count each grievance once, regardless of whether more
than one grievance is filed by the same enrollee.
There is no national process for filing and resolving grievances; each state determines
the process and levels of review a grievance may take.
None
Quarter (CMS-constructed)
Grievances and appeals and qualitative information on referral into treatment
State-specific subpopulations
None
Administrative records
Not applicable

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.

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Metric #37: Appeals Related to Services for SMI/SED
Metric element
Measure
sets/endorsements
Description
Population of interest
Numerator

Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
None
Number of appeals filed during the measurement period that are related to services for
SMI/SED
Appeals filed during the measurement period
Number of appeals related to SMI/SED services filed by or on behalf of enrollees
during the reporting quarter, by type (that is, reason for the appeal). Count each
appeal once, regardless of whether more than one appeal is filed by the same
enrollee. Appeals that are processed through multiple levels of review should only be
counted once.
There is no typology for tracking appeals filed by Medicaid beneficiaries; each state
tracks and categorizes appeals differently. A state should report appeal types
according to its own definition.
None
Quarter (CMS-constructed)
Grievances and appeals and qualitative information on referral into treatment
State-specific subpopulations
None
Administrative records
Not applicable

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.

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Metric #38: Critical Incidents Related to Services for SMI/SED
Metric element
Measure
sets/endorsements
Description
Population of interest
Numerator

Additional guidance
Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics
Data source
Claim type
Note:

Description
None
Number of critical incidents filed during the measurement period that are related to
services for SMI/SED
Critical incidents filed during the measurement period
The number of critical incidents related to SMI/SED services filed by or on behalf of
enrollees during the measurement period. Count each critical incident once,
regardless of whether more than one critical incident is filed by the same enrollee.
There is no national typology for tracking critical incidents; each state tracks and
categorizes critical incidents differently.
None
Quarter (CMS-constructed)
Grievances and appeals and qualitative information on referral into treatment
State-specific subpopulations
None
Administrative records
Not applicable

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.

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Metric #39: Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries
with SMI/SED
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator

Description
None
Total Medicaid costs for beneficiaries in the demonstration population who had claims
for inpatient or residential treatment for mental health in an IMD during the reporting
year
Medicaid mental health services costs among all beneficiaries in the SMI/SED
demonstration population with full benefits enrolled in Medicaid for at least one month
(30 consecutive days) during the measurement period. The SMI/SED demonstration
population is defined as any beneficiary with an SMI/SED diagnosis in the
measurement period and/or in the 12 months before the measurement period.
Additional guidance on identifying the eligible population is provided in Chapter I.
The sum of all Medicaid costs for inpatient or residential treatment for mental health
within IMDs among beneficiaries in the demonstration population during the
measurement period.
Step 1. Identify qualifying IMD discharges for inpatient or residential treatment for
mental health during the measurement period. This method may be specific to each
state; a state may maintain centralized databases of IMD stays. Alternatively, a state
may be able to identify IMD stays in T-MSIS data or through other methods.
Step 1a. Identify claims with a place of service, HCPCS, or UB Revenue code listed
below:
Place of Service Codes:
•
51 – Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
HCPCS Codes:
•
H0017 – Behavioral health; residential
•
H0018 – Behavioral health; short-term residential
•
H0019 – Behavioral health; long-term residential
•
T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2020 Inpatient Stay Value Set
Step 1b. Among the claims identified in Step 1a, retain claims with a primary mental
health diagnosis from the HEDIS 2020 Mental Health Diagnosis Value Set.
Step 2. Among records identified in Step 1 (1a and 1b), retain inpatient or residential
treatment stays in IMDs. (See the additional guidance section for a definition of an
IMD.) Only include IMDs receiving Federal Financial Participation under the
demonstration.
Step 3. Use the remaining claims to identify FFS mental health claims.
Step 4. Sum the total amount paid by Medicaid on the claims from Step 3. If using TMSIS data to calculate this metric, this data element is named TOT-MEDICAID-PAIDAMT.
Step 5. Identify managed care mental health encounter records and sum the amount
paid by Medicaid for the encounters. There are several ways to estimate the amount
paid by Medicaid on encounter claims:
•
If available, a state should use payment rates reported by managed care
organizations to identify costs for mental health encounters.

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Metric #39: Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries
with SMI/SED
Metric element
Numerator (continued)

Additional guidance

Description
Determine the FFS cost to Medicaid for a service (such as by using an FFS
Medicaid physician fee schedule) and apply that figure to encounter claims
for the same service. This method may not be appropriate if there are no FFS
claims for the same service types to use as a reference. A state may
maintain the FFS fee schedules and frequently make them publicly available.
•
Use a Medicaid-to-Medicare Fee Index. These indices enable researchers to
assume that Medicaid rates for a given service are set at a certain
percentage of Medicare rates. In other words, they estimate the Medicaid
fees for each state relative to the Medicare fees and provide a conversion
factor. For each service, apply the conversion factor to the Medicare fee
schedule to estimate the cost to Medicaid.
­ An example of Medicaid-to-Medicare fee comparisons is MACPAC’s
comparison of medical hospital payments between Medicaid and Medicare,
available at https://www.macpac.gov/wp-content/uploads/
2017/04/Medicaid-Hospital-Payment-A-Comparison-across-States-and-toMedicare.pdf.
­ The Medicare fee schedule is available at https://www.cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/
index.html. CMS’s searchable Medicare Physician Fee schedule contains
Medicare payment information for more than 10,000 services and can be
found at https://www.cms.gov/apps/physician-fee-schedule/search/searchcriteria.aspx.
•
Use Medicaid FFS equivalent amounts for encounter records reported in TMSIS. This field, MEDICAID-FFS-EQUIVALENT-AMT, should be populated
with the amount that would have been paid had the services been provided
on an FFS basis.
Step 6. Exclude any room and board costs, if included in steps 4 and 5.
Step 7. Sum the net amount paid by Medicaid from steps 4, 5 and 6 to determine total
Medicaid spending associated with treatment for mental health in an IMD during the
measurement period.
Use the discharge date to identify claims in the measurement period for residential
and inpatient services. Do not count expenditures for an ongoing stay during the
measurement period if the patient is not discharged in that period. If a discharge date
is not explicitly reported, identify all claims associated with a single stay and use the
latest end date of service on the claims. Use one of the following approaches to
combine claims for the same stay:
•
Combine claims for the same beneficiary, provider and admission date; or
•
If an admission date is not reported on all claims, combine claims for the
same patient and provider that have less than a one day break between the
end date of the first claim and the start date of the next claim. For example, if
the end date of the first claim is December 18 and the start date of the next
claim is December 19, then combine the claims as a single stay. However, if
the second claim has a start date of December 20 or later, then do not
combine the claims.
A state that uses fee schedules to calculate this metric should update them each year
to reflect changes in payment rates over time. However, to ensure consistency, the
method used to calculate this metric should stay the same across measurement
periods. For example, a state should not calculate managed care costs using a
Medicaid-to-Medicare Fee Index in one year and the MEDICAID-FFS-EQUIVALENTAMT field in other years.
An IMD is defined as a hospital, nursing facility, or other institution that has more than
16 beds and is primarily engaged in providing diagnosis, treatment, or care for people
with mental diseases. Only include IMDs receiving Federal Financial Participation
under the demonstration.
•

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Metric #39: Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries
with SMI/SED
Metric element
Additional guidance
(continued)

Measurement period
(Metric type)
Reporting category
Subpopulation
categories
Relationship to other
metrics

Data source
Claim type
Note:

Description
A state may have a published list of IMDs in which the designation is made by the
state. If available, use that list to identify facilities; obtain the associated billing provider
IDs, and identify claims in Steps 1a or 1b associated with those provider IDs.
Otherwise, refer to the State Medicaid Manual for additional regulatory guidance.
Per the guidance in Section 4390 of the State Medicaid Manual, the following five
criteria should be used to evaluate whether the overall character of a facility is that of
an IMD:
1. The facility is licensed as a psychiatric facility.
2. The facility is accredited as a psychiatric facility.
3. The facility is under the jurisdiction of the state’s mental health authority.
(This criterion does not apply to facilities under the state’s mental health
authority that are not providing services to mentally ill persons.).
4. The facility specializes in providing psychiatric/psychological care and
treatment. This may be ascertained through review of patients’ records. It
may also be indicated by the fact that an unusually large proportion of the
staff has specialized psychiatric/psychological training or that a large
proportion of the patients are receiving psychopharmacological drugs.
5. The current need for institutionalization for more than 50 percent of all the
patients in the facility results from mental diseases.
a. When applying the 50 percent guideline determine whether each
patient’s current need for institutionalization results from a mental
disease. It is not necessary to determine whether any mental health care
is being provided in applying this guideline.
b. If more than 50 percent of the patients are residing in the institution
because of implications of mental health or substance use diagnoses,
then the facility may be determined to be an IMD.
Instructions for accessing HEDIS value sets are provided in Appendix C: How to Use
Supporting Measure Specifications, Value Sets, and Code Lists to Calculate
Metrics.
Year (CMS-constructed)
Other annual metrics
State-specific subpopulations
The definition of an IMD should be the same in Metrics #19a, #19b and #20. The IMDs
identified in this metric is a subset of the IMDs in Metric #19a, but the same group of
IMDs in Metrics #19b and #20. The approach to identify mental health diagnoses in
this metric also applies to Metrics #13 - #19, #32 - #33, and #40. The total spending
identified in this metric is used to calculate Metric #40: Per Capita Associated With
Treatment for Mental Health in an IMD Among Beneficiaries with SMI/SED.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

80

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

MATHEMATICA

Metric #40: Per Capita Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries
With SMI/SED
Metric element
Measure
sets/endorsements
Description
Population of interest

Numerator
Denominator

Metric calculation

Additional guidance

Description
None
Per capita Medicaid costs for beneficiaries in the demonstration population who had
claims for inpatient or residential treatment for mental health in an IMD during the
reporting year
Medicaid mental health services costs among all beneficiaries in the SMI/SED
demonstration population with full benefits enrolled in Medicaid for at least one month
(30 consecutive days) during the measurement period. Additional guidance on
identifying the eligible population is provided in Chapter I. The SMI/SED
demonstration population is defined as any beneficiary with an SMI/SED diagnosis in
the measurement period and/or in the 12 months before the measurement period.
Total Medicaid costs associated with treatment for mental health within IMDs during
the measurement period
Number of beneficiaries in the demonstration population with a claim for inpatient or
residential treatment for mental health in an IMD during the reporting year.
Step 1. Identify qualifying IMD discharges for inpatient or residential treatment for
mental health during the measurement period. This method may be specific to each
state; a state may maintain centralized databases of IMD stays. Alternatively, a state
may be able to identify IMD stays in T-MSIS data or through other methods.
Step 1a. Identify claims with a place of service, HCPCS, or UB Revenue code listed
below:
Place of Service Codes:
•
51 – Inpatient Psychiatric Facility
•
56 – Psychiatric Residential Treatment Center
HCPCS Codes:
•
H0017 – Behavioral health; residential
•
H0018 – Behavioral health; short-term residential
•
H0019 – Behavioral health; long-term residential
•
T2048 – Behavioral health; long-term care residential
UB Revenue Codes:
•
1001 – Residential treatment, psychiatric
•
From the HEDIS 2020 Inpatient Stay Value Set
Step 1b. Among the claims identified in Step 1a, retain claims with a primary mental
health diagnosis from the HEDIS 2020 Mental Health Diagnosis Value Set.
Step 2. Among the claims identified in Step 1 (1a and 1b), retain claims for inpatient
or residential treatment in an IMD. (See the additional guidance section for a
definition of IMDs). Only include IMDs receiving Federal Financial Participation under
the demonstration.
Step 3. Determine the total number of unique beneficiaries (de-duplicated) with
claims that meet the criteria in Steps 1 and 2.
Calculate per capita mental health spending by dividing spending on mental health
treatment in the numerator by the number of beneficiaries in the denominator, as
follows:
Spending on mental health treatment / Number of beneficiaries
Use the discharge date to identify claims in the measurement period for residential
and inpatient services. Do not count expenditures for an ongoing stay during the
measurement period if the patient is not discharged in that period. If a discharge date
is not explicitly reported, identify all claims associated with a single stay and use the
latest end date of service on the claims. Use one of the following approaches to
combine claims for the same stay:

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MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

MATHEMATICA

Metric #40: Per Capita Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries
With SMI/SED
Metric element
Additional guidance
(continued)

Measurement period
(Metric type)
Reporting category
Subpopulation categories
Relationship to other
metrics

Data source
Claim type

Description
Combine claims for the same beneficiary, provider and admission date; or
If an admission date is not reported on all claims, combine claims for the
same patient and provider that have less than a one day break between the
end date of the first claim and the start date of the next claim. For example,
if the end date of the first claim is December 18 and the start date of the
next claim is December 19, then combine the claims as a single stay.
However, if the second claim has a start date of December 20 or later, then
do not combine the claims.
An IMD is defined as a hospital, nursing facility, or other institution that has more than
16 beds and is primarily engaged in providing diagnosis, treatment, or care for people
with mental diseases. Only include IMDs receiving Federal Financial Participation
under the demonstration.
A state may have a published list of IMDs in which the designation is made by the
state. If available, use that list to identify facilities; obtain the associated billing
provider IDs, and identify claims in Steps 1a or 1b associated with those provider IDs.
Otherwise, refer to the State Medicaid Manual for additional regulatory guidance.
Per the guidance in Section 4390 of the State Medicaid Manual, the following five
criteria should be used to evaluate whether the overall character of a facility is that of
an IMD:
1. The facility is licensed as a psychiatric facility.
2. The facility is accredited as a psychiatric facility.
3. The facility is under the jurisdiction of the state’s mental health authority.
(This criterion does not apply to facilities under the state’s mental health
authority that are not providing services to mentally ill persons.).
4. The facility specializes in providing psychiatric/psychological care and
treatment. This may be ascertained through review of patients’ records. It
may also be indicated by the fact that an unusually large proportion of the
staff has specialized psychiatric/psychological training or that a large
proportion of the patients are receiving psychopharmacological drugs.
5. The current need for institutionalization for more than 50 percent of all the
patients in the facility results from mental diseases.
a. When applying the 50 percent guideline determine whether each
patient’s current need for institutionalization results from a mental
disease. It is not necessary to determine whether any mental health
care is being provided in applying this guideline.
b. If more than 50 percent of the patients are residing in the institution
because of implications of mental health or substance use diagnoses,
then the facility may be determined to be an IMD.
Year (CMS-constructed)
•
•

Other annual metrics
State-specific subpopulations
The definition of an IMD should be the same in Metrics #19a, #19b and #20. The
IMDs identified in this metric is a subset of the IMDs in Metric #19a, but the same
group of IMDs in Metrics #19b and #20. The approach to identify mental health
diagnoses in this metric also applies to Metrics #13 - #19, and #32 - #33, and #39.
The numerator in this metric is the total costs calculated in Metric #39: Total Costs
Associated With Treatment for Mental Health in an IMD Among Beneficiaries with
SMI/SED.
Claims
Only use paid claims. (Do not use suspended, pending, or denied claims.)

82

MEDICAID SECTION 1115 SMI AND SED DEMONSTRATIONS

Note:

MATHEMATICA

The state should report this metric for the population of interest and subpopulation categories specified in
this table. Guidance on reporting by CMS-provided and state-specific subpopulation categories is provided
in Chapter I.
State-specific codes. The state may use state-specific diagnosis, procedure, treatment, or other types of
codes. When applicable, the state should supplement the codes referenced in metric specifications with
state-specific codes that are not included in the value sets. State-specific codes must be for services
specific to mental health treatment. If the service code can be for either mental health or SUD services,
then a mental health diagnosis code must be included on the claim. The state should describe these statespecific codes in the “Explanation of any deviations from the CMS-provided specifications” column in Part A
(monitoring protocol workbook) of its monitoring protocol submission. See Version 2.0 of the Section 1115
SMI/SED Monitoring Protocol Instructions for further guidance. If the state would like to upload this
information in an attachment, the state should enter “See attachment” in the appropriate column in Part A.

