within a business entity or related entities. The Offeror shall provide immediate written notice to the Procurement Manager or Buyer if, at any time prior to contract award, the Offeror learns that its disclosure was erroneous when submitting or became erroneous by reason of changed circumstances. A disclosure that any of the items in this requirement exist will not necessarily result in withholding an award under this solicitation. However, the disclosure will be considered in the determination of the Offeror’s responsibility. Failure of the Offeror to furnish a disclosure or provide additional information as requested will render the Offeror nonresponsive. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the disclosure required by this document. The knowledge and information of an Offeror is not required to exceed that which is the normally possessed by a prudent person in the ordinary course of business dealings. The disclosure requirement provided is a material representation of fact upon which reliance was placed when making an award and is a continuing material representation of the facts. If during the performance of the contract, the contractor is indicted for or otherwise criminally or civilly charged by any government entity (federal, state or local) with commission of any offenses named in this document the contractor must provide immediate written notice to the Procurement Manager or Buyer. If it is later determined that the Offeror knowingly rendered an erroneous disclosure, in addition to other remedies available to the Government, the State Purchasing Agent or Central Purchasing Officer may terminate the involved contract for cause. Still further the State Purchasing Agent or Central Purchasing Officer may suspend or debar the contractor from eligibility for future solicitations until such time as the matter is resolved to the satisfaction of the State Purchasing Agent or Central Purchasing Officer. 32. Conflict of Interest; Governmental Conduct Act The Offeror warrants that it presently has no interest and shall not acquire any interest, direct or indirect, which would conflict in any manner or degree with the performance or services required under the Agreement. The Offeror certifies requirements of the Governmental Conduct Act, Sections 10-16-1 through 10-16-18, NMSA 1978, regarding contracting with a public officer or state employee or former state employee have been followed.
Figure 1. Logic Model for Centennial Care Evaluation Inputs Activities Outputs Outcomes -- Impact Short-Term Medium-Term Long-Term Federal government – CMS State government – NM HSD MCOs Providers (including physical health, behavioral health, and LTSS) Enrollees NM citizens and advocacy groups Enroll individuals in Centennial Care Determine care coordination level for each participant by assessing risks and health needs Improve access to physical health, behavioral health, and LTSS by providing care coordination and Patient-Centered Medical Homes Integrate care across physical health, behavioral health, and LTSS by giving MCOs full responsibility for all services Ensure quality of services delivered under Centennial Care to Medicaid recipients and their providers through monitoring and incentive systems Improve infrastructure to streamline health service delivery Care coordinators have responsibility and knowledge of individual participants Participants have improved access even when their health needs are complex, requiring physical health, behavioral health, and LTSS services Providers have responsible point of contact for clients’ needs and can obtain necessary supports Providers receive better compensation for delivering quality services Citizens and advocates receive better value for Medicaid expenditures Participants access to appropriate physical health, behavioral health, and LTSS Continuity of care for participants across the spectrum of services and the duration of their needs Efficient provider credentialing Improved claims adjudication Improved grievance and appeals processing Appropriate utilization of outpatient, inpatient, institutional, and HCBS services Effective and use of electronic health records and telemedicine Provider network adequacy across all domains of service (physical health, behavioral health, and LTSS) Satisfaction among all providers of care (physical health, behavioral health, and LTSS) Participant satisfaction Improved overall health status for Centennial Care participants Decline in growth rate of Medicaid expenditures Health service provider payment reform Delivery system reform
Table 2. Measures for Centennial Care Evaluation Research Questions Measure NQF Number Data Source Stratification Category Comparison Groups Frequency Goal 1. Assure that Medicaid beneficiaries in the program receive the right amount of care, delivered at the right time, in the right setting A. Has Centennial Care impacted access to care for all populations and services covered under the waiver, including physical health, behavioral health, and LTSS services? Access to preventive/ambulatory health services among Centennial Care enrollees in aggregate and within subgroups Similar to 1332 HEDIS /NCQA MCO; demographic characteristics* (such as age, gender, race/ethnicity, geographic region (including rural, urban, and frontier), county) Comparison to baseline; trending over time Annual Mental health services utilization HEDIS/NCQA MCO; demographic characteristics Comparison to baseline; trending over time Annual Number of telemedicine providers and telemedicine utilization MCO telehealth report MCO; geographic region; service type (physical health, LTSS, and behavioral health) Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Number and percentage of people meeting nursing facility LOC who are in a nursing facility MMIS and encounter data MCO; demographic characteristics; care coordination level Pre-Centennial Care compared to post Centennial Care; trending over time Annual Number and percentage of people meeting nursing facility LOC who MMIS and encounter data MCO; demographic characteristics; care coordination level; self-directed Pre-Centennial Care compared to post Centennial Annual
