Performance Measure Data Submissions for Medicaid
Indicator Descriptions
These are a set of measures used to report the performance of health plans. Medicaid Beneficiaries can use this information to compare health plans and determine the relative value of care offered by managed care health plans. The measures allow the users to understand how well health plans achieve results that matter, such as, how effective and accessible is the care delivered.
Adherence to Antipsychotic Medications for Individuals With Schizophrenia
The percentage of members 19-64 years of age during the measurement year with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period.
Adolescent Well-Care Visits
The percentage of enrolled members 12-21 years of age who received at least one comprehensive well-care visit with a PCP or OB/GYN practitioner during the measurement year.
Adult BMI Assessment
The percentage of members 18-74 years of age who received an outpatient visit and their body mass index documented during the measurement year or the year prior.
Adults' Access to Preventive/Ambulatory Health Services – ages 20-44
The percentage of members 20-44 years of age who received an ambulatory or preventive care visit during the measurement year.
Adults' Access to Preventive/Ambulatory Health Services – ages 45-64
The percentage of members 45-64 years of age who received an ambulatory or preventive care visit during the measurement year.
Adults' Access to Preventive/Ambulatory Health Services – ages 65+
The percentage of members 65 years and older who received an ambulatory or preventive care visit during the measurement year.
Adults' Access to Preventive/Ambulatory Health Services – Total
The percentage of members 20 years and older who received an ambulatory or preventive care visit during the measurement year.
Annual Dental Visit – Total
The percentage of members 2-21 years of age who received at least one dental visit during the measurement year.
Annual Monitoring for Patients on Persistent Medications – ACEs/ARBs
The percentage of members 18 years of age and older who received at least 180 treatment days of ACE inhibitors or ARBs during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year.
Annual Monitoring for Patients on Persistent Medications – Diuretics
The percentage of members 18 years of age and older who received at least 180 treatment days of diuretics during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year.
Annual Monitoring for Patients on Persistent Medications – Total
The percentage of members 18 years of age and older who received at least 180 treatment days of ACE inhibitors or ARBs or diuretics during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year.
Antidepressant Medication Management – Effective Acute Phase Treatment
The percentage of members 18 years of age and older who were diagnosed with a new episode of major depression and remained on antidepressant medication for at least 84 days.
Antidepressant Medication Management – Effective Continuation Phase Treatment
The percentage of members 18 years of age and older who were diagnosed with a new episode of major depression and remained on antidepressant medication for at least 180 days.
Breast Cancer Screening
The percentage of women 50-74 years of age who received a mammogram to screen for breast cancer.
Call Answer Timeliness
The percentage of calls received by the plan's Member Services call centers (during operating hours) during the measurement year that were answered by a live voice within 30 seconds.
Cervical Cancer Screening
The percentage of women 21-64 years of age with one or more Pap tests during the measurement year or the two years prior to the measurement year.
Childhood Immunization Status – Combination 2
The percentage of children who received four DTaP; three IPV; one MMR; three Hib; three hepatitis B; and one VZV vaccination on or before the child's second birthday.
Childhood Immunization Status – Combination 3
The percentage of children who received all antigens listed in Combination 2 and four pneumococcal conjugate vaccinations on or before the child's second birthday.
Children and Adolescents’ Access to PCPs – ages 12-24 months
The percentage of children 12-24 months of age who had a visit with a PCP during the measurement year.
Children and Adolescents’ Access to PCPs – ages 25 months – 6 years
The percentage of children 25 months – 6 years of age who had a visit with a PCP during the measurement year.
Children and Adolescents’ Access to PCPs – ages 7-11 years
The percentage of children 7-11 years of age who had a visit with a PCP during the measurement year or the year prior to the measurement year.
Children and Adolescents’ Access to PCPs – ages 12-19 years
The percentage of children 12-19 years of age who had a visit with a PCP during the measurement year or the year prior to the measurement year.
Comprehensive Diabetes Care – Eye Exam
The percentage of members 18-75 years of age with diabetes who received a retinal or dilated eye exam by an eye care professional during the measurement year or a negative retinal exam by an eye professional in the year prior to the measurement year.
Comprehensive Diabetes Care – HbA1c Good Control (<8%)
The percentage of members 18-75 years of age with diabetes and most recent HbA1c level of <8.0%.
Comprehensive Diabetes Care – HbA1c Poor Control (Inverse Measure)
The percentage of members 18-75 years of age with diabetes and most recent HbA1c level of >9.0% or is missing or was not done during the measurement year.
Comprehensive Diabetes Care – HbA1c Testing
The percentage of members 18-75 years of age with a HbA1c test performed during the measurement year.
Comprehensive Diabetes Care – Nephropathy
The percentage of members 18-75 years of age with a nephropathy screening or monitoring test or evidence of nephropathy during the measurement year.
Controlling High Blood Pressure – Total
The percentage of members 18-85 years of age with a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year.