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APPENDIX A
ESTABLISHED MEASURES AND MEASURE SETS
REFERENCED IN TECHNICAL SPECIFICATIONS

This page has been left blank for double-sided copying.

APPENDIX A

MATHEMATICA

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

1

SUD Screening of Beneficiaries
Admitted to Psychiatric Hospitals or
Residential Treatment Settings
(SUB-2)

2

Use of First-Line Psychosocial Care
for Children and Adolescents on
Antipsychotics (APP-CH)
All-Cause Emergency Department
Utilization Rate for Medicaid
Beneficiaries who may Benefit From
Integrated Physical and Behavioral
Health Care (PMH-20)
30-Day All-Cause Unplanned
Readmission Following Psychiatric
Hospitalization in an Inpatient
Psychiatric Facility (IPF)
Medication Reconciliation Upon
Admission
Medication Continuation Following
Inpatient Psychiatric Discharge
Follow-up After Hospitalization for
Mental Illness: Ages 6-17 (FUH-CH)

3

4

5
6
7

8
9

10
23

24
25

26

Follow-up After Hospitalization for
Mental Illness: Age 18 and Older
(FUH-AD)
Follow-up After Emergency
Department Visit for Alcohol and
Other Drug Abuse Dependence
(FUA-AD)
Follow-up After Emergency
Department Visit for Mental Illness
(FUM-AD)
Diabetes Care for Patients with
Serious Mental Illness: Hemoglobin
A1c (HbA1c) poor control (>9.0%)
(HPCMI-AD)
Screening for Depression and
Follow-up Plan: 18 years and Older
(CDF-AD)
Screening for Depression and
Follow-up Plan: Ages 12-17(CDFCH)
Access to Preventive/ Ambulatory
Health Services for Medicaid
Beneficiaries with SMI

Established measure
name (if different from
the metric name)

Measure set
The Joint
Commission
National Hospital
Inpatient Quality
Measures

Measure set
version
5. 6 b

SUB-2 Alcohol Use Brief
Intervention Provided or
Offered
SUB-2a Alcohol Use Brief
Intervention
n.a.

Child Core Set

n.a.

CMS

n.a.

n.a.

Inpatient
Psychiatric Facility
Quality Reporting
(IPFQR) program
CMS

2019 reporting b

n.a.

CMS

2019 reporting b

n.a.

Child Core Set

FFY 2020 b

n.a.

Adult Core Set

FFY 2020 b

n.a.

Adult Core Set

FFY 2020 b

n.a.

Adult Core Set

FFY 2020 a

n.a.

Adult Core Set

FFY 2020 a

n.a.

Adult Core Set

FFY 2020 a

n.a.

Child Core Set

FFY 2020 a

Adults’ Access to
Preventive/Ambulatory
Health Services (AAP)

HEDIS

A.3

FFY 2020 a
2019 reporting b

2019 reporting

2020 b

APPENDIX A

Metric
Number
27

28
29
30

MATHEMATICA

Metric name
Tobacco Use Screening and Followup for People with Serious Mental
Illness or Alcohol or Other Drug
Dependence
Alcohol Screening and Follow-up for
People with Serious Mental Illness
Metabolic Monitoring for Children
and Adolescents on Antipsychotics
(APM-CH)
Follow-up Care for Adult Medicaid
Beneficiaries Who are Newly
Prescribed an Antipsychotic
Medication

Established measure
name (if different from
the metric name)

Measure set

Measure set
version

n.a.

NCQA

b

n.a.

NCQA

b

n.a.

Child Core Set

n.a.

HEDIS

a Specifications

FFY 2020 b
2020 b

for calculating established quality measures that are part of the Medicaid Child and Adult Core Sets
can be found in Appendix D: Technical Specifications for Established Quality Measures Adapted from FFY
2020 Child and Adult Core Sets Specifications.
b Specifications for established quality measures that are not part of the Core Set are available in 1115 SMI
Monitoring Metrics Supporting Information v2.zip file accompanying this manual, and in the Reference Materials
Section of PMDA
n.a. = not applicable

A.4

APPENDIX B
VALUE SETS REFERENCED IN METRIC SPECIFICATIONS

This page has been left blank for double-sided copying.

APPENDIX B

MATHEMATICA

Table B.1 identifies the value sets that are referenced in the monitoring metrics. HEDIS and other value sets listed in Table B.1.
are located in the file “1115 SMI Monitoring Metrics HEDIS Value Set Directory_v2.xlsx” which can be found in the 1115 SMI
Monitoring Metrics Supporting Information v2.zip file accompanying this manual, and are also accessible to the state through PMDA
in the Reference Materials section.
Table B.1. HEDIS and other value sets and code lists referenced in metric specifications

Value Set Name
Acute Inpatient (HEDIS
2020)
Acute Inpatient POS
(HEDIS 2020)
Advanced Illness (HEDIS
2020)
AOD Abuse and
Dependence (HEDIS
2020)
AOD Procedures (HEDIS
2016)
Alcohol Screening and
Brief Counseling (2015)
Alcohol Disorders (HEDIS
2020)
Ambulatory Surgical
Center POS (HEDIS
2020)

Relevant metrics
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)
#10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated with Mental Health Services among Beneficiaries with SMI/SED – Inpatient
or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated with Mental Health Services among Beneficiaries with SMI/SED –
Inpatient or Residential

B.3

Part of reported
Core Set
measure (Y/N)
Y
Y

Y
Y

N
N
N
Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
Ambulatory Visits (HEDIS
2020)
BH Acute Inpatient
(HEDIS 2016)

Relevant metrics
•

#26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With SMI

N

•

#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
#12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
#12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#10:Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)

N

•
•
•

BH Acute Inpatient POS
(HEDIS 2016)

BH Stand Alone Acute
Inpatient (HEDIS 2016)

•
•
•
•
•
•
•
•
•
•
•

BH Stand Alone
Outpatient/PH/IOP
(HEDIS 2016)
BH Outpatient (HEDIS
2020)

Part of reported
Core Set
measure (Y/N)

•
•
•
•
•
•
•
•
•
•

B.4

N

Y

N

Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
BH Outpatient/PH/IOP
(HEDIS 2016)

BH Outpatient/PH/IOP
POS (HEDIS 2016)

BH ED (HEDIS 2016)

Relevant metrics
•
•
•
•
•
•
•
•

BH ED POS (HEDIS
2016)

BH Stand Alone Nonacute
Inpatient (HEDIS 2016)

•
•
•
•
•
•
•
•
•
•

BH Nonacute Inpatient
(HEDIS 2016)

•
•
•
•

#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
#12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
#12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence#28: Alcohol Screening and Follow-up for People with Serious Mental Illness

B.5

Part of reported
Core Set
measure (Y/N)
N

N

N

N

Y

N

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
BH Nonacute Inpatient
POS (HEDIS 2016)

Bipolar Disorder (HEDIS
2016)

Relevant metrics

N

•
•

#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)

•

#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)

Y

•
•
•
•
•
•
•
•
•
•

Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)
#10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)

Y

•
•
•
•
•
•
•
•

Cholesterol Lab Test
(HEDIS 2020)
Cholesterol Test Result or
Finding (HEDIS 2020)
Community Mental Health
Center POS (HEDIS
2020)

Part of reported
Core Set
measure (Y/N)

•
•
Detoxification (HEDIS
2020)
Diabetes (HEDIS 2020)

•

Diabetes Exclusions
(HEDIS 2020)

•

•

B.6

Y

Y

N
Y
Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
ED (HEDIS 2020)

Relevant metrics
•
•
•
•
•

ED POS (HEDIS 2020)

•
•
•
•
•
•
•

ED Procedure Code
(HEDIS 2016)
Electroconvulsive Therapy
(HEDIS 2020)

•
•
•
•
•
•
•
•
•
•
•
•
•

Frailty Device (HEDIS
2020)
Frailty Diagnosis (HEDIS
2020)

•
•

Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD) #10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#16: Mental Health Services Utilization - ED #18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD) #27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness
or Alcohol or Other Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
Standardized definition of SMI (HEDIS 2020)
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#16: Mental Health Services Utilization - ED
#18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)
#10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
B.7

Part of reported
Core Set
measure (Y/N)
Y

Y

N
Y

Y
Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
Frailty Encounter (HEDIS
2020)
Frailty Symptom (HEDIS
2020)
Glucose Lab Test (HEDIS
2020)
Glucose Test Result or
Finding (HEDIS 2020)
HbA1c Level 7.0-9.0
(HEDIS 2020)
HbA1c Level Greater
Than 9.0 (HEDIS 2020)
HbA1c Level Less Than
7.0 (HEDIS 2020)
HbA1c Lab Test (HEDIS
2020)
HbA1c Test Result or
Finding (HEDIS 2020)
Hospice Encounter
(HEDIS 2020)

Relevant metrics

Y

•

#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)

•

#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)

Y

•

Y

•

#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)

•

#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)

Y

•
•

#8:Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#10: Follow-Up After Emergency Department Visit for Mental Illness (FUM-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#8:Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence

Y

•
•

•
•

•
•
Hospice Intervention
(HEDIS 2020)

•
•
•
•

IET POS Group 1 (HEDIS
2020)
IET POS Group 2 (HEDIS
2020)
IET Stand Alone Visits
(HEDIS 2020)

Part of reported
Core Set
measure (Y/N)

•
•
•
•

B.8

Y
Y

Y
Y
Y

Y

Y
Y
Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
IET Visits Group 1 (HEDIS
2020)
IET Visits Group 2 (HEDIS
2020)
Inpatient Stay (HEDIS
2020)

Relevant metrics
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Intentional Self-Harm
(HEDIS 2020)

•
•
•

#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
#12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
#13: Mental Health Services Utilization - Inpatient
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#18: Mental Health Services Utilization - Any Services
#19: Average Length of Stay in IMDs
#20: Beneficiaries With SMI/SED Treated in an IMD for Mental Health
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED Inpatient or Residential
#39: Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries With
SMI/SED
#40: Per Capita Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries With
SMI/SED
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
B.9

Part of reported
Core Set
measure (Y/N)
Y

Y

Y

Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
LDL-C Lab Test (HEDIS
2020)
LDL-C Test Result or
Finding (HEDIS 2020)
Major Depression (HEDIS
2016)

Relevant metrics
•

#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)

Y

•

#29: Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)

Y

•
•

Standardized definition of SMI
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness
#7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)
#10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#11: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (count)
#12: Suicide or Overdose Death Within 7 and 30 Days of Discharge From an Inpatient Facility or
Residential Treatment for Mental Health Among Beneficiaries With SMI or SED (rate)
#13: Mental Health Services Utilization - Inpatient
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#19: Average Length of Stay in IMDs
#20: Beneficiaries With SMI/SED Treated in an IMD for Mental Health
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED Inpatient or Residential
#39: Total Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries With
SMI/SED
#40: Per Capita Costs Associated With Treatment for Mental Health in an IMD Among Beneficiaries With
SMI/SED

N

•
Mental Health Diagnosis
(HEDIS 2020)

Part of reported
Core Set
measure (Y/N)

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

B.10

Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
Mental Health Practitioner
(HEDIS 2020)

Relevant metrics
•
•
•
•
•
•
•
•
•

Mental Illness (HEDIS
2020)
MPT IOP/PH Group 1
(HEDIS 2020)

•
•
•
•
•
•
•
•
•
•

MPT IOP/PH Group 2
(HEDIS 2020)

•
•
•
•
•
•
•

#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#14: Mental Health Services Utilization - Intensive outpatient and partial hospitalization
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED Inpatient or Residential
#14: Mental Health Services Utilization - Intensive outpatient and partial hospitalization
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED Inpatient or Residential

B.11

Part of reported
Core Set
measure (Y/N)
Y

Y
N

N

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
MPT Stand Alone
Outpatient Group 1
(HEDIS 2020)

Relevant metrics
•
•
•
•
•
•

MPT Stand Alone
Outpatient Group 2
(HEDIS 2020)

•
•
•
•
•
•

Nonacute Inpatient
(HEDIS 2020)
Nonacute Inpatient POS
(HEDIS 2020)
Nonacute Inpatient Stay
(HEDIS 2020)

•
•
•
•
•

#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED Inpatient or Residential
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED Inpatient or Residential
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
Standardized definition of SMI
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)

B.12

Part of reported
Core Set
measure (Y/N)
N

N

Y
Y
Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
Observation
(HEDIS 2020)

Relevant metrics
•
•
•
•
•
•
•
•
•
•
•
•
•

Online Assessments
(HEDIS 2020)

•
•
•
•
•
•
•

Other Ambulatory Visits
(HEDIS 2020)
Other Bipolar Disorder
(HEDIS 2020)

•

Other Psychotic and
Developmental Disorders
(HEDIS 2020)
Outpatient (HEDIS 2020)

•

•
•

•

Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED Inpatient or Residential
#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With SMI
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With SMI

Part of reported
Core Set
measure (Y/N)
Y

Y

N

Standardized definition of SMI
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)

Y

#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)

Y

B.13

Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
Outpatient POS (HEDIS
2020)

Relevant metrics
•
•
•
•
•
•
•
•
•
•
•
•

Partial Hospitalization or
Intensive Outpatient
(HEDIS 2020)

•
•
•
•
•
•
•
•
•
•

Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#7: Follow-up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older (FUH-AD)
#10: Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED Inpatient or Residential
Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#10:Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential

B.14

Part of reported
Core Set
measure (Y/N)
Y

Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
Partial Hospitalization
POS
(HEDIS 2020)

Relevant metrics
•
•
•
•
•
•
•
•
•
•
•
•

Psychosocial Care
(HEDIS 2020)
Schizophrenia (HEDIS
2016)

•
•
•
•
•
•
•

Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#10:Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED Inpatient or Residential
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#3: All-Cause Emergency Department Utilization Rate for Medicaid Beneficiaries who may Benefit From
Integrated Physical and Behavioral Health Care (PMH-20)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#28: Alcohol Screening and Follow-up for People with Serious Mental Illness

B.15

Part of reported
Core Set
measure (Y/N)
Y

Y
Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
Telehealth Modifier
(HEDIS 2020)

Relevant metrics
•
•
•
•
•
•
•
•
•
•
•

Telehealth POS (HEDIS
2020)

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Standardized definition of SMI
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED Inpatient or Residential
Standardized definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#10:Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#33: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Inpatient
or Residential
#34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#35: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential

B.16

Part of reported
Core Set
measure (Y/N)
Y

Y

APPENDIX B

MATHEMATICA

Table B.1. (continued)

Value Set Name
Telephone Visits (HEDIS
2020)

Relevant metrics
•
•
•
•
•
•
•

Tobacco Cessation
Counseling (2015)
Transcranial Magnetic
Stimulation (HEDIS 2020)

•
•
•
•
•
•

Transitional Care
Management Services
(HEDIS 2020)
Visit Setting Unspecified
(HEDIS 2020)

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

#9: Follow-up After Emergency Department Visit for Alcohol and Other Drug Abuse Dependence (FUAAD)
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#26: Access to Preventive/Ambulatory Health Services for Medicaid Beneficiaries With SMI
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#34: Per Capita Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#27: Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other
Drug Dependence
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#18: Mental Health Services Utilization - Any Services
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
Standardizied definition of SMI
#2: Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)
#7: Follow up After Hospitalization for Mental Illness: Ages 6-17 (FUH-CH)
#8: Follow up After Hospitalization for Mental Illness: Age 18 and older (FUH-AD)
#10:Follow-up After Emergency Department Visit for Mental Illness (FUM-AD)
#14: Mental Health Services Utilization - Intensive Outpatient and Partial Hospitalization
#15: Mental Health Services Utilization - Outpatient
#16: Mental Health Services Utilization - ED
#17: Mental Health Services Utilization - Telehealth
#18: Mental Health Services Utilization - Any Services
#23: Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control
(>9.0%) (HPCMI-AD)
#32: Total Costs Associated With Mental Health Services Among Beneficiaries With SMI/SED - Not
Inpatient or Residential
#34: Per Capita Costs Associated with Mental Health Services Among Beneficiaries with SMI/SED - Not
Inpatient or Residential

B.17

Part of reported
Core Set
measure (Y/N)
Y

N
N

Y
Y

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APPENDIX C
HOW TO USE SUPPORTING MEASURE SPECIFICATIONS,
VALUE SETS, AND CODE LISTS TO CALCULATE METRICS

This page has been left blank for double-sided copying.