receive HCBS population Care; trending over time Number and percentage of people with annual dental visit 1388 HEDIS/NCQA CMS Core Quality Measure for Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Enrollment in Centennial Care as a percentage of state population MMIS and Current Population Survey Demographic characteristics Comparison to baseline; trending over time Annual Number of Native Americans opting in and opting out of Centennial Care MMIS Demographic characteristics Comparison to pre-Centennial Care; trending over time; comparison of opt-in v. population Annual ? Number and percentage of participants who accessed a physical health, behavioral health, and LTSS service MMIS and encounter data MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual Number and percentage of participants with behavioral health conditions who accessed any of the 3 new behavioral health MMIS and encounter data MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual
services (respite, family support, and recovery) Number and percentage of unduplicated participants with at least one PCP visit, in aggregate and among subgroups MMIS and encounter data CMS Core Quality Measure for Children MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual Number/ratio of participating providers to enrollees MCO network adequacy, PCP, and geographic access reports MCO; provider type (PCP, etc.) Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Percentage of PCP panel slots open MCO PCP report MCO Comparison to baseline; trending over time Reported by MCOs monthly; evaluator may summarize to present annually B. Is access to care timely? Number and percentage of substance use disorder participants with follow-up 7 and 30 days after leaving residential treatment center (RTC) Similar to 0576 MMIS and encounter data MCO; demographic characteristics; participants leaving RTC placement Comparison to baseline; trending over time Annual
placement Number and percentage of acute care participants with a follow-up outpatient visit 7 days and 30 days after hospitalization Similar to 0576 MMIS and encounter data/NCQA Demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual Number and percentage of behavioral health participants with follow-up after hospitalization for mental illness 0576 HEDIS /NCQA CMS Core Quality Measure for Adults and Children MCO; care coordination level; demographic characteristics Comparison to baseline; trending over time Annual Childhood immunization status 0038 HEDIS /NCQA CMS Core Quality Measure for Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Immunizations for adolescents 1407 HEDIS /NCQA CMS Core Quality Measure for Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Well-child visits in first 15 months of life 1392 HEDIS/NCQA CMS Core Quality Measure for MCO; demographic characteristics Comparison to baseline; trending over time Annual
Children Well-child visits in third, fourth, fifth, and sixth years of life 1516 HEDIS /NCQA CMS Core Quality Measure for Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Adolescent well care visits HEDIS /NCQA CMS Core Quality Measure for Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Prenatal and postpartum care: timeliness of prenatal care and percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery 1517 HEDIS/NCQA CMS Core Quality Measure for Adults and Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Frequency of ongoing prenatal care 1391 HEDIS/NCQA CMS Core Quality Measure for Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Breast cancer screening for women HEDIS/NCQA CMS Core Quality Measure for Adults MCO; demographic characteristics Comparison to baseline; trending over time Annual
Cervical cancer screening for women 0032 HEDIS/NCQA CMS Core Quality Measure for Adults MCO; demographic characteristics Comparison to baseline; trending over time Annual Flu vaccinations for adults 0039 CAHPS or MMIS claims and encounter data/NCQA CMS Core Quality Measure for Adults MCO; demographic characteristics Comparison to baseline; trending over time Annual Initiation and engagement of alcohol and other drug dependence treatment 0004 HEDIS/NCQA CMS Core Quality Measure for Adults MCO; demographic characteristics Comparison to baseline; trending over time Annual Geographic access measures MCO network adequacy and geographic access reports MCO; geographic regions Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually C. Are care coordination activities meeting the goals of right amount of care, delivered at the Number and percentage of participants with health risk assessments completed within contract timeframes MCO care coordination report MCO; demographic characteristics; population; care coordination level; population with behavioral health needs Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually
right time, in the right setting? Number and percentage of participants who received a care coordination designation and assignment of care coordinator within contract timeframes MCO care coordination report MCO; care coordination level; demographic characteristics; population; population with behavioral health needs; geographic region Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Number and percentage of participants in care coordination level 2 that had comprehensive needs assessments scheduled and completed within contract timeframes MCO care coordination report MCO; care coordination level; demographic characteristics; population with behavioral health needs Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Number and percentage of participants in care coordination level 3 that had comprehensive needs assessments scheduled and completed within contract timeframes MCO care coordination report MCO; care coordination level; demographic characteristics; population with behavioral health needs Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually
Number and percentage of participants in care coordination level 2 who received visits and telephone contact within contract timeframes MCO care coordination report MCO; care coordination level; demographic characteristics; population; population with behavioral health needs Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Number and percentage of participants in care coordination level 3 who received visits and telephone contact within contract timeframes MCO care coordination report MCO; care coordination level; demographic characteristics; population; population with behavioral health needs Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Number and percentage of participants the MCO is unable to locate for care coordination MCO unreachable members report MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Reported by MCOs monthly; evaluator may summarize to present annually
Number and percentage of members transitioning from HCBS to a nursing facility; number and percentage of participants in nursing facilities transitioning to community (HCBS) MMIS and encounter data MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual Number and percentage of participants receiving HCBS whose Individualized Service Plans (ISPs) address all assessed needs from the comprehensive needs assessment (services and supports needed to live in the community) Record review of a representative sample MCO; care coordination level; demographic characteristics; population with LTSS needs; population with behavioral health needs Comparison to baseline; trending over time Annual
Number and percentage of participants receiving HCBS whose services were delivered in accordance with the ISP (type, scope, amount, and frequency) MMIS and encounter data; record review of a representative sample MCO; care coordination level; demographic characteristics; population with LTSS needs; population with behavioral health needs; self-directed population Comparison to baseline; trending over time Annual Number and percentage of participants who refuse care coordination MCO unreachable members report MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Reported by MCOs monthly; evaluator may summarize to present annually Goal 2. Ensure that expenditures for care and services being provided are measured in terms of quality and not solely by quantity A. Has quality of care improved under Centennial Care? EPSDT screening ratio CMS 416 report MCO; demographic characteristics Comparison to baseline; trending over time Annual Monitoring for patients on persistent medications HEDIS/NCQA CMS Core Quality Measure for Adults MCO; demographic characteristics Comparison to baseline; trending over time Annual Neonatal mortality rate (AHRQ Pediatric Quality Indicators) MMIS and encounter MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual
Number and percentage of births pre-term MMIS and encounter MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual Low birth weight rate (AHRQ Prevention Quality Indicators) 0278 MMIS and encounter/AHRQ CMS Core Quality Measure for Children MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual Medication management for people with asthma 1799 HEDIS/NCQA CMS Core Quality Measure for Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Use of appropriate medications for people with asthma 0036 HEDIS/NCQA MCO; demographic characteristics Comparison to baseline; trending over time Annual Asthma medication ratio 1800 HEDIS/NCQA MCO; demographic characteristics Comparison to baseline; trending over time Annual Adult BMI assessment; weight assessment for children/adolescents 0024, 0421 HEDIS/NCQA CMS Core Quality Measure for Adults and Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Comprehensive diabetes care 0061, 0055, 0575, 0059, HEDIS/NCQA CMS Core Quality Measure for Adults MCO; demographic characteristics Comparison to baseline; trending over time Annual
0057, 0064, 0063, 0062 Ambulatory care sensitive (ACS) admission rates (AHRQ Prevention Quality Indicators):diabetes short- and long-term complications, uncontrolled admission rates 0274, 0272, 0638 MMIS and encounter/AHRQ CMS Core Quality Measure for Adults MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual ACS admission rates (AHRQ Prevention Quality Indicators): COPD or asthma in older adults; asthma in younger adults 0275, 0283 MMIS and encounter/AHRQ CMS Core Quality Measure for Adults MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual ACS admission rates (AHRQ Prevention Quality Indicators): hypertension Similar to 0709 MMIS and encounter/AHRQ MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual ACS admission rates (AHRQ Pediatric Quality Indicators):pediatric asthma 0283 MMIS and encounter/AHRQ MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual
Number and percentage of emergency department (ED) visits that are potentially avoidable MMIS and encounter MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual Smoking and tobacco use cessation 0027 HEDIS/NCQA CMS Core Quality Measure for Adults MCO; demographic characteristics Comparison to baseline; trending over time Annual Number of critical incidents by reporting category (abuse, neglect, exploitation, environment hazard, emergency services, law enforcement, elopement/missing, and death) MCO critical incidents report MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Monthly Drug overdose mortality rate MMIS and encounter MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual Antidepressant medication management 0105 HEDIS/NCQA CMS Core Quality Measure for Adults MCO; demographic characteristics Comparison to baseline; trending over time Annual Inpatient admissions to psychiatric hospitals and RTCs MMIS and encounter MCO; demographic characteristics; populations of special interest Comparison to baseline; trending over time Annual