Dental Treatment Services
The percentage of enrollees 1-20 years of age who are enrolled in Medicaid or CHIP Medicaid expansion programs for at least 90 continuous days, are eligible for EPSDT services, and who received at least one dental treatment service during the federal fiscal year.
Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
The percentage of members 18-64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year.
Engagement of Alcohol and Other Drug Dependence Treatment – Total
The percentage of members who initiated treatment and who had two or more additional alcohol or other drug dependence services or medication treatment within 34 days of the initiation visit.
Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence Treatment – 7 Day – Total
The percentage of emergency department visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug abuse or dependence, who had a follow-up visit for alcohol or other drug abuse within 7 days.
Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence Treatment – 30 Day – Total
The percentage of emergency department visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug abuse or dependence, who had a follow-up visit for alcohol or other drug abuse within 30 days.
Follow-up After Emergency Department Visit for Mental Illness – 7 Day
The percentage of emergency department visits for members 6 years of age and older with a principal diagnosis of mental illness, who had a follow-up visit for mental illness within 7 days.
Follow-up After Emergency Department Visit for Mental Illness – 30 Day
The percentage of emergency department visits for members 6 years of age and older with a principal diagnosis of mental illness, who had a follow-up visit for mental illness within 30 days.
Follow-Up After Hospitalization for Mental Illness – 7 Day
The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health diagnoses and who received a follow-up visit with a mental health practitioner within 7 days after discharge.
Follow-Up After Hospitalization for Mental Illness – 30 Day
The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health diagnoses and who received a follow-up visit with a mental health practitioner within 30 days after discharge.
Follow-Up Care for Children Prescribed ADHD Medication – Initiation Phase
The percentage of members 6-12 years of age newly prescribed ADHD medication who received one follow-up visit with practitioner with prescribing authority during the 30-day initiation phase.
Follow-Up Care for Children Prescribed ADHD Medication – Continuation and Maintenance Phase
The percentage of members 6-12 years of age newly prescribed ADHD medication who remained on the prescription for at least 210 days, received one follow-up visit in the initiation phase, and two follow-up visits within 9 months after the initiation phase ended.
HIV Viral Load Suppression – ages 18-64
The percentage of enrollees 18-64 years of age with a diagnosis of HIV who had a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.
HIV Viral Load Suppression – ages 65+
The percentage of enrollees 65 years of age and older with a diagnosis of HIV who had a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.
Immunization for Adolescents – Combination 1
The percentage of adolescents 13 years of age who received one dose of meningococcal vaccine and one Tdap vaccine by their 13th birthday.
Initiation of Alcohol and Other Drug Dependence Treatment – Total
The percentage of members who initiate treatment through an inpatient alcohol or other drug dependence admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth or medication treatment within 14 days of diagnosis.
Lead Screening in Children
The percentage of children 2 years of age who received one or more capillary or venous lead blood tests for lead poisoning by their second birthday.
Medication Management for People with Asthma – 75% Medication Compliance – Total
The percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period.
Mental Health Readmission Rate (Inverse Measure)
The percentage of acute care facility discharges for enrollees 6 years of age and older who were hospitalized for a mental health diagnosis that resulted in a readmission for a mental health diagnosis within 30 days.
Metabolic Monitoring for Children and Adolescents on Antipsychotics – Total
The percentage of children and adolescents 1-17 years of age who had two or more antipsychotic prescriptions and had metabolic testing.
Plan All-Cause Readmissions – ages 18-64 – Total
For members 18-64 years of age, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission.
Plan All-Cause Readmissions – ages 65+ – Total
For members 65 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission.
Timeliness of Prenatal Care
The percentage of deliveries that received a prenatal care visit as a member of the plan in the first trimester, on the enrollment start date, or within 42 days of enrollment in the plan.
Postpartum Care
The percentage of deliveries that received a postpartum visit on or between 21 and 56 days after delivery.
Preventive Dental Services
The percentage of enrollees 1-20 years of age who are enrolled in Medicaid or CHIP Medicaid expansion programs for at least 90 continuous days, are eligible for EPSDT services, and who received at least one preventive dental service during the federal fiscal year.
Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
The percentage of children and adolescents 1-17 years of age who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first-line treatment.
Use of Multiple Concurrent Antipsychotics in Children and Adolescents (Inverse Measure)
The percentage of children and adolescents 1-17 years of age who were on two or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year.
Well-Child Visits in the First 15 Months of Life – 0 Visits (Inverse Measure)
The percentage of children who turned 15 months old during the measurement year who received zero well-child visits with a PCP.
Well-Child Visits in the First 15 Months of Life – 6+ Visits
The percentage of children who turned 15 months old during the measurement year who received six or more well-child visits with a PCP.
Well-Child Visits in the Third, Fourth, Fifth, & Sixth Years of Life
The percentage of members 3-6 years of age who received one or more well-child visits with a PCP during the measurement year.
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