APPENDIX C

MATHEMATICA

Table C.1. How to use supporting measure specifications, value sets, and code lists to calculate metrics
Metrics
CMS-constructed metrics that do not use supporting
measure specifications or value sets:
•
#36: Grievances related to services for
SMI/SED
•
#37: Appeals related services for to SMI/SED
•
#38: Critical incidents related to services for
SMI/SED
CMS-constructed metrics that use HEDIS value sets.
•
#11: Suicide or Overdose Death Within 7 and
30 Days of Discharge From an Inpatient
Facility or Residential Treatment for Mental
Health Among Beneficiaries With SMI or SED
(count)
•
#12: Suicide or Overdose Death Within 7 and
30 Days of Discharge From an Inpatient
Facility or Residential Treatment for Mental
Health Among Beneficiaries With SMI or SED
(rate)
•
#13: Mental Health Services Utilization Inpatient
•
#14: Mental Health Services Utilization Intensive Outpatient and Partial
Hospitalization
•
#15: Mental Health Services Utilization Outpatient
•
#16: Mental Health Services Utilization - ED
•
#17: Mental Health Services Utilization Telehealth
•
#18: Mental Health Services Utilization - Any
Services
•
#19: Average Length of Stay in IMDs
•
#20: Beneficiaries With SMI/SED Treated in
an IMD for Mental Health
•
#21: Count of Beneficiaries With SMI/SED
(monthly)
•
#22: Count of Beneficiaries With SMI/SED
(annually)

Supporting Measure Specifications,
Value Sets, and Code Lists
None

Value Sets:
•
1115 SMI Monitoring Metrics
HEDIS Value Set Directory
Version 2

C.3

Instructions
None

Value Sets:
•
Step 1: Open “1115 SMI Monitoring Metrics
HEDIS Value Set Directory_v2.xlsx” file
(available in the 1115 SMI Monitoring Metrics
Supporting Information v2.zip file
accompanying this manual and the Reference
Materials section on PMDA).
•
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

APPENDIX C

MATHEMATICA

Table C.1. (continued)
Metrics
#32: Total Costs Associated With Mental
Health Services Among Beneficiaries With
SMI/SED - Not Inpatient or Residential
•
#33: Total Costs Associated with Mental
Health Services among Beneficiaries with
SMI/SED – Inpatient or Residential
•
#34: Per Capita Costs Associated with Mental
Health Services Among Beneficiaries with
SMI/SED - Not Inpatient or Residential
•
#35: Per Capita Costs Associated with Mental
Health Services among Beneficiaries with
SMI/SED – Inpatient or Residential
•
#39: Total Costs Associated With Treatment
for Mental Health in an IMD Among
Beneficiaries With SMI/SED
•
#40: Per Capita Costs Associated With
Treatment for Mental Health in an IMD
Among Beneficiaries With SMI/SED
Established quality measures that use HEDIS
specifications included in the Child and Adult Core
Sets Measure Specifications technical specifications
manual.
•
#2: Use of First-Line Psychosocial Care for
Children and Adolescents on Antipsychotics
(APP-CH)
•
#7: Follow-up After Hospitalization for Mental
Illness: Ages 6-17 (FUH-CH)
•
#8: Follow-up After Hospitalization for Mental
Illness: Age 18 and Older (FUH-AD)
•
#9: Follow-up After Emergency Department
Visit for Alcohol and Other Drug Abuse
Dependence (FUA-AD)
•
#10: Follow-up After Emergency Department
Visit for Mental Illness (FUM-AD)
•
#23: Diabetes Care for People with Serious
Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)
•
#24: Screening for Depression and Follow-up
Plan: Age 18 and Older (CDF-AD)

Supporting Measure Specifications,
Value Sets, and Code Lists

Instructions

•

Measure Specifications:
•
The Core Set of Adult Health
Care Quality Measures for
Medicaid (Adult Core Set) and
the Core Set of Children’s Health
Care Quality Measures for
Medicaid and CHIP (Child Core
Set) Technical Specifications and
Resource Manuals for Federal
Fiscal Year 2020 Reporting
­ Appendix D: Technical
Specifications for Established
Quality Measures Adapted
From FFY 2020 Child and
Adult Core Sets Measure
Specifications
Value Sets:
•
1115 SMI Monitoring Metrics
HEDIS Value Set Directory
Version 2

C.4

Measure Specifications:
•
Step 1: Locate specifications for measures
listed at left in Appendix D of this manual.
Value Sets:
•
Step 1: Open “1115 SMI Monitoring Metrics
HEDIS Value Set Directory_v2.xlsx” file
(available in the 1115 SMI Monitoring Metrics
Supporting Information v2.zip file
accompanying this manual and the Reference
Materials section on PMDA).
•
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

APPENDIX C

MATHEMATICA

Table C.1. (continued)
Metrics
#25: Screening for Depression and Follow-up
Plan: Ages 12–17 (CDF-CH)
•
#29: Metabolic Monitoring for Children and
Adolescents on Antipsychotics (APM-CH)
Established quality measures that use TJC
specifications (and are not part of the Medicaid Adult
or Child Core Set).
•
#1: SUB-2 Alcohol Use Brief Intervention
Provided or Offered and SUB-2a Alcohol Use
Brief Intervention

Supporting Measure Specifications,
Value Sets, and Code Lists

Instructions

•

Measure Specifications:
•
2_6_2_SUB_v5_6.pdf
Code Sets:
•
Appendix-A.1.xlxs
Data Dictionary:
•
1b_Alpha_DD.pdf

C.5

Measure Specifications:
•
Step 1: Download the measure specifications
by clicking the Substance Use (SUB) link in
Section 2 of
https://qualitynet.org/files/5d84e2543a87ff001f3
3645e?filename=HIQR-Specs_Man_v5-6a.ZIP
Step 2: Locate specification for SUB-2 in
specifications manual.
•
Step 3: Follow the guidance in the measure
specification to calculate the metric
Code Sets:
•
Step 1: Download the ICD 10 Code table by
clicking on the A.1 XLS file under the
Appendices section of
https://qualitynet.org/inpatient/specificationsmanuals#tab3
•
Step 2: Filter the “Appendix A.1_v5.6a”” tab to
select Table Numbers (column A) identified in
metric specification
•
Step 3: Include listed codes (column C) when
calculating metric
Data Dictionary:
•
Step 1: Download data dictionary by clicking on
the ‘Alphabetical Data Dictionary’ file under the
Section 1 of
https://www.qualitynet.org/inpatient/specificatio
ns-manuals#tab3
•
Step 2: Locate the relevant data elements as
per the measure specifications

APPENDIX C

MATHEMATICA

Table C.1. (continued)
Metrics
Established quality measures that use NCQA
specifications and value sets that are part of HEDIS
(and not part of the Medicaid Core set):
•
Standardized definition of SMI (see
Appendix E: Standardized Definition of
SMI)
•
#26: Access to Preventive/Ambulatory Health
Services for Medicaid Beneficiaries With SMI

Supporting Measure Specifications,
Value Sets, and Code Lists
Measure Specifications:
•
HEDIS Measure Specifications
Version 2
Value Sets:
•
1115 SMI Monitoring Metrics
HEDIS Value Set Directory
Version 2

C.6

Instructions
Measure Specifications:
•
Step 1: Open “NCQA Measure
Specifications_v2.pdf” file (available in the 1115
SMI Monitoring Metrics Supporting Information
v2.zip file provided with this manual, or through
the Reference Materials section on PMDA).
•
Step 2: Locate specification for Adults’ Access
to Preventive/Ambulatory Health services (AAP)
•
Step 3: Follow the guidance in the measure
specification to calculate the metric and use the
HEDIS General Guideline 17_Hospice.pdf for
the hospice exclusion
Value Sets:
•
Step 1: Open “1115 SMI Monitoring Metrics
HEDIS Value Set Directory_v2.xls” file
(available in the 1115 SMI Monitoring Metrics
Supporting Information v2.zip file provided with
this manual, or through the Reference Materials
section on PMDA).
•
Step 2: Filter the “2020 Value Sets to Codes”
tab to select value set names (column A)
identified in metric specification.
•
Step 3: Include listed codes when calculating
metric.

APPENDIX C

MATHEMATICA

Table C.1. (continued)
Metrics

Supporting Measure Specifications,
Value Sets, and Code Lists

Established quality measures that use NCQA
specifications (and not part of HEDIS and not part of
the Medicaid Core Set):
•
#27: Tobacco Use Screening and Follow-up
for People with Serious Mental Illness or
Alcohol or Other Drug Dependence
•
#28: Alcohol Screening and Follow-up for
People with Serious Mental Illness

Measure Specifications:
•
NCQA Measure specifications
Value Sets:
•
1115 SMI Monitoring Metrics
HEDIS Value Set Directory

Established quality measures that use CMS
specifications developed for the Inpatient Psychiatric
Quality Reporting (IPFQR) program (and are not part
of the Medicaid Adult and Core Sets).
•
#5: Medication Reconciliation Upon
Admission
•
#6: Medication Continuation Following
Inpatient Psychiatric Discharge

Measure Specifications:
•
IPFQR CMS Measure
Specifications

Established quality measures that are based on the
CMS specifications from the Inpatient Psychiatric
Quality Reporting (IPFQR) program.
•
#4: 30-Day All-Cause Unplanned
Readmission Following Psychiatric
Hospitalization in an Inpatient Psychiatric
Facility (IPF)

Measure Specifications:
•
Claims-Based Measure
Specifications

C.7

Instructions
Measure Specifications:
•
Step 1: Open “NCQA Measure
Specifications_v2.pdf” file (available in the 1115
SMI Monitoring Metrics Supporting Information
v2.zip file accompanying this manual and the
Reference Materials section on PMDA).
•
Step 2: Locate specifications
•
Step 3: Follow the guidance in the measure
specification to calculate the metric
Value Sets:
•
Step 1: Open “1115 SMI Monitoring Metrics
HEDIS Value Set Directory_v2.xlsx” file
(available in the 1115 SMI Monitoring Metrics
Supporting Information v2.zip file
accompanying this manual and the Reference
Materials section on PMDA).
•
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
Measure Specifications:
•
Step 1: Open “IPFQR_CMS_ Measure
Specifications_v2.zip” file (available in the 1115
SMI Monitoring Metrics Supporting Information
v2.zip file accompanying this manual and the
Reference Materials section on PMDA).
•
Step 2: Locate specifications
•
Step 3: Follow the guidance in the measure
specification to calculate the metric
Measure Specifications:
•
Step 1: Download the Claims-based measure
Specifications (available at:
https://qualitynet.org/files/5df7a5ca62faad001ff
d7a87?filename=FY20_IPFQR_CBM_Specs.pd
f)
•
Step 2: Locate specification for 30-Day AllCause Unplanned Readmission Following
Psychiatric Hospitalization in an IPF

APPENDIX C

MATHEMATICA

Table C.1. (continued)
Metrics
Established quality measures that use CMS
specifications (and are not part of the Medicaid Child
and Adult Core Sets or IPFQR program).
•
#3: All-Cause Emergency Department
Utilization Rate for Medicaid Beneficiaries
who may Benefit From Integrated Physical
and Behavioral Health Care (PMH-20)
•
#30: Follow-up Care for Adult Medicaid
Beneficiaries Who are Newly Prescribed an
Antipsychotic Medication

Supporting Measure Specifications,
Value Sets, and Code Lists
Measure Specifications:
•
PMH-20 Tech Specs Manual
•
Follow-up Care Specs
Value Sets:
•
PMH-20 CCW Value Set
•
PMH-20 ED Value Set
•
PMH-20 SMI Value Set
•
Follow-up Care Codes

C.8

Instructions
Measure Specifications:
•
Step 1: Open
“Other_CMS_measurespecs_valuesets_v2.zip”
file (available in the 1115 SMI Monitoring
Metrics Supporting Information v2.zip file
accompanying this manual and the Reference
Materials section on PMDA).
•
Step 2: Locate specifications
•
Step 3: Follow the guidance in the measure
specification to calculate the metric
Value Sets:
•
Step 1: Open
“Other_CMS_measurespecs_valuesets_v2.zip”
and find the appropriate value set or code file
(available in the 1115 SMI Monitoring Metrics
Supporting Information v2.zip file
accompanying this manual and the Reference
Materials section on PMDA).

APPENDIX D
TECHNICAL SPECIFICATIONS FOR ESTABLISHED QUALITY MEASURES
ADAPTED FROM FFY 2020 CHILD AND ADULT CORE SET
MEASURE SPECIFICATIONS

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APPENDIX D

MATHEMATICA

This appendix provides the technical specifications for the Adult and Child Core Set
measures included in the 1115 SMI/SED monitoring metrics. These specifications have been
adapted from state-level specifications for use in the 1115 SMI/SED demonstration.
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 Core Set measure
included in the 1115 SMI/SED monitoring metrics can be found in Table D1. For many
measures, the denominator measurement period for FFY 2020 corresponds to calendar year 2019
(January 1, 2019–December 31, 2019). However, for some measures, the measurement period
begins before the calendar year. For example, the Metric #2: Use of First-Line Psychosocial Care
for Children and Adolescents on Antipsychotics (APP-CH) requires the state to review
utilization and continuous enrollment prior to January 1, 2019, when constructing the
denominator. This is referred to as a “look-back period” or a negative medication history review
period.
Continuous enrollment. Continuous enrollment specifies the minimum amount of time that
a beneficiary must be enrolled before becoming eligible for a measure and is determined by the
measure steward. The continuous enrollment period is specified for each measure in Table D1.
To be considered continuously enrolled, a beneficiary must also be continuously enrolled with
the benefit specified for each measure (e.g., pharmacy or mental health), accounting for any
allowable gap (see next bullet).
Allowable gap. Some measures specify an allowable gap that can occur any time during
continuous enrollment. The allowable gap specifies the maximum amount of time a beneficiary
can be unenrolled and still qualify for inclusion in the measure. The allowable gap is specified
for each measure in Table D1. For example, the Metric #29: Metabolic Monitoring for Children
and Adolescents on Antipsychotics (APM-CH) measure requires continuous enrollment
throughout the measurement year (January 1–December 31) and allows one gap in enrollment of
up to 45 days. Thus, a beneficiary who enrolls for the first time on February 1 of the
measurement year is considered continuously enrolled as long as there are no other gaps in
enrollment throughout the remainder of the measurement year, because this beneficiary has one
31-day gap (January 1–January 31). A beneficiary who switches between Medicaid or CHIP
programs, delivery systems, or managed care plans should be included in a measure as long as
there is no gap in Medicaid or CHIP coverage that exceeds the allowable gap specified in the
measure.
Anchor date. Some measures include an anchor date, which is the date that an individual
must be enrolled in the demonstration and have the required benefit 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
measurement period (for example, December 31, 2019 for the FFY 2020 measurement period).
For other measures, the anchor date is based on a specific event, such as an ED visit date or
prescription start date. The state should use the specified anchor dates along with the continuous
enrollment requirements and allowable gaps for each measure to determine the measure-eligible

D.3

APPENDIX D

MATHEMATICA

population. The anchor date (if any) is provided in the detailed measure specifications in Section
II of this appendix below.
Hospice exclusion. The SMI/SED monitoring metrics #2, 7, 8, 9, 10, 23, and 29 include a
required hospice exclusion. For these measures, a state should 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 data, or
claims/encounter data (Hospice Encounter Value Set; Hospice Intervention Value Set), or
supplemental data. Supplemental data are data other than claims and encounters used by
organizations to collect information about delivery of health services to their beneficiaries. An
example of supplemental data includes case management program data. The Hospice Encounter
Value Set and Hospice Intervention Value Set are provided in the 1115 SMI Monitoring Metrics
Supporting Information v2.zip file accompanying this manual. These materials are also available
to the state through PMDA in the Reference Materials section.
The state should remove these beneficiaries prior to determining a measure’s eligible
population and drawing the sample for hybrid measures. If a beneficiary is found to be in hospice
or using hospice services during medical record review, the beneficiary is removed as a valid
data error from the sample and replaced by a beneficiary from the oversample. 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.
Telehealth. Some Core Set measures included in the 1115 SMI monitoring metrics are
HEDIS measures that include synchronous telehealth (which requires real-time interactive audio
and video telecommunications), telephone visits and online assessments, as appropriate. A
HEDIS measure specification will indicate when telephone visits or online assessments are
eligible for use in reporting. This applies to the following metrics: 2, 8, 10, and 23.
•

A HEDIS measure specification that is silent about telehealth includes telehealth. This is
because telehealth is billed using standard CPT and HCPCS codes for professional
services in conjunction with a telehealth modifier and/or a telehealth POS code.
Therefore, the CPT or HCPCS code in the value set will meet criteria (regardless of
whether a telehealth modifier or POS code is present).