Percentage of nursing facility residents who transitioned from a low nursing facility to a high nursing facility MMIS and encounter Demographic characteristics Comparison to baseline; trending over time Annual Percentage of members aged 65 years and older who have had a fall or problem with balance in the past 12 months who were seen by a practitioner in the last 12 months and who have received a fall risk intervention) 0035 HEDIS/NCQA Demographic characteristics Comparison to baseline; trending over time Annual Linkage to HIV medical care: number of persons with HIV who attended a routine HIV medical care visit within 3 months of HIV diagnosis MMIS and Encounter Data/HHS Persons with HIV Diagnosis Comparison to baseline; trending over time Annual Retention in HIV medical care: number of persons with HIV who had at least one HIV medical care visit in each of the measurement 2079 MMIS and Encounter Data/HRSA Persons with HIV Diagnosis Comparison to baseline; trending over time Annual
period Antiretroviral therapy (ART) among persons In HIV medical care: number of persons with HIV who are prescribed ART in the 12-month measurement period 2083 MMIS and Encounter Data/HHS Persons with HIV Diagnosis Comparison to baseline; trending over time Annual B. Is care integration effective? Percentage of population accessing a behavioral health service that received a PCP visit in the same year MMIS and encounter data MCO; demographic characteristics; participants diagnosed with a behavioral health condition Comparison to baseline; trending over time Annual Percentage of population accessing an LTSS service that received a PCP visit in the same year MMIS and encounter data MCO; demographic characteristics; participants diagnosed with a behavioral health condition Comparison to baseline; trending over time Annual Percentage of population accessing an LTSS service that also accessed a behavioral health service in the same year MMIS and encounter data MCO; demographic characteristics; participants diagnosed with a behavioral health condition Comparison to baseline; trending over time Annual
level/LOC c. Move to a higher care coordination level/LOC Percentage of population accessing a behavioral health service that received an outpatient, ambulatory visit in the same year MMIS and encounter data MCO; demographic characteristics Comparison to baseline; trending over time Annual Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications 1932 HEDIS/NCQA MCO; demographic characteristics Comparison to baseline; trending over time Annual Diabetes monitoring for people with diabetes and schizophrenia 1934 HEDIS/NCQA MCO; demographic characteristics Comparison to baseline; trending over time Annual Goal 3. Slow the growth rate of costs or "bend the cost curve" over time without cutting benefits or services, changing eligibility, or reducing provider rates A. To what extent did service utilization and costs increase or decrease due to Total program expenditures Audited MCO financial reports; encounter payment data Total program; populations of special interest; demographic characteristics; domains of service; Trending over time Annual
the implementation of the Centennial Care program for Medicaid/CHIP beneficiaries in New Mexico? care coordination level; self-directed population; behavioral health population Costs per member Audited MCO financial reports; encounter payment data Total program; populations of special interest; demographic characteristics; domains of service; care coordination level; self-directed population Trending over time Annual Cost per user of services Encounter payment data Total program; populations of special interest; demographic characteristics; domains of service; care coordination level; self-directed population Trending over time Annual Utilization by category of service MMIS and encounter Populations of special interest; demographic characteristics Trending over time Annual Hospital costs Encounter payment data; expenditures by category of services report Populations of special interest; demographic characteristics Trending over time Quarterly
Use of HCBS Encounter payment data; MCO report Domains of service; care coordination level Trending over time Quarterly Use of institutional care (skilled nursing facilities) Encounter payment data; MCO facilities readmission report Populations of special interest; demographic characteristics; care coordination level Trending over time Quarterly Use of mental health services Encounter payment data; MCO utilization by category of services report; MCO expenditures by category of services report; MCO over/under utilization report Populations of special interest; demographic characteristics Trending over time Quarterly Use of substance abuse services Encounter payment data; MCO utilization by category of services report; MCO expenditures by category of services report; MCO over/under utilization report Populations of special interest; demographic characteristics Trending over time Quarterly