•

A HEDIS measure specification will indicate when telehealth is not eligible for use and
should be excluded.

D.4

APPENDIX D

MATHEMATICA

Table D.1. Measurement Period for Denominators and Numerators for the section 1115 SMI/SED Monitoring Metrics Adapted from FFY
2020 Adult and Child Core Sets Measures
FFY 2020 Measurement Perioda
Measure
Metric #2: Use of First-Line
Psychosocial Care for Children
and Adolescents on
Antipsychotics (APP-CH)

Metric #7: Follow-up After
Hospitalization for Mental
Illness: Ages 6–17 (FUH-CH)

Denominator
IPSD: January 1, 2019 –
December 1, 2018
Negative medication history
review: September 3, 2018 –
August 3, 2019
(120 days before the IPSD)
Discharge date: January 1,
2019 – December 31, 2019

Metric #8: Follow-up After
Hospitalization for Mental
Illness: Age 18 and Older
(FUH-AD)

Discharge date: January 1,
2019 – December 1, 2019

Metric #9: Follow-up After
Emergency Department Visit for
Alcohol and Other Drug Abuse
or Dependence (FUA-AD)

Emergency Department (ED)
visit date: January 1, 2019 –
December 1, 2019

Numerator

Continuous Enrollment Period

October 3, 2018 – December 31,
2019
(90 days prior to IPSD through 30
days after the IPSD)

September 3, 2018 - December 31,
2019
(120 days prior to IPSD through 30
days after IPSD)

7 Day Follow-up: January 2, 2019 –
December 8, 2019
(7 days after discharge date)
30 Day Follow-up: January 2, 2019
– December 31, 2019
(30 days after discharge date)
7 Day Follow-up: January 2, 2019 –
December 8, 2019
(7 days after discharge date)
30 Day Follow-up: January 2, 2019
– December 31, 2019
(30 days after discharge date)
7 Day Follow-up: January 1, 2019 –
December 8, 2019
(ED visit date through 7 days after
visit date)
30 Day Follow-up: January 1, 2019
– December 31, 2019
(ED visit date through 30 days after
visit date)

January 1, 2019 – December 31,
2019
(30 days after discharge date)

D.5

January 1, 2019 – December 31,
2019
(30 days after discharge date)

January 1, 2019 – December 31,
2019
(ED visit date through 30 days after
visit date)

APPENDIX D

MATHEMATICA

FFY 2020 Measurement Perioda
Measure

Denominator

Numerator

Continuous Enrollment Period

Metric #10: Follow-up After
Emergency Department Visit for
Mental Illness (FUM-AD)

ED visit date: January 1, 2019 –
December 1, 2019

January 1, 2019 – December 31,
2019
(ED visit date through 30 days after
visit date)

Metric #23: Diabetes Care for
People With Serious Mental
Illness: Hemoglobin A1c
(HBA1c) Poor Control
(>9.0%)(HPCMI-AD)
Metric #24: Screening for
Depression and Follow-up Plan:
Age 18 and Older (CDF-AD)
Metric #25: Screening for
Depression and Follow-up Plan:
Ages 12-17 (CDF-CH)
Metric #29: Metabolic
Monitoring for Children and
Adolescents on Antipsychotics
(APM-CH)

January 1, 2019 – December
31, 2019
Diabetes diagnosis: January 1,
2018 – December 31, 2019

7 Day Follow-up: January 1, 2019 –
December 8, 2019
(ED visit date through 7 days after
visit date)
30 Day Follow-up: January 1, 2019
– December 31, 2019
(ED visit date through 30 days after
visit date)
January 1, 2019 – December 31,
2019

January 1, 2019 – December 31,
2019b

January 1, 2019 – December
31, 2019

January 1, 2019 – December 31,
2019

None

January 1, 2019 – December
31, 2019

January 1, 2019 – December 31,
2019

None

January 1, 2019 – December
31, 2019

January 1, 2019 – December 31,
2019

January 1, 2019 – December 31,
2019b

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 prescription or treatment start dates and discharge dates). For these measures, two ranges are shown. The first date range identifies the full
range of possible dates that a state 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 No more than one gap in enrollment of up to 45 days during the continuous enrollment period.

D.6

APPENDIX D

MATHEMATICA

II. DEFINITION OF A MENTAL HEALTH PRACITIONER

The Adult and Child Core Sets define a mental health practitioner as a practitioner who
provides mental health services and meets any of the following criteria:
•

An MD or Doctor of Osteopathy (DO) who is certified as a psychiatrist or child
psychiatrist by the American Medical Specialties Board of Psychiatry and Neurology or
by the American Osteopathic Board of Neurology and Psychiatry; or, if not certified, who
successfully completed an accredited program of graduate medical or osteopathic
education in psychiatry or child psychiatry and is licensed to practice patient care
psychiatry or child psychiatry, if required by the state of practice

•

An individual who is licensed as a psychologist in his/her state of practice, if required by
the state of practice

•

An individual who is certified in clinical social work by the American Board of
Examiners; who is listed on the National Association of Social Worker’s Clinical
Register; or who has a master’s degree in social work and is licensed or certified to
practice as a social worker, if required by the state of practice

•

A Registered Nurse (RN) who is certified by the American Nurses Credentialing Center
(a subsidiary of the American Nurses Association) as a psychiatric nurse or mental health
clinical nurse specialist, or who has a master’s degree in nursing with a specialization in
psychiatric/mental health and two years of supervised clinical experience and is licensed
to practice as a psychiatric or mental health nurse, if required by the state of practice

•

An individual (normally with a master’s or a doctoral degree in marital and family
therapy and at least two years of supervised clinical experience) who is practicing as a
marital and family therapist and is licensed or a certified counselor by the state of
practice, or if licensure or certification is not required by the state of practice, who is
eligible for clinical membership in the American Association for Marriage and Family
Therapy

•

An individual (normally with a master’s or doctoral degree in counseling and at least two
years of supervised clinical experience) who is practicing as a professional counselor and
who is licensed or certified to do so by the state of practice, or if licensure or certification
is not required by the state of practice, is a National Certified Counselor with Specialty
Certification in Clinical Mental Health Counseling from the National Board for Certified
Counselors (NBCC)

D.7

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MEASURE APP-CH: USE OF FIRST-LINE PSYCHOSOCIAL CARE FOR CHILDREN AND ADOLESCENTS
ON ANTIPSYCHOTICS

MATHEMATICA

III. TECHNICAL SPECIFICATIONS

Metric #2: Use of First-Line Psychosocial Care for Children and Adolescents
on Antipsychotics (APP-CH)
Measure Steward: National Committee for Quality Assurance
Developed with financial support from the Agency for Healthcare Research and Quality (AHRQ)
and CMS under the CHIPRA Pediatric Quality Measures Program Centers of Excellence grant
number U18HS025296.
A. DESCRIPTION
Percentage of children and adolescents ages 1 to 17 who had a new prescription for an
antipsychotic medication and had documentation of psychosocial care as first-line
treatment.
Data Collection Method: Administrative
Guidance for Reporting:
• This measure intends to assess use of psychosocial care as a first-line treatment
for conditions for which antipsychotic medications are not indicated. This
measure’s value set contains typical forms of psychological services, such as
behavioral interventions, psychological therapies, and crisis intervention.
• 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 Antipsychotic
Medications and Antipsychotic Combination Medications is available to order free
of charge in the NCQA Store
(http://store.ncqa.org/index.php/catalog/product/view/id/3741/s/hedis-2020-ndc).
Once ordered, the Medication List Directory can be accessed through the NCQA
Download Center (https://my.ncqa.org/?ReturnUrl=%2fDownloads).
The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, ICD-10PCS, Modifier, NDC, POS, RxNorm, SNOMED, and UB. Refer to the Acknowledgments
section at the beginning of the manual for copyright information.
B. DEFINITION
Intake Period

January 1 through December 1 of the measurement year.

IPSD

Index Prescription Start Date (IPSD). The earliest prescription
dispensing date for an antipsychotic medication where the date is in
the Intake Period and there is a Negative Medication History.

Negative
Medication
History

A period of 120 days (4 months) before the IPSD when the beneficiary
had no antipsychotic medications dispensed for either new or refill
prescriptions.

Version of Specification: HEDIS 2020

D.9

MEASURE APP-CH: USE OF FIRST-LINE PSYCHOSOCIAL CARE FOR CHILDREN AND ADOLESCENTS
ON ANTIPSYCHOTICS

MATHEMATICA

C. ELIGIBLE POPULATION
Age

Ages 1 to 17 as of December 31 of the measurement year. Report two
age stratifications and a total rate:
• Ages 1 to 11
• Ages 12 to 17
• Total ages 1 to 17

Continuous
enrollment

120 days (4 months) prior to the IPSD through 30 days after the IPSD.

Allowable gap

No allowable gaps in the continuous enrollment period.

Anchor date

IPSD.

Benefit

Medical, mental health, and pharmacy.

Event/diagnosis

Follow the steps below to identify the eligible population.
Step 1
Identify all beneficiaries in the specified age range who were
dispensed an antipsychotic medication (Antipsychotic Medications List
and Antipsychotic Combination Medications List, see link to the
Medication List Directory in Guidance for Reporting above) during the
Intake Period.
Step 2
Test for Negative Medication History. For each beneficiary identified in
step 1, test each antipsychotic prescription for a Negative Medication
History. The IPSD is the dispensing date of the earliest antipsychotic
prescription in the Intake Period with a Negative Medication History.
Step 3
Calculate continuous enrollment. Beneficiaries must be continuously
enrolled for 120 days (4 months) prior to the IPSD through 30 days
after the IPSD.
Step 4: Required Exclusions
Exclude beneficiaries for whom first-line antipsychotic medications
may be clinically appropriate. Any of the following during the
measurement year meet criteria:
• At least one acute inpatient encounter with a diagnosis of
schizophrenia, schizoaffective disorder, bipolar disorder, other
psychotic disorder, autism, or other developmental disorder
during the measurement year. Any of the following code
combinations meet criteria:
- BH Stand Alone Acute Inpatient Value Set with
(Schizophrenia Value Set; Bipolar Disorder Value Set;
Other Psychotic and Developmental Disorders Value
Set)
- Visit Setting Unspecified Value Set with Acute Inpatient
POS Value Set with (Schizophrenia Value Set; Bipolar
Disorder Value Set; Other Psychotic and
Developmental Disorders Value Set)

Version of Specification: HEDIS 2020

D.10

MEASURE APP-CH: USE OF FIRST-LINE PSYCHOSOCIAL CARE FOR CHILDREN AND ADOLESCENTS
ON ANTIPSYCHOTICS

Event/diagnosis
(continued)

•

MATHEMATICA

At least two visits in an outpatient, intensive outpatient, or
partial hospitalization setting, on different dates of service, with
a diagnosis of schizophrenia, schizoaffective disorder, bipolar
disorder, other psychotic disorder, autism, or other
developmental disorder during the measurement year. Any of
the following code combinations with (Schizophrenia Value Set;
Bipolar Disorder Value Set; Other Psychotic and
Developmental Disorders Value Set), meet criteria:
- An outpatient visit (Visit Setting Unspecified Value Set
with Outpatient POS Value Set)
- An outpatient visit (BH Outpatient Value Set)
- An intensive outpatient encounter or partial
hospitalization (Visit Setting Unspecified Value Set with
Partial Hospitalization POS Value Set)
- An intensive outpatient encounter or partial
hospitalization (Partial Hospitalization or Intensive
Outpatient Value Set)
- A community mental health center visit (Visit Setting
Unspecified Value Set with Community Mental Health
Center POS Value Set)
- Electroconvulsive therapy (Electroconvulsive Therapy
Value Set)
- An observation visit (Observation Value Set)
- A telehealth visit (Visit Setting Unspecified Value Set
with Telehealth POS Value Set)

D. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerator
Documentation of psychosocial care (Psychosocial Care Value Set) in the 121-day period
from 90 days prior to the IPSD through 30 days after the IPSD.

Version of Specification: HEDIS 2020

D.11

MEASURE FUH-CH: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGES 6-17

MATHEMATICA

Metric #7: Follow-up After Hospitalization for Mental Illness: Ages 6-17
(FUH-CH)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of discharges for children ages 6 to 17 who were hospitalized for treatment of
selected mental illness or intentional self-harm diagnoses and who had a follow-up visit with
a mental health practitioner. Two rates are reported:
•

Percentage of discharges for which the child received follow-up within 30 days after
discharge

•

Percentage of discharges for which the child received follow-up within 7 days after
discharge

Data Collection Method: Administrative
Guidance for Reporting:
• Follow the detailed specifications to (1) include the appropriate discharge when
the beneficiary was transferred directly or readmitted to an acute or non-acute
care facility for a mental health diagnosis, and (2) exclude discharges in which the
beneficiary was transferred directly or readmitted to an acute or non-acute care
facility for a non-mental health diagnosis.
• The denominator for this measure 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.
• This measure specifies that when a visit code or procedure code must be used in
conjunction with a diagnosis code, both the visit/procedure code and the
diagnosis code must be on the same claim or from the same visit.
• This measure references value sets that include codes used on professional
claims (e.g., CPT, HCPCS) and codes used on facility claims (e.g., UB).
Diagnosis and procedure codes from both facility and professional claims should
be used to identify services and diagnoses (the codes can be on the same claim
or from the save visit).
• For value sets that include codes used only on facility claims (e.g., UB), use
facility claims only 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
• Refer to Section II: Definition of a Mental Health Practitioner for the definition of a
mental health practitioner.
The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, ICD-10PCS, POS, Provider Taxonomy, SNOMED, and UB. Refer to the Acknowledgments section
at the beginning of the manual for copyright information.

Version of Specification: HEDIS 2020

D.12

MEASURE FUH-CH: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGES 6-17

MATHEMATICA

B. ELIGIBLE POPULATION
Age
Continuous
enrollment
Allowable gap
Anchor date
Benefit
Event/diagnosis

Acute readmission
or direct transfer

Ages 6 to 17 as of date of discharge.
Date of discharge through 30 days after discharge.
No allowable gaps in the continuous enrollment period.
None.
Medical and mental health (inpatient and outpatient).
An acute inpatient discharge with a principal diagnosis of
mental illness or intentional self-harm (Mental Illness Value Set;
Intentional Self-Harm Value Set) on the discharge claim on or
between January 1 and December 1 of the measurement year.
To identify acute inpatient discharges:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set).
3. Identify the discharge date for the stay to determine whether it
falls on or between January 1 and December 1 of the
measurement year.
The denominator for this measure is based on discharges, not on
beneficiaries. If beneficiaries have more than one discharge,
include all discharges on or between January 1 and December 1 of
the measurement year.
Identify readmissions and direct transfers to an acute inpatient care
setting during the 30-day follow-up period:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set).
3. Identify the admission date for the stays to determine whether
they fall after December 1 of the measurement year.
Exclude both the initial discharge and the readmission/direct
transfer discharge if the last discharge occurs after December 1 of
the measurement year. If the readmission/direct transfer to the
acute inpatient care setting was for a principal diagnosis (use only
the principal diagnosis on the discharge claim) of mental health
disorder or intentional self-harm (Mental Health Diagnosis Value
Set; Intentional Self-Harm Value Set), count only the last discharge.
If the readmission/direct transfer to the acute inpatient care setting
was for any other principal diagnosis (use only the principal
diagnosis on the discharge claim) exclude both the original and the
readmission/direct transfer discharge.

Version of Specification: HEDIS 2020

D.13

MEASURE FUH-CH: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGES 6-17

Nonacute
readmission or
direct transfer

MATHEMATICA

Exclude discharges followed by readmission or direct transfer to a
nonacute inpatient care setting within the 30-day follow-up period,
regardless of principal diagnosis for the readmission. To identify
readmissions and direct transfers to a nonacute inpatient care
setting:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Confirm the stay was for nonacute care based on the presence
of a nonacute code (Nonacute Inpatient Stay Value Set) on the
claim.
3. Identify the admission date for the stay to determine whether it
occurs within the 30-day follow-up period.
These discharges are excluded from this measure because
rehospitalization or direct transfer may prevent an outpatient
followup visit from taking place.

C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerators
30 Day Follow-up: A follow-up visit with a mental health practitioner within 30 days after
discharge. Do not include visits that occur on the date of discharge.
7 Day Follow-up: A follow-up visit with a mental health practitioner within 7 days after
discharge. Do not include visits that occur on the date of discharge.
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 mental health practitioner (Mental Health Practitioner Value Set)

•

An outpatient visit (BH Outpatient Value Set) with a mental health practitioner (Mental
Health Practitioner Value Set)

•

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified
Value Set) with (Partial Hospitalization POS Value Set) with a mental health
practitioner (Mental Health Practitioner Value Set)

•

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or
Intensive Outpatient Value Set) with a mental health practitioner (Mental Health
Practitioner Value Set)

•

A community mental health center visit (Visit Setting Unspecified Value Set) with
(Community Mental Health Center POS Value Set) with a mental health practitioner
(Mental Health Practitioner 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 mental health
practitioner (Mental Health Practitioner Value Set)

•

A telehealth visit (Visit Setting Unspecified Value Set) with (Telehealth POS Value Set)
with a mental health practitioner (Mental Health Practitioner Value Set)

Version of Specification: HEDIS 2020

D.14

MEASURE FUH-CH: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGES 6-17

MATHEMATICA

•

An observation visit (Observation Value Set) with a mental health practitioner (Mental
Health Practitioner Value Set)

•

Transitional care management services (Transitional Care Management Services
Value Set), with a mental health practitioner (Mental Health Practitioner Value Set)

D. ADDITIONAL NOTE
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 period specified (e.g., within 30 days
after discharge or within 7 days after discharge).
The Mental Health Practitioner Value Set contains provider taxonomy codes and is included
for a state that reports the measure using clinical data. If a state does not use the codes in
the Mental Health Practitioner Value Set, it must map providers to a code in the value set
for reporting. Only providers who meet the definition of “mental health practitioner” (Section
II: Definition of a Mental Health Practitioner) are eligible to be mapped.
Because taxonomy codes are not found in claims data, a state must develop their own
methods to identify mental health practitioners in claims data. Refer to Section II: Definition
of a Mental Health Practitioner for the definition of “mental health practitioner.”

Version of Specification: HEDIS 2020

D.15

MEASURE FUH-AD: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGE 18 AND OLDER

MATHEMATICA

Metric #8: Follow-up After Hospitalization for Mental Illness: Age 18 and Older
(FUH-AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of discharges for beneficiaries age 18 and older who were hospitalized for
treatment of selected mental illness or intentional self-harm diagnoses and who had a
follow-up visit with a mental health practitioner. Two rates are reported:
•

Percentage of discharges for which the beneficiary received follow-up within 30 days
after discharge

•

Percentage of discharges for which the beneficiary received follow-up within 7 days
after discharge

Data Collection Method: Administrative
Guidance for Reporting:
•

•
•
•

•
•
•

Follow the detailed specifications to (1) include the appropriate discharge when the
beneficiary was transferred directly or readmitted to an acute or non-acute care
facility for a mental health diagnosis, and (2) exclude discharges in which the
beneficiary was transferred directly or readmitted to an acute or non-acute care
facility for a non-mental health diagnosis.
The denominator for this measure 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.
This measure specifies that when a visit code or procedure code must be used in
conjunction with a diagnosis code, both the visit/procedure code and the diagnosis
code must be on the same claim or from the same visit.
- This measure references value sets that include codes used on professional
claims (e.g., CPT, HCPCS) and codes used on facility claims (e.g., UB).
Diagnosis and procedure codes from both facility and professional claims
should be used to identify services and diagnoses (the codes can be on the
same claim or from the same visit).
- For value sets that include codes used only on facility claims (e.g., UB), use
facility claims only 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
Refer to Section II: Definition of a Mental Health Practitioner for the definition of a
mental health practitioner.

The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, ICD-10PCS, POS, Provider Taxonomy, SNOMED and UB. Refer to the Acknowledgments section
at the beginning of the manual for copyright information.

Version of Specification: HEDIS 2020

D.16

MEASURE FUH-AD: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGE 18 AND OLDER

MATHEMATICA

B. ELIGIBLE POPULATION
Age

Age 18 and older as of date of discharge.

Continuous
enrollment

Date of discharge through 30 days after discharge.

Allowable gap

No allowable gaps in the continuous enrollment period.

Anchor date

None.

Benefit

Medical and mental health (inpatient and outpatient).

Event/diagnosis An acute inpatient discharge with a principal diagnosis of mental illness
or intentional self-harm (Mental Illness Value Set; Intentional Self-Harm
Value Set) on the discharge claim on or between January 1 and
December 1 of the measurement year.
To identify acute inpatient discharges:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set).
3. Identify the discharge date for the stay to determine whether it
falls on or between January 1 and December 1 of the
measurement year.
The denominator for this measure is based on discharges, not on
beneficiaries. If beneficiaries have more than one discharge, include all
discharges on or between January 1 and December 1 of the
measurement year.
Acute
readmission or
direct transfer

Identify readmissions and direct transfers to an acute inpatient care
setting during the 30-day follow-up period:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set).
3. Identify the admission date for the stays to determine whether
they occur after December 1 of the measurement year.
Exclude both the initial discharge and the readmission/direct transfer
discharge if the last discharge occurs after December 1 of the
measurement year.
If the readmission/direct transfer to the acute inpatient care setting was
for a principal diagnosis (use only the principal diagnosis on the
discharge claim) of mental health disorder or intentional self-harm
(Mental Health Diagnosis Value Set; Intentional Self-Harm Value Set),
count only the last discharge.
If the readmission/direct transfer to the acute inpatient care setting was
for any other principal diagnosis (use only the principal diagnosis on
the discharge claim) exclude both the original and the
readmission/direct transfer discharge.

Version of Specification: HEDIS 2020

D.17

MEASURE FUH-AD: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGE 18 AND OLDER

Nonacute
readmission or
direct transfer

MATHEMATICA

Exclude discharges followed by readmission or direct transfer to a
nonacute inpatient care setting within the 30-day follow-up period,
regardless of principal diagnosis for the readmission. To identify
readmissions and direct transfers to a nonacute inpatient care setting:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Confirm the stay was for nonacute care based on the
presence of a nonacute code (Nonacute Inpatient Stay Value
Set) on the claim.
3. Identify the admission date for the stay to determine whether it
occurs within the 30-day follow-up period.
These discharges are excluded from this measure because
rehospitalization or direct transfer may prevent an outpatient follow-up
visit from taking place.

C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerators
30-Day Follow-up: A follow-up visit with a mental health practitioner within 30 days after
discharge. Do not include visits that occur on the date of discharge.
7-Day Follow-up: A follow-up visit with a mental health practitioner within 7 days after
discharge. Do not include visits that occur on the date of discharge.
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 mental health practitioner (Mental Health Practitioner Value Set)

•

An outpatient visit (BH Outpatient Value Set) with a mental health practitioner (Mental
Health Practitioner Value Set)

•

An intensive outpatient encounter or partial hospitalization (Visit Setting Unspecified
Value Set with Partial Hospitalization POS Value Set) with a mental health practitioner
(Mental Health Practitioner Value Set)

•

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or
Intensive Outpatient Value Set) with a mental health practitioner (Mental Health
Practitioner Value Set)

•

A community mental health center visit (Visit Setting Unspecified Value Set with
Community Mental Health Center POS Value Set) with a mental health practitioner
(Mental Health Practitioner 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 mental health
practitioner (Mental Health Practitioner Value Set)

•

A telehealth visit: Visit Setting Unspecified Value Set with Telehealth POS Value Set
with a mental health practitioner (Mental Health Practitioner Value Set)

Version of Specification: HEDIS 2020

D.18

MEASURE FUH-AD: FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS: AGE 18 AND OLDER

MATHEMATICA

•

An observation visit (Observation Value Set) with a mental health practitioner (Mental
Health Practitioner Value Set)

•

Transitional care management services (Transitional Care Management Services Value
Set), with a mental health practitioner (Mental Health Practitioner 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 period specified for the rate (e.g., within
30 days after discharge or within 7 days after discharge).
The Mental Health Practitioner Value Set contains provider taxonomy codes and is included
for a state that reports the measure using clinical data. If a state does not use the codes in
the Mental Health Practitioner Value Set, it must map providers to a code in the value set
for reporting. Only providers who meet the definition of “mental health practitioner” (refer to
Section II: Definition of a Mental Health Practitioner) are eligible to be mapped.
Because provider taxonomy codes are not found in claims data, a state must develop their
own methods to identify mental health practitioners in claims data. Refer to Section II:
Definition of a Mental Health Practitioner.

Version of Specification: HEDIS 2020

D.19

MEASURE FUA-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR ALCOHOL AND OTHER DRUG ABUSE
OR DEPENDENCE
MATHEMATICA

Metric #9: Follow-up After Emergency Department Visit for Alcohol and Other
Drug Abuse Dependence (FUA-AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of emergency department (ED) visits for beneficiaries age 18 and older with a
principal diagnosis of alcohol or other drug (AOD) abuse or dependence who had a followup visit for AOD abuse or dependence. Two rates are reported:
•

Percentage of ED visits for which the beneficiary received follow-up within 30 days of
the ED visit (31 total days)

•

Percentage of ED visits 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 from the same visit.
- 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
from the same visit).
- 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, POS,
SNOMED, and UB. Refer to the Acknowledgments section at the beginning of the manual
for copyright information.
B. ELIGIBLE POPULATION
Age
Continuous
enrollment
Allowable gap
Anchor date
Benefit

Age 18 and older as of the ED visit.
Date of the ED visit through 30 days after the ED visit (31 total
days).
No allowable gaps in the continuous enrollment period.
None.
Medical and chemical dependency.
Note: Beneficiaries with detoxification-only chemical dependency
benefits do not meet these criteria.

Version of Specification: HEDIS 2020

D.20

MEASURE FUA-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR ALCOHOL AND OTHER DRUG ABUSE
OR DEPENDENCE
MATHEMATICA

Event/diagnosis

Multiple visits in a
31-day period

ED visits followed
by inpatient
admission

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.
The denominator for this measure is based on ED visits, not on
beneficiaries. 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 31day 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.

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:
Version of Specification: HEDIS 2020

D.21

MEASURE FUA-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR ALCOHOL AND OTHER DRUG ABUSE
OR DEPENDENCE
MATHEMATICA

•

IET Stand Alone Visits Value Set with a principal diagnosis of AOD abuse or
dependence (AOD Abuse and Dependence 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)

•

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)

•

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 2020

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MEASURE FUA-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR MENTAL ILLNESS

MATHEMATICA

Metric #10: 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 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 for which the beneficiary received follow-up
within 30 days of the ED visit (31 total days)

•

Percentage of ED visits for mental illness 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 from the same visit.
- 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
from the same visit).
- 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, ICD-10PCS, POS, SNOMED, and UB. Refer to the Acknowledgments section at the beginning of
the manual for copyright information.
B. ELIGIBLE POPULATION
Ages

Age 18 and older as of the date of the ED visit.

Continuous
enrollment

Date of the ED visit through 30 days after the ED visit (31 total
days).

Allowable gap

No allowable gaps in the continuous enrollment period.

Anchor date

None.

Benefit

Medical and mental health.

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MEASURE FUM-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR MENTAL ILLNESS

24

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.
The denominator for this measure is based on ED visits, not on
beneficiaries. 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 31day 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.

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
Version of Specification: HEDIS 2020

D.24

MEASURE FUM-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR MENTAL ILLNESS

25

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)

•

An outpatient visit (BH Outpatient Value Set) with a principal diagnosis of a mental
health disorder (Mental Health Diagnosis 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)

•

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or
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)

•

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)

•

An observation visit (Observation Value Set) with a principal diagnosis of a mental
health disorder (Mental Health Diagnosis Value Set)

•

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)

•

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)

•

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)

•

An intensive outpatient encounter or partial hospitalization (Partial Hospitalization or
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)

Version of Specification: HEDIS 2020

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MEASURE FUM-AD: FOLLOW-UP AFTER EMERGENCY DEPARTMENT VISIT FOR MENTAL ILLNESS

26

•

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)

•

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 2020

D.26

MEASURE HPCMI-AD: DIABETES CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS:
HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9.0%)

MATHEMATICA

Metric #23: Diabetes Care for Patients with Serious Mental Illness:
Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (HPCMI-AD)
Measure Steward: National Committee for Quality Assurance
A. DESCRIPTION
Percentage of beneficiaries ages 18 to 75 with a serious mental illness and diabetes (type 1
and type 2) whose most recent Hemoglobin A1c (HbA1c) level during the measurement
year is > 9.0%.
Note: A lower rate indicates better performance.
Data Collection Method: Administrative or Hybrid
Guidance for Reporting:
•
•
•

•

This is a NCQA owned and copyrighted measure that is not currently contained in
HEDIS®.
Include all paid, suspended, pending, and denied claims.
Beneficiaries in hospice are excluded from the eligible population. If a state
reports this measure using the Hybrid method, and a beneficiary is found to be in
hospice or using hospice services during medical record review, the beneficiary is
removed from the sample and replaced by a beneficiary from the oversample. 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 Dementia Medications
and Diabetes Medications is available to order free of charge in the NCQA Store
(http://store.ncqa.org/index.php/catalog/product/view/id/3741/s/hedis-2020-ndc).
Once ordered, the Medication List Directory can be accessed through the NCQA
Download Center (https://my.ncqa.org/?ReturnUrl=%2fDownloads)..