Use of pharmacy services Encounter payment data; MCO utilization by category of services report; MCO expenditures by category of services report; MCO over/under utilization report Populations of special interest; demographic characteristics Trending over time Quarterly Inpatient services exceeding $50,000 Encounter payment data Total program; populations of special interest; demographic characteristics; domains of service; care coordination level. Vendor to identify high cost diagnoses for monitoring Trending over time Annual Use of diagnostic imaging Encounter payment data Total program; populations of special interest; demographic characteristics; domains of service; care coordination level Trending over time Annual
exam) Prenatal program (earned when signing up for the MCO’s program) MMIS and encounter data; MCO member rewards report Populations of special interest; demographic characteristics Comparison to baseline; trending over time Annual Treatment adherence MMIS and encounter data; MCO member rewards report Populations of special interest; demographic characteristics Comparison to baseline; trending over time Annual Treatment adherence– bipolar MMIS and encounter data; MCO member rewards report Populations of special interest; demographic characteristics Comparison to baseline; trending over time Annual Osteoporosis management in elderly women – females aged 65+ years MMIS and encounter data; MCO member rewards report Populations of special interest; demographic characteristics Comparison to baseline; trending over time Annual Annual dental visit – adult MMIS and encounter data; MCO member rewards report Populations of special interest; demographic characteristics Comparison to baseline; trending over time Annual Annual dental visit – child MMIS and encounter data; MCO member rewards report Populations of special interest; demographic characteristics Comparison to baseline; trending over time Annual
Number of members spending credits Fulfillment vendor report on member rewards program activities Populations of special interest; demographic characteristics Comparison to baseline; trending over time Annual Goal 4. Streamline and modernize the Medicaid program in the state A. Are enrollees satisfied with their providers and the services they receive? Percentage of grievances with expedited resolution within 3 business days MCO grievances and appeals report MCO; populations of special interest Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Percentage of grievances resolved within 30 days MCO grievances and appeals report MCO; populations of special interest Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Percentage of appeals upheld MCO grievances and appeals report MCO; populations of special interest Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Percentage of appeals partially overturned MCO grievances and appeals report MCO; populations of special interest Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present
Measure for Adults and Children time How well doctors communicate composite measure 0006 CAHPS/NCQA CMS Core Quality Measure for Adults and Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Customer service composite measure 0006 CAHPS/NCQA CMS Core Quality Measure for Adults and Children MCO; demographic characteristics Comparison to baseline; trending over time Annual Rating of specialist seen most often 0006 CAHPS/NCQA CMS Core Quality Measure for Adults and Children MCO; demographic characteristics Comparison to baseline; trending over time Annual B. Are provider claims paid accurately and on time? Percentage of clean claims adjudicated in 30/90 days MCO claims activity reports Provider type: behavioral health, physical health, I/T/U, specialty pay provider Comparison to baseline; trending over time Reported by MCOs weekly; evaluator may summarize to present annually Percentage of claims denied MCO claims activity reports Provider type: behavioral health, physical health, I/T/U, specialty pay provider Comparison to baseline; trending over time Reported by MCOs weekly; evaluator may summarize to present annually
Dollar accuracy rate MCO claims payment accuracy reports Claim type: inpatient hospital, behavioral health, nursing facility, I/T/U, crossover, HCBS, dental, FQHC/RHC Comparison to baseline; trending over time Reported by MCOs monthly; evaluator may summarize to present annually Percentage of grievances resolved on time MCO grievances and appeals report MCO Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Percentage of provider appeals resolved on time MCO grievances and appeals report MCO Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually Provider satisfaction survey results MCO provider satisfaction survey report MCO Comparison to baseline; trending over time Annual C. Has the state successfully implemented new processes and technologies for program management, Number and percentage of providers using electronic health records/participating in the Health Information Exchange MCO performance improvement project report MCO Comparison to baseline; trending over time Annual
reporting, and delivery system reform? Use of different care delivery models, such as number of health home participants TBD once implemented TBD once implemented TBD once implemented TBD once implemented Percentage of claims paid accurately MCO claims payment accuracy reports MCO Comparison to baseline; trending over time Reported by MCOs monthly; evaluator may summarize to present annually Use and outcomes of payment reforms, e.g., bundled rates for adult diabetes, pediatric asthma, and urban hospitals TBD once implemented TBD once implemented TBD once implemented TBD once implemented Number and percentage of visits in compliance with electronic visit verification system requirement MCO electronic visit verification report MCO Comparison to baseline; trending over time Reported by MCOs monthly; evaluator may summarize to present annually Adoption of electronic case management/care coordination system by MCOs MCO care coordination report MCO Comparison to baseline; trending over time Reported by MCOs quarterly; evaluator may summarize to present annually