The following coding systems are used in this measure: CPT, HCPCS, ICD-10-CM, ICD-10PCS, LOINC, Modifier, NDC, POS, RxNorm, SNOMED, and UB. Refer to the
Acknowledgments section at the beginning of the manual for copyright information.
B. ELIGIBLE POPULATION
Age

Ages 18 to 75 as of December 31 of the measurement year.

Continuous
enrollment

The measurement year.

Allowable
gap

No more than one gap in continuous enrollment of up to 45 days during
the measurement year. 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.

Benefit

Medical.

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MEASURE HPCMI-AD: DIABETES CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS:
HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9.0%)

Event/
diagnosis

MATHEMATICA

Follow the steps below to identify beneficiaries with diabetes and serious
mental illness.
Step 1
Identify beneficiaries ages 18 to 75 as of the end of the measurement
year.
Step 2
Identify beneficiaries from step 1 with a diagnosis of serious mental illness.
Beneficiaries are identified as having serious mental illness if they met at
least one of the following criteria during the measurement year:
• At least one acute inpatient claim/encounter with any diagnosis of
schizophrenia, schizoaffective disorder or bipolar disorder using
any of the following code combinations:
- BH Stand Alone Acute Inpatient Value Set with
(Schizophrenia Value Set; Bipolar Disorder Value Set;
Other Bipolar Disorder Value Set)
- Visit Setting Unspecified Value Set with Acute Inpatient
POS Value Set with Schizophrenia Value Set; Bipolar
Disorder Value Set; Other Bipolar Disorder Value Set
OR
• At least two of the following, on different dates of service, with or
without a telehealth modifier (Telehealth Modifier Value Set) where
both encounters have any diagnosis of schizophrenia or
schizoaffective disorder (Schizophrenia Value Set) or both
encounters have any diagnosis of bipolar disorder (Bipolar
Disorder Value Set; Other Bipolar Disorder Value Set)
- An outpatient visit (Visit Setting Unspecified Value Set) with
Outpatient POS Value Set
- An outpatient visit (BH Outpatient Value Set)
- An intensive outpatient encounter or partial hospitalization
(Visit Setting Unspecified Value Set with Partial
Hospitalization POS Value Set)
- An intensive outpatient encounter or partial hospitalization
(Partial Hospitalization or Intensive Outpatient Value Set)
- A community mental health center visit (Visit Setting
Unspecified Value Set with Community Mental Health
Center POS Value Set)
- Electroconvulsive therapy (Electroconvulsive Therapy
Value Set)
- An observation visit (Observation Value Set)
- An ED visit (ED Value Set)
- An ED visit (Visit Setting Unspecified Value Set with ED
POS Value Set)
- A nonacute inpatient encounter (BH Stand Alone Nonacute
Inpatient Value Set)
- A nonacute inpatient encounter (Visit Setting Unspecified
Value Set with Nonacute Inpatient POS Value Set)
- A telehealth visit (Visit Setting Unspecified Value Set with
Telehealth POS Value Set)

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MEASURE HPCMI-AD: DIABETES CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS:
HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9.0%)

Event/
diagnosis
(continued)

MATHEMATICA

Step 3
Identify beneficiaries from step 2 with diabetes. There are two ways to
identify beneficiaries with diabetes: by claim/encounter data and by
pharmacy data. The state must use both methods to identify the eligible
population, but a beneficiary need only be identified by one method to be
included in this measure. Beneficiaries may be identified as having
diabetes during the measurement year or the year prior to the
measurement year.
Claim/encounter data. Beneficiaries who met any of the following criteria
during the measurement year or the year prior to the measurement year
(count services that occur over both years):
• At least one acute inpatient encounter (Acute Inpatient Value Set), with a
diagnosis of diabetes (Diabetes Value Set) without (Telehealth Modifier
Value Set; Telehealth POS Value Set)
• At least one acute inpatient discharge with a diagnosis of diabetes
(Diabetes Value Set) on the discharge claim. To identify an acute
inpatient discharge:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value
Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value
Set).
3. Identify the discharge date for the stay.
• At least two outpatient visits (Outpatient Value Set), observation visits
(Observation Value Set), telehealth visits (Telephone Visits Value Set),
online assessments (Online Assessments Value Set), ED visits (ED
Value Set), or nonacute inpatient encounters (Nonacute Inpatient Value
Set), or nonacute inpatient discharges (instructions below; the diagnosis
must be on the discharge claim), on different dates of service, with a
diagnosis of diabetes (Diabetes Value Set). Visit type need not be the
same for the two encounters. To identify a nonacute inpatient discharge:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value
Set).
2. Confirm the stay was for nonacute care based on the presence of a
nonacute code (Nonacute Inpatient Stay Value Set) on the claim.
3. Identify the discharge date for the stay.
Only include nonacute inpatient encounters (Nonacute Inpatient Value
Set) without telehealth (Telehealth Modifier Value Set; Telehealth POS
Value Set)
Only one of the two visits may be an outpatient telehealth visit, a
telephone visit or an online assessment. Identify telehealth visits by the
presence of a telehealth modifier (Telehealth Modifier Value Set) or the
presence of a telehealth POS code (Telehealth POS Value Set)
associated with the outpatient visit. Pharmacy data. Beneficiaries who
were dispensed insulin or hypoglycemics/ antihyperglycemics on an
ambulatory basis during the measurement year or the year prior to the
measurement year. For prescriptions that can be used to identify
beneficiaries with diabetes, refer to the Diabetes Medications List (see link
to the Medication List Directory in Guidance for Reporting above).

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MEASURE HPCMI-AD: DIABETES CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS:
HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9.0%)

Exclusions

MATHEMATICA

Exclude beneficiaries age 66 and older as of December 31 of the
measurement year with frailty and advanced illness. Beneficiaries must
meet both of the following frailty and advanced illness criteria to be
excluded:
1.
At least one claim/encounter for frailty (Frailty Device Value Set;
Frailty Diagnosis Value Set; Frailty Encounter Value Set; Frailty
Symptom Value Set) during the measurement year
2.
Any of the following during the measurement year or the year prior to
the measurement year (count services that occur over both years):
- At least two outpatient visits (Outpatient Value Set), observation
visits (Observation Value Set), ED visits (ED Value Set),
nonacute inpatient encounters (Nonacute Inpatient Value Set), or
nonacute inpatient discharges (instructions below; the diagnosis
must be on the discharge claim) on different dates of service, with
an advanced illness diagnosis (Advanced Illness Value Set). Visit
type need not be the same for the two visits. To identify a
nonacute inpatient discharge:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Confirm the stay was for nonacute care based on the
presence of a nonacute code (Nonacute Inpatient Stay Value
Set) on the claim.
3. Identify the discharge date for the stay.
- At least one acute inpatient encounter (Acute Inpatient Value Set)
with an advanced illness diagnosis (Advanced Illness Value Set)
- At least one acute inpatient discharge with an advanced illness
diagnosis (Advanced Illness Value Set) on the discharge claim.
To identify an acute inpatient discharge:
1. Identify all acute and nonacute inpatient stays (Inpatient Stay
Value Set).
2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay
Value Set).
3. Identify the discharge date for the stay.
A dispensed dementia medication (Dementia Medications List, see
link to the Medication List Directory in Guidance for Reporting above)

C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerator
Use codes (see HbA1c Lab Test Value Set; HbA1c Test Result or Finding Value Set) to
identify the most recent HbA1c test during the measurement year. The beneficiary is
numerator compliant if the most recent HbA1c level is > 9.0% or is missing a result, or if an
HbA1c test was not done during the measurement year. The beneficiary is not numerator
compliant if the result for the most recent HbA1c test during the measurement year is ≤
9.0%.

Version of Specification: NCQA 2020

D.30

MEASURE HPCMI-AD: DIABETES CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS:
HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9.0%)

MATHEMATICA

A state that uses CPT Category II codes to identify numerator compliance for this measure
must search for all codes in the following value sets and use the most recent code during
the measurement year to evaluate whether the beneficiary is numerator compliant.
Value Set

Numerator Compliance

HbA1c Level Less Than 7.0 Value Set

Not compliant

HbA1c Level Greater Than or Equal To 7.0
and Less Than 8.0 Value Set

Not compliant

HbA1c Level Greater Than or Equal To 8.0
and Less Than or Equal To 9.0 Value Set

Not compliant

HbA1c Level 7.0-9.0 Value Set

Not compliant

HbA1c Level Greater Than 9.0 Value Set

Compliant

Note: A lower rate indicates better performance for this indicator (i.e., low rates of poor
control indicate better care).
Exclusions (optional)
Beneficiaries who do not have a diagnosis of diabetes (Diabetes Value Set), in any setting,
during the measurement year or year prior to the measurement year and who had a
diagnosis of gestational diabetes or steroid-induced diabetes (Diabetes Exclusions Value
Set), in any setting, during the measurement year or the year prior to the measurement
year.
If the beneficiary was included in this measure based on claim or encounter data, as
described in the event/ diagnosis criteria, the optional exclusions do not apply because the
beneficiary had a diagnosis of diabetes.
D. HYBRID SPECIFICATION
Denominator
A systematic sample drawn from the eligible population. Sampling should be systematic to
ensure that all eligible individuals have an equal chance of inclusion. The sample size
should be 411, unless special circumstances apply. Regardless of the selected sample
size, NCQA recommends an oversample to allow for substitution in the event that cases in
the original sample turn out to be ineligible for the measure.
Numerator
The most recent HbA1c level (performed during the measurement year) is > 9.0% or is
missing, or was not done during the measurement year, as documented through automated
laboratory data or medical record review.
Note: A lower rate indicates better performance for this indicator (i.e., low rates of poor
control indicate better care).
Administrative Data
Refer to the Administrative Specification to identify positive numerator hits from
administrative data.
Medical Record Review
At a minimum, documentation in the medical record must include a note indicating the date
when the HbA1c test was performed and the result. The beneficiary is numerator compliant
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MEASURE HPCMI-AD: DIABETES CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS:
HEMOGLOBIN A1C (HBA1C) POOR CONTROL (>9.0%)

MATHEMATICA

if the result for the most recent HbA1c level during the measurement year is > 9.0% or is
missing, or if an HbA1c test was not done during the measurement year. The beneficiary is
not numerator compliant if the most recent HbA1c level during the measurement year is ≤
9.0%.
Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is
required for numerator compliance.
Exclusions (optional)
Refer to the Administrative Specification for exclusion criteria. Identify beneficiaries who did
not have a diagnosis of diabetes, in any setting, during the measurement year or the year
prior to the measurement year and who had a diagnosis of gestational diabetes or steroidinduced diabetes, in any setting, during the measurement year or the year prior to the
measurement year.

Version of Specification: NCQA 2020

D.32

MEASURE CDF-AD: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGE 18 AND OLDER

MATHEMATICA

Metric #24: Screening for Depression and Follow-up Plan: Age 18 and Older
(CDF-AD)
Measure Steward: Centers for Medicare & Medicaid Services
A. DESCRIPTION
Percentage of beneficiaries age 18 and older screened for depression on the date of the
encounter using an age appropriate standardized depression screening tool, and if positive,
a follow-up plan is documented on the date of the positive screen.
Data Collection Method: Administrative or EHR
Guidance for Reporting:
• The denominator for this measure includes beneficiaries age 18 and older with an
outpatient visit during the measurement year. The numerator for this measure includes
the following two groups:
1. Those beneficiaries with a positive screen for depression during an outpatient
visit using a standardized tool with a follow-up plan documented.
2. Those beneficiaries with a negative screen for depression during an outpatient
visit using a standardized tool.
• This measure can be calculated using administrative data only. Medical record review
may be used to validate the state's administrative data (for example, documentation of
the name of the standardized depression screening tool utilized). However, validation
is not required to calculate and report this measure.
• This measure contains both exclusions and exceptions:
- Denominator exclusion criteria are evaluated before checking if a
beneficiary meets the numerator criteria; a beneficiary who qualifies for
the denominator exclusion should be removed from the denominator.
- Denominator exception criteria are only evaluated if the beneficiary does
not meet the numerator criteria; beneficiaries who do not meet numerator
criteria and also meet denominator exception criteria (e.g., medical reason
for not performing a screening) should be removed from the denominator.
• This measure is intended to promote screening of beneficiaries never previously
diagnosed with depression or bipolar disorder. As such, any beneficiary with an “active
diagnosis” for depression/bipolar disorder would be excluded from the measure.
- An “active diagnosis” for a depression/bipolar disorder is a diagnosis that starts
prior to the start of the encounter and is still active at the start of the encounter.
The diagnosis itself may or may not have an end date associated with it. If a
beneficiary had a qualifying encounter in 2019, for example, and had a depression
diagnosis in 2014 and the diagnosis did not have an end date/time prior to January
1, 2019, then the diagnosis is considered active and the beneficiary would be
excluded from the measure calculation.
- The codes to identify active diagnosis of depression (Exclusions) include
both depression diagnoses and depression remission diagnoses because
both indicate a prior diagnosis.
Beneficiaries with active antidepressant medications listed in their medical record
without an active bipolar/depression diagnosis documented in their record should
not be excluded from this measure.

Version of Specification: Quality ID: 134 Claims and Registry Version 2.0 for 2019 Reporting
D.33

MEASURE CDF-AD: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGE 18 AND OLDER

MATHEMATICA

• The Quality Payment Program (QPP) claims/clinical quality measure (CQM)
specifications for this measure included six G codes intended to capture whether
individual providers reported on this measure. For the purpose of 1115 SMI/SED
demonstration reporting, there are two G codes included in the numerator to capture
whether depression screening using an age appropriate standardized tool was done
on the date of the eligible encounter and if the screen was positive, whether a followup plan was documented on the date of the positive screen.
• When multiple encounters that meet criteria for inclusion in the measure denominator
take place in the measurement year, the most recent eligible encounter at which the
screening took place should be used. The beneficiary should be counted in the
denominator and numerator only once based on the most recent screening
documented at the eligible encounter.
For example, if a beneficiary had a qualifying encounter in January of the
measurement year and no depression screening was performed and then had a
qualifying encounter in December of the same measurement year and had a
depression screening, the encounter during December would be used for the
measure denominator. If a beneficiary had an eligible encounter during January
with a depression screening performed and an encounter during December with
no screening performed, the January encounter would be used for the measure
denominator.
• The date of encounter and screening must occur on the same date of service.
• If recommended follow-up includes additional screening, the additional screening must
occur at the same encounter as the initial positive screen. The results of the additional
screen are not necessary for data abstraction. An additional screen alone would not
count toward a valid follow-up intervention to an initial positive screen.
• The screening tools listed in the measure specifications are examples of standardized
tools. However, a state may use any assessment tool that has been appropriately
normalized and validated for the population in which it is being utilized. The name of
the age-appropriate standardized depression screening tool utilized must be
documented in the medical record.
• Include all paid, suspending, pending, and denied claims.
• The electronic specification for FFY 2020 is located on the eCQI resource center at
https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v8.html.
The following coding systems are used in this measure: CPT and HCPCS. Refer to the
Acknowledgments section at the beginning of the manual for copyright information.
B. DEFINITIONS
Screening

Completion of a diagnostic tool used to identify people at risk of
developing or having a certain disease or condition, even in the absence
of symptoms.
Screening tests can predict the likelihood of someone having or
developing a particular disease or condition. This measure looks for the
screening being conducted in the practitioner’s office that is filing the
code.

Version of Specification: Quality ID: 134 Claims and Registry Version 2.0 for 2019 Reporting
D.34

MEASURE CDF-AD: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGE 18 AND OLDER

Standardized
tool

MATHEMATICA

A normalized and validated depression screening tool developed for the
population in which it is being utilized. The name of the age-appropriate
standardized depression screening tool utilized must be documented in
the medical record. Examples of depression screening tools include but
are not limited to:
• Adult Screening Tools (age 18 and older)
Patient Health Questionnaire (PHQ-9), Beck Depression Inventory
(BDI or BDI-II), Center for Epidemiologic Studies Depression Scale
(CES-D), Depression Scale (DEPS), Duke Anxiety- Depression Scale
(DADS), Geriatric Depression Scale (GDS), Cornell Scale for
Depression in Dementia (CSDD), PRIME MD-PHQ2, Hamilton Rating
Scale for Depression (HAM-D), and Quick Inventory of Depressive
Symptomatology Self-Report (QID-SR)
• Perinatal Screening Tools
Edinburgh Postnatal Depression Scale, Postpartum Depression
Screening Scale, Patient Health Questionnaire 9 (PHQ-9), Beck
Depression Inventory, Beck Depression Inventory–II, Center for
Epidemiologic Studies Depression Scale, and Zung Self-rating
Depression Scale

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Follow-up
plan

MATHEMATICA

Proposed outline of treatment to be conducted as a result of depression
screening. Follow-up for a positive depression screening must include
one (1) or more of the following:
• Additional evaluation for depression
• Suicide risk assessment
• Referral to a practitioner who is qualified to diagnose and treat
depression
• Pharmacological interventions
• Other interventions or follow-up for the diagnosis or treatment of
depression
Examples of a follow-up plan include but are not limited to:
• Additional evaluation or assessment for depression such as psychiatric
interview, psychiatric evaluation, or assessment for bipolar disorder
• Completion of any Suicide Risk Assessment such as Beck Depression
Inventory or Beck Hopelessness Scale
• Referral to a practitioner or program for further evaluation for
depression, for example, referral to a psychiatrist, psychologist, social
worker, mental health counselor, or other mental health service such
as family or group therapy, support group, depression management
program, or other service for treatment of depression
Other interventions designed to treat depression such as psychotherapy,
pharmacological interventions, or additional treatment options
• Pharmacologic treatment for depression is often indicated during
pregnancy and/or lactation. Review and discussion of the risks of
untreated versus treated depression is advised. Consideration of each
patient’s prior disease and treatment history, along with the risk
profiles for individual pharmacologic agents, is important when
selecting pharmacologic therapy with the greatest likelihood of
treatment effect.
The documented follow-up plan must be related to positive depression
screening, for example: “Patient referred for psychiatric evaluation due to
positive depression screening.”

C. ELIGIBLE POPULATION
Age

Age 18 or older on date of encounter.

Event/diagnosis

Outpatient visit (Table CDF-A) during the measurement year.

Continuous
enrollment

None.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population with an outpatient visit during the measurement year (Table CDF-A).

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MATHEMATICA

Table CDF-A. Codes to Identify Outpatient Visits
CPT

HCPCS

59400, 59510, 59610, 59618, 90791, 90792, 90832,
90834, 90837, 92625, 96116, 96121, 96130, 96131,
96132, 96133, 96136, 96137, 96138, 96139, 96146,
96150, 96151, 97165, 97166, 97167, 99201, 99202,
99203, 99204, 99205, 99212, 99213, 99214, 99215,
99304, 99305, 99306, 99307, 99308, 99309, 99310,
99315, 99316, 99318, 99324, 99325, 99326, 99327,
99328, 99334, 99335, 99336, 99337, 99339, 99340,
99483, 99484, 99492, 99493, 99384, 99385, 99386,
99387, 99394, 99395, 99396, 99397

G0101, G0402, G0438,
G0439, G0444

Numerator
Beneficiaries screened for depression using a standardized tool AND, if positive, a followup plan is documented on the date of the positive screen using one of the codes in Table
CDF-B.
Table CDF-B. Codes to Document Depression Screen
Code

Description

G8431

Screening for depression is documented as being positive and a follow-up
plan is documented

G8510

Screening for depression is documented as negative, a follow-up plan is not
required

Exclusions
A beneficiary is not eligible if one or more of the following conditions are documented in the
beneficiary medical record:
•

Beneficiary has an active diagnosis of depression or bipolar disorder

Use the codes in Table CDF-C, CDF-D, and CDF-E to identify exclusions.
Table CDF-C. HCPCS Code to Identify Exclusions
Code
G9717

Description
Documentation stating the patient has an active diagnosis of depression or has
a diagnosed bipolar disorder, therefore screening or follow-up not required

Table CDF-D. ICD-10 Codes to Identify Active Diagnosis of Depression (Exclusions)
ICD-10 Code

Description

F01.51

Vascular dementia with behavioral disturbance

F32.0

Major depressive disorder, single episode, mild

F32.1

Major depressive disorder, single episode, moderate

F32.2

Major depressive disorder, single episode, severe without psychotic
features

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ICD-10 Code

MATHEMATICA

Description

F32.3

Major depressive disorder, single episode, severe with psychotic
features

F32.4

Major depressive disorder, single episode, in partial remission

F32.5

Major depressive disorder, single episode, in full remission

F32.89

Other specified depressive episodes

F32.9

Major depressive disorder, single episode, unspecified

F33.0

Major depressive disorder, recurrent, mild

F33.1

Major depressive disorder, recurrent, moderate

F33.2

Major depressive disorder, recurrent severe without psychotic features

F33.3

Major depressive disorder, recurrent, severe with psychotic symptoms

F33.40

Major depressive disorder, recurrent, in remission, unspecified

F33.41

Major depressive disorder, recurrent, in partial remission

F33.42

Major depressive disorder, recurrent, in full remission

F33.8

Other recurrent depressive disorders

F33.9

Major depressive disorder, recurrent, unspecified

F34.1

Dysthymic disorder

F34.81

Disruptive mood dysregulation disorder

F34.89

Other specified persistent mood disorders

F43.21

Adjustment disorder with depressed mood

F43.23

Adjustment disorder with mixed anxiety and depressed mood

F53.0

Postpartum depression

F53.1

Puerperal psychosis

O90.6

Postpartum mood disturbance

O99.340

Other mental disorders complicating pregnancy, unspecified trimester

O99.341

Other mental disorders complicating pregnancy, first trimester

O99.342

Other mental disorders complicating pregnancy, second trimester

O99.343

Other mental disorders complicating pregnancy, third trimester

O99.345

Other mental disorders complicating the puerperium

Table CDF-E. ICD-10 Codes to Identify Diagnosed Bipolar Disorder (Exclusions)
ICD-10 Code

Description

F31.10

Bipolar disorder, current episode manic without psychotic features,
unspecified

F31.11

Bipolar disorder, current episode manic without psychotic features, mild

F31.12

Bipolar disorder, current episode manic without psychotic features,
moderate

F31.13

Bipolar disorder, current episode manic without psychotic features,
severe

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MATHEMATICA

ICD-10 Code

Description

F31.2

Bipolar disorder, current episode manic severe with psychotic features

F31.30

Bipolar disorder, current episode depressed, mild or moderate severity,
unspecified

F31.31

Bipolar disorder, current episode depressed, mild

F31.32

Bipolar disorder, current episode depressed, moderate

F31.4

Bipolar disorder, current episode depressed, severe, without psychotic
features

F31.5

Bipolar disorder, current episode depressed, severe, with psychotic
features

F31.60

Bipolar disorder, current episode mixed, unspecified

F31.61

Bipolar disorder, current episode mixed, mild

F31.62

Bipolar disorder, current episode mixed, moderate

F31.63

Bipolar disorder, current episode mixed, severe, without psychotic
features

F31.64

Bipolar disorder, current episode mixed, severe, with psychotic features

F31.70

Bipolar disorder, currently in remission, most recent episode unspecified

F31.71

Bipolar disorder, in partial remission, most recent episode hypomanic

F31.72

Bipolar disorder, in full remission, most recent episode hypomanic

F31.73

Bipolar disorder, in partial remission, most recent episode manic

F31.74

Bipolar disorder, in full remission, most recent episode manic

F31.75

Bipolar disorder, in partial remission, most recent episode depressed

F31.76

Bipolar disorder, in full remission, most recent episode depressed

F31.77

Bipolar disorder, in partial remission, most recent episode mixed

F31.78

Bipolar disorder, in full remission, most recent episode mixed

F31.81

Bipolar II disorder

F31.89

Other bipolar disorder

F31.9

Bipolar disorder, unspecified

Exceptions
A beneficiary that does not meet the numerator criteria and meets the following exception
criteria should be excluded from the measure denominator. However, if the beneficiary
meets the numerator criteria, the beneficiary would be included in the measure
denominator.
•

Beneficiary refuses to participate

•

Beneficiary is in an urgent or emergent situation where time is of the essence and to
delay treatment would jeopardize the beneficiary’s health status

•

Situations where the beneficiary’s functional capacity or motivation to improve may
impact the accuracy of results of nationally recognized standardized depression
assessment tools. For example: certain court-appointed cases or cases of delirium

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MEASURE CDF-AD: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGE 18 AND OLDER

Table CDF-F. HCPCS Code to Identify Exceptions
Code

Description

G8433

Screening for depression not completed, documented reason

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MATHEMATICA

MEASURE CDF-CH: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGES 12-17

MATHEMATICA

Metric #25: Screening for Depression and Follow-up Plan: Ages 12–17
(CDF-CH)
Measure Steward: Centers for Medicare & Medicaid Services
A. DESCRIPTION
Percentage of beneficiaries ages 12 to 17 screened for depression on the date of the
encounter using an age appropriate standardized depression screening tool, and if positive,
a follow-up plan is documented on the date of the positive screen.
Data Collection Method: Administrative or EHR
Guidance for Reporting:
• The denominator for this measure includes beneficiaries ages 12 to 17 with an
outpatient visit during the measurement year. The numerator for this measure includes
the following two groups:
1. Those beneficiaries with a positive screen for depression during an outpatient
visit using a standardized tool with a follow-up plan documented.
2. Those beneficiaries with a negative screen for depression during an outpatient
visit using a standardized tool.
• This measure can be calculated using administrative data only. Medical record review
may be used to validate the state's administrative data (for example, documentation of
the name of the standardized depression screening tool utilized). However, validation
is not required to calculate and report this measure.
• This measure contains both exclusions and exceptions:
Denominator exclusion criteria are evaluated before checking if a beneficiary
meets the numerator criteria; a beneficiary who qualifies for the denominator
exclusion should be removed from the denominator.
Denominator exception criteria are only evaluated if the beneficiary does not
meet the numerator criteria; beneficiaries who do not meet numerator criteria
and also meet denominator exception criteria (e.g., medical reason for not
performing a screening) should be removed from the denominator.
• This measure is intended to promote screening of beneficiaries never previously
diagnosed with depression or bipolar disorder. As such, any beneficiary with an
“active diagnosis” for depression/bipolar disorder would be excluded from the
measure.
An “active diagnosis” for a depression/bipolar disorder is a diagnosis that starts
prior to the start of the encounter and is still active at the start of the encounter.
The diagnosis itself may or may not have an end date associated with it. If a
beneficiary had a qualifying encounter in 2019, for example, and had a
depression diagnosis in 2014 and the diagnosis did not have an end date/time
prior to January 1, 2019, then the diagnosis is considered active and the
beneficiary would be excluded from the measure calculation.
The codes to identify active diagnosis of depression (Exclusions) include both
depression diagnoses and depression remission diagnoses because both
indicate a prior diagnosis.
Beneficiaries with active antidepressant medications listed in their medical
record without an active bipolar/depression diagnosis documented in their record
should not be excluded from this measure.
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MATHEMATICA

• The QPP claims/CQM specifications for this measure included six G codes intended
to capture whether individual providers reported on this measure. For the purpose of
1115 SMI/SED demonstration reporting, there are two G codes included in the
numerator to capture whether depression screening using an age appropriate
standardized tool was done and if the screen was positive, whether a follow-up plan
was documented on the date of the positive screen.
• When multiple encounters that meet criteria for inclusion in the measure denominator
take place in the measurement year, the most recent eligible encounter at which the
screening took place should be used. The beneficiary should be counted in the
denominator and numerator only once based on the most recent screening
documented at the eligible encounter.
For example, if a beneficiary had a qualifying encounter in January of the
measurement year and no depression screening was performed and then had a
qualifying encounter in December of the same measurement year and had a
depression screening, the encounter during December would be used for the
measure denominator. If a beneficiary had an eligible encounter during January
with a depression screening performed and an encounter during December with
no screening performed, the January encounter would be used for the measure
denominator.
• The date of encounter and screening must occur on the same date of service.
• If recommended follow-up includes additional screening, the additional screening must
occur at the same encounter as the initial positive screen. The results of the additional
screen are not necessary for data abstraction. An additional screen alone would not
count toward a valid follow-up intervention to an initial positive screen.
• The screening tools listed in the measure specifications are examples of standardized
tools. However, a state may use any assessment tool that has been appropriately
normalized and validated for the population in which it is being utilized. The name of
the age-appropriate standardized depression screening tool utilized must be
documented in the medical record.
• Include all paid, suspended, pending, and denied claims.
• The electronic specification for FFY 2020 is located on the eCQI resource center at
https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v8.html.

The following coding systems are used in this measure: CPT and HCPCS. Refer to the
Acknowledgments section at the beginning of the manual for copyright information.
B. DEFINITIONS
Screening

Completion of a diagnostic tool used to identify people at risk of
developing or having a certain disease or condition, even in the absence
of symptoms.
Screening tests can predict the likelihood of someone having or
developing a particular disease or condition. This measure looks for the
screening being conducted in the practitioner’s office that is filing the
code.

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MATHEMATICA

Standardized
tool

A normalized and validated depression screening tool developed for the
population in which it is being utilized. The name of the age-appropriate
standardized depression screening tool utilized must be documented in
the medical record. Examples of depression screening tools include but
are not limited to:
• Adolescent Screening Tools (12-17 years)
Patient Health Questionnaire for Adolescents (PHQ-A), Beck
Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling
Questionnaire (MFQ), Center for Epidemiologic Studies Depression
Scale (CES-D), Patient Health Questionnaire (PHQ-9), Pediatric
Symptom Checklist (PSC-17), and PRIME MD-PHQ2
• Perinatal Screening Tools
Edinburgh Postnatal Depression Scale, Postpartum Depression
Screening Scale, Patient Health Questionnaire 9 (PHQ-9), Beck
Depression Inventory, Beck Depression Inventory–II, Center for
Epidemiologic Studies Depression Scale, and Zung Self-rating
Depression Scale

Follow-up
plan

Proposed outline of treatment to be conducted as a result of depression
screening. Follow-up for a positive depression screening must include
one (1) or more of the following:
• Additional evaluation for depression
• Suicide risk assessment
• Referral to a practitioner who is qualified to diagnose and treat
depression
• Pharmacological interventions
• Other interventions or follow-up for the diagnosis or treatment of
depression
Examples of a follow-up plan include but are not limited to:
• Additional evaluation or assessment for depression such as psychiatric
interview, psychiatric evaluation, or assessment for bipolar disorder
• Completion of any Suicide Risk Assessment such as Beck Depression
Inventory or Beck Hopelessness Scale
• Referral to a practitioner or program for further evaluation for
depression, for example, referral to a psychiatrist, psychologist, social
worker, mental health counselor, or other mental health service such
as family or group therapy, support group, depression management
program, or other service for treatment of depression
Other interventions designed to treat depression such as psychotherapy,
pharmacological interventions, or additional treatment options

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MEASURE CDF-CH: SCREENING FOR DEPRESSION AND FOLLOW-UP PLAN: AGES 12-17

Follow-up
plan
(continued)

MATHEMATICA

• Pharmacologic treatment for depression is often indicated during
pregnancy and/or lactation. Review and discussion of the risks of
untreated versus treated depression are advised. Consideration of
each beneficiary’s prior disease and treatment history, along with the
risk profiles for individual pharmacologic agents, is important when
selecting pharmacologic therapy with the greatest likelihood of
treatment effect.
• The documented follow-up plan must be related to positive depression
screening, for example: “Patient referred for psychiatric evaluation due
to positive depression screening.”

C. ELIGIBLE POPULATION
Age

Ages 12 to 17 on date of encounter.

Event/diagnosis

Outpatient visit (Table CDF-A) during the measurement year.

Continuous
enrollment

None.

D. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population with an outpatient visit during the measurement year (Table CDF-A).
Table CDF-A. Codes to Identify Outpatient Visits
CPT

HCPCS

59400, 59510, 59610, 59618, 90791, 90792, 90832,
90834, 90837, 92625, 96116, 96121, 96130, 96131,
96132, 96133, 96136, 96137, 96138, 96139, 96146,
96150, 96151, 97165, 97166, 97167, 99201, 99202,
99203, 99204, 99205, 99212, 99213, 99214, 99215,
99304, 99305, 99306, 99307, 99308, 99309, 99310,
99315, 99316, 99318, 99324, 99325, 99326, 99327,
99328, 99334, 99335, 99336, 99337, 99339, 99340,
99483, 99484, 99492, 99493, 99384, 99385, 99386,
99387, 99394, 99395, 99396, 99397

G0101, G0402, G0438,
G0439, G0444

Numerator
Beneficiaries screened for depression using a standardized tool and, if positive, a follow-up
plan is documented on the date of the positive screen using one of the codes in Table CDFB.
Table CDF-B. Codes to Document Depression Screen
Code

Description

G8431

Screening for depression is documented as being positive and a follow-up
plan is documented

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MATHEMATICA

Code

Description

G8510

Screening for depression is documented as negative, a follow-up plan is not
required

Exclusions
A beneficiary is not eligible if one or more of the following conditions are documented in the
beneficiary medical record:
•

Beneficiary has an active diagnosis of Depression or Bipolar Disorder

Use the codes in Table CDF-C, CDF-D, and CDF-E to identify exclusions.
Table CDF-C. HCPCS Code to Identify Exclusions
Code
G9717

Description
Documentation stating the patient has an active diagnosis of
depression or has a diagnosed bipolar disorder, therefore screening
or follow-up not required

Table CDF-D. ICD-10 Codes to Identify Active Diagnosis of Depression (Exclusions)
ICD-10 Code

Description

F01.51

Vascular dementia with behavioral disturbance

F32.0

Major depressive disorder, single episode, mild

F32.1

Major depressive disorder, single episode, moderate

F32.2

Major depressive disorder, single episode, severe without psychotic
features

F32.3

Major depressive disorder, single episode, severe with psychotic
features

F32.4

Major depressive disorder, single episode, in partial remission

F32.5

Major depressive disorder, single episode, in full remission

F32.89

Other specified depressive episodes

F32.9

Major depressive disorder, single episode, unspecified

F33.0

Major depressive disorder, recurrent, mild

F33.1

Major depressive disorder, recurrent, moderate

F33.2

Major depressive disorder, recurrent severe without psychotic
features

F33.3

Major depressive disorder, recurrent, severe with psychotic
symptoms

F33.40

Major depressive disorder, recurrent, in remission, unspecified

F33.41

Major depressive disorder, recurrent, in partial remission

F33.42

Major depressive disorder, recurrent, in full remission

F33.8

Other recurrent depressive disorders

F33.9

Major depressive disorder, recurrent, unspecified

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MATHEMATICA

ICD-10 Code

Description

F34.1

Dysthymic disorder

F34.81

Disruptive mood dysregulation disorder

F34.89
F43.21
F43.23
F53.0
F53.1
O90.6
O99.340
O99.341
O99.342
O99.343
O99.345

Other specified persistent mood disorders
Adjustment disorder with depressed mood
Adjustment disorder with mixed anxiety and depressed mood
Postpartum depression
Puerperal psychosis
Postpartum mood disturbance
Other mental disorders complicating pregnancy, unspecified trimester
Other mental disorders complicating pregnancy, first trimester
Other mental disorders complicating pregnancy, second trimester
Other mental disorders complicating pregnancy, third trimester
Other mental disorders complicating the puerperium

Table CDF-E. ICD-10 Codes to Identify Diagnosed Bipolar Disorder (Exclusions)
ICD-10 Code

Description

F31.10

Bipolar disorder, current episode manic without psychotic features,
unspecified

F31.11

Bipolar disorder, current episode manic without psychotic features, mild

F31.12

Bipolar disorder, current episode manic without psychotic features,
moderate

F31.13

Bipolar disorder, current episode manic without psychotic features,
severe

F31.2

Bipolar disorder, current episode manic severe with psychotic features

F31.30

Bipolar disorder, current episode depressed, mild or moderate severity,
unspecified

F31.31

Bipolar disorder, current episode depressed, mild

F31.32

Bipolar disorder, current episode depressed, moderate

F31.4

Bipolar disorder, current episode depressed, severe, without psychotic
features

F31.5

Bipolar disorder, current episode depressed, severe, with psychotic
features

F31.60

Bipolar disorder, current episode mixed, unspecified

F31.61

Bipolar disorder, current episode mixed, mild

F31.62

Bipolar disorder, current episode mixed, moderate

F31.63

Bipolar disorder, current episode mixed, severe, without psychotic
features

F31.64

Bipolar disorder, current episode mixed, severe, with psychotic features

F31.70

Bipolar disorder, currently in remission, most recent episode unspecified

F31.71

Bipolar disorder, in partial remission, most recent episode hypomanic

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MATHEMATICA

ICD-10 Code

Description

F31.72

Bipolar disorder, in full remission, most recent episode hypomanic

F31.73

Bipolar disorder, in partial remission, most recent episode manic

F31.74

Bipolar disorder, in full remission, most recent episode manic

F31.75

Bipolar disorder, in partial remission, most recent episode depressed

F31.76

Bipolar disorder, in full remission, most recent episode depressed

F31.77

Bipolar disorder, in partial remission, most recent episode mixed

F31.78

Bipolar disorder, in full remission, most recent episode mixed

F31.81

Bipolar II disorder

F31.89

Other bipolar disorder

F31.9

Bipolar disorder, unspecified

Exceptions
A beneficiary that does not meet the numerator criteria and meets the following exception
criteria should be removed from the measure denominator. However, if the beneficiary
meets the numerator criteria, the beneficiary would be included in the measure
denominator.
•

Beneficiary refuses to participate

•

Beneficiary is in an urgent or emergent situation where time is of the essence and to
delay treatment would jeopardize the beneficiary’s health status

•

Situations where the beneficiary’s functional capacity or motivation to improve may
impact the accuracy of results of nationally recognized standardized depression
assessment tools. For example: certain court-appointed cases or cases of delirium

Table CDF-F. HCPCS Code to Identify Exceptions
Code

Description

G8433

Screening for depression not completed, documented reason

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MEASURE APM-CH: METABOLIC MONITORING FOR CHILDREN AND ADOLESCENTS ON ANTIPSYCHOTICS MATHEMATICA

Metric #29: Metabolic Monitoring for Children and Adolescents
on Antipsychotics (APM-CH)
National Committee for Quality Assurance*
*Developed with financial support from the Agency for Healthcare Research and Quality
(AHRQ) and CMS under the CHIPRA Pediatric Quality Measures Program Centers of
Excellence grant number U18HS025296.
A. DESCRIPTION
Percentage of children ages 1 to 17 who had two or more antipsychotic prescriptions and
had metabolic testing. Three rates are reported:
•

Percentage of children and adolescents on antipsychotics who received blood glucose
testing

•

Percentage of children and adolescents on antipsychotics who received cholesterol
testing

•

Percentage of children and adolescents on antipsychotics who received blood glucose
and cholesterol testing

Data Collection Method: Administrative
Guidance for Reporting:
• 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 II. Data Collection and
Reporting of the Child Core Set.
• NCQA’s Medication List Directory (MLD) for Antipsychotic, Antipsychotic
Combination, and Prochlorperazine medications are available to order free of charge
in the NCQA Store
(http://store.ncqa.org/index.php/catalog/product/view/id/3741/s/hedis-2020-ndc).
Once ordered, the Medication List Directory can be accessed through the NCQA
Download Center (https://my.ncqa.org/?ReturnUrl=%2fDownloads).
The following coding systems are used in this measure: CPT, HCPCS, LOINC, SNOMED,
and UB. Refer to the Acknowledgments section at the beginning of the manual for copyright
information.
B. ELIGIBLE POPULATION
Age

Ages 1 to 17 as of December 31 of the measurement year. Report two
age stratifications and a total rate for each of the three indicators:
• Ages 1 to 11
• Ages 12 to 17
• Total ages 1 to 17

Continuous
enrollment

The measurement year.

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MEASURE APM-CH: METABOLIC MONITORING FOR CHILDREN AND ADOLESCENTS ON ANTIPSYCHOTICS MATHEMATICA

Allowable gap

No more than one gap in enrollment of up to 45 days during the
measurement year. To determine continuous enrollment for a
beneficiary for whom enrollment is verified monthly, the adolescent
may not have more than a 1-month gap in coverage (i.e., an
adolescent whose coverage lapses for 2 months [60 days] is not
considered continuously enrolled).

Anchor date

December 31 of the measurement year.

Benefit

Medical and pharmacy.

Event/diagnosis

At least two antipsychotic medication dispensing events (Antipsychotic
Medications List, Antipsychotic Combination Medications List,
Prochlorperazine Medications List, see link to the Medication List
Directory in Guidance for Reporting above) of the same or different
medications, on different dates of service during the measurement
year.

C. ADMINISTRATIVE SPECIFICATION
Denominator
The eligible population as defined above.
Numerator
Blood Glucose
Beneficiaries who received at least one test for blood glucose (Glucose Lab Test Value Set;
Glucose Test Result or Finding Value Set) or HbA1c (HbA1c Lab Test Value Set; HbA1c
Test Result or Finding Value Set) during the measurement year.
Cholesterol
Beneficiaries who received at least one test for LDL-C (LDL-C Lab Test Value Set; LDL-C
Test Result or Finding Value Set) or cholesterol (Cholesterol Lab Test Value Set;
Cholesterol Test Result or Finding Value Set) during the measurement year.
Blood Glucose and Cholesterol
Beneficiaries who received both the following during the measurement year on the same or
different dates of service.
•

At least one test for blood glucose (Glucose Lab Test Value Set, Glucose Test Result or
Finding Value Set) or HbA1c (HbA1c Lab Test Value Set, HbA1c Test Result or Finding
Value Set).

•

At least one test for LDL-C (LDL-C Lab Test Value Set; LDL-C Test Result or Finding
Value Set) or cholesterol (Cholesterol Lab Test Value Set; Cholesterol Test Result or
Finding Value Set).

Version of Specification: HEDIS 2020

D.49

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APPENDIX E
STANDARDIZED DEFINITION OF SMI

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APPENDIX E

MATHEMATICA

We refer to the National Committee for Quality Assurance (NCQA) definition of SMI as the
standardized definition of SMI. The following definition is based on the definition of SMI in
Metric #23 (Diabetes Care for Patients with Serious Mental Illness: Hemoglobin A1c (HbA1c)
Poor Control (>9.0%) (HPCMI-AD)) from the FFY 2020 Adult Core Set. NCQA defines
individuals with SMI as those who meet at least one of the following criteria within the
measurement period:
•

At least one acute inpatient claim/encounter with any diagnosis of schizophrenia,
schizoaffective disorder or bipolar disorder using any of the following code
combinations:
- BH Stand Alone Acute Inpatient Value Set with (Schizophrenia Value Set;
Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Major Depression
Value Set)
- Visit Setting Unspecified Value Set with Acute Inpatient POS Value Set with
(Schizophrenia Value Set; Bipolar Disorder Value Set; Other Bipolar Disorder
Value Set; ; Major Depression Value Set)

•

At least two of the following, on different dates of service, with or without a telehealth
modifier (Telehealth Modifier Value Set) where both encounters have any diagnosis of
schizophrenia or schizoaffective disorder (Schizophrenia Value Set) or both encounters
have any diagnosis of bipolar disorder (Bipolar Disorder Value Set; Other Bipolar
Disorder Value Set)
- An outpatient visit (Visit Setting Unspecified Value Set) with Outpatient POS
Value Set
- An outpatient visit (BH Outpatient Value Set)
- An intensive outpatient encounter or partial hospitalization (Visit Setting
Unspecified Value Set with Partial Hospitalization POS Value Set)
- An intensive outpatient encounter or partial hospitalization (Partial
Hospitalization or Intensive Outpatient Value Set)
- A community mental health center visit (Visit Setting Unspecified Value Set with
Community Mental Health Center POS Value Set)
- Electroconvulsive therapy (Electroconvulsive Therapy Value Set)
- An observation visit (Observation Value Set)
- An ED visit (ED Value Set)
- An ED visit (Visit Setting Unspecified Value Set with ED POS Value Set)
- A nonacute inpatient encounter (BH Stand Alone Nonacute Inpatient Value Set)
- A nonacute inpatient encounter (Visit Setting Unspecified Value Set with
Nonacute Inpatient POS Value Set)
- A telehealth visit (Visit Setting Unspecified Value Set with Telehealth POS Value
Set)

OR

E.3

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APPENDIX F
AVERAGE LENGHTH OF STAY (ALOS) STANDARD DEVIATIONS

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APPENDIX F

MATHEMATICA

For Metric #19, the state’s goal should be to decrease the average length of stay in
participating psychiatric hospitals and residential settings to achieve an overall demonstration
target of no more than 30 days. If requested by CMS at the midpoint assessment, a state may be
required to provide the standard deviation based on the mean in Metric #19.
The state should review the distribution of the lengths of stay data to assess normality of the
data. If the length of stay data are skewed, the state should determine if data transformation is
appropriate. Table F.1 provides example transformation methods a state may consider for
skewed data. For example, a state with substantial right-skewed data may consider using log
transformation to calculate the standard deviation. The state should assess the normalization of
the transformed data before proceeding to the standard deviation calculation.
Table F.1. Data distribution and transformation methods
Data Distribution
Moderate positive skew
Substantial positive skewa
Moderate negative skew
Substantial negative skewa

Transformation Methods
Square root
Logarithmic (Log 10)
Reflect and Square root
Reflect and Logarithmic (Log 10)

a Substantial

skewness can be assessed using the rule of thumb of -1 to 1 amplitude.
Source: Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics (5th ed.). Boston: Allyn
and Bacon.

After reviewing the data’s skewness and transforming the data, as appropriate, the state
should calculate the standard deviation of the data. Standard deviation can be calculated as:

σ=

σ

∑
µ

∑( X − µ)

2

n

= population standard deviation
= sum of
= population mean

n = number scores in the sample

As requested by CMS at the midpoint assessment, the state should provide CMS with the
information in Table F.2.
Table F.2. State data for average length of stay and standard deviation
Data type
Description of data
Data Transformation Used (if any)
Average Length of Stay
(transformed, if applying data
transformation methods)
Standard Deviation
(transformed, if applying data
transformation methods)

State data
E.g., normal, right skewed, left skewed, outliers present
E.g., log 10 transformation
If not transforming data, use value from metric #19.

F.3

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