RESPONDENT NAME: Group A State #1: Florida State #2: Hawaii State #3: Georgia HEDIS Performance Metric CY 2015 Rate CY 2016 Rate CY 2015 Rate CY 2016 Rate CY 2015 Rate CY 2016 Rate Adolescent Well-Care Visits - (AWC) Antidepressant Medication Management - (AMM) Adult BMI Assessment Childhood Immunization Status – (CIS) – Combo 2 and 3 Comprehensive Diabetes Care – (CDC) Hemoglobin A1c (HbA1c) testing HbA1c poor control HbA1c control (<8%) Eye exam (retinal) performed Medical attention for nephropathy Follow-up Care for Children Prescribed ADHD Medication – (ADD) Immunizations for Adolescents – (IMA) Chlamydia Screening in Women – (CHL) Prenatal and Postpartum Care – (PPC) Medication Management for People
Criteria #12 – Potentially Preventable Events Respondent will describe its organizational commitment to quality improvement as it relates to reducing potentially preventable events. More specifically, the Respondent will describe its overall approach and specific strategies that will be used to ensure a reduction in potentially preventable hospital admissions and readmissions, a reduction in the use of the emergency department for non-emergent/urgent visits, and a reduction in the use of unnecessary ancillary services during hospitalization and outpatient visits. Respondent’s approach will also include: A description of the Respondent’s assessment (using available data sources) of hospital utilization rates and the potential for improvement; A description of performance benchmarks for each area of focus; A description of incentives that will be implemented for providers and enrollees aimed at diverting care to more appropriate and cost-effective settings; and A description of interventions and strategies that will be used to target super-utilizers, particularly related to pain management and behavioral health conditions. Evaluation Criteria: The extent to which the Respondent identified specific localized opportunities for improvement in achieving a reduction in potentially preventable events and subsequent steps the Respondent will implement to overcome any barriers across and within different systems of care (i.e., medical, behavioral health). The extent to which the Respondent describes specific care coordination protocols, including a description of the risk stratification algorithm used to identify The extent to the Respondent describes strategies to improve data exchanges and communications between practitioners to improve care coordination efforts for high-risk enrollees, using specific local examples. The extent to which the Respondent plans to include the use of AHCA’s Event Notification System as a means to extract relevant data from hospitals. The adequacy of the Respondent’s description of specific indicators or measures that will be used to evaluate the effectiveness of evidenced-based programs and interventions that target super-utilizers. The extent to which the Respondent describes financial and non-financial provider and enrollee incentives that are aimed at diverting care to more appropriate and cost-effective settings (e.g., incentives for primary care providers that agree to extended or after-hours clinic care for their Medicaid and CHIP patients).
Category Procedure Code Description Procedure/CPT Code Min Age Max Age Current Florida Medicaid Coverage Expanded Benefit Coverage (Units) Emergency and Planned Respite Respite Respite Care-in home Respite Care-out of home S9125-in-home H0045-out of home 0 21 yrs For model and DD waiver enrollees, this is covered via FFS For non-model and DD waiver enrollees, 200 hours a year for in home. 10 days of out of home. Behavioral Health Crisis Stabilization 0910 2 yrs 21 yrs As needed to divert hospitalization, emergency room visits, or prevent placement Modifications to divert institutional stay or home maintenance and minor home or environmental modifications including vehicle modifications Home maintenance and minor home/environmental modifications s5165 0 21 yrs Only in $5,000 every 3 years. Housing related supports/supplemental adaptive device or equipment Home helper catalog item 0 21 yrs Not covered 1 item a year.
Housing related supports/supplemental adaptive device or equipment hypoallergenic bedding 0 21 yrs $100 1x credit $100 1x credit Community Behavioral Health Self-Help/Peer 0 21 yrs In lieu of Psychosocial Rehabilitation Mobile Crisis Crisis Intervention S9485; H2011 0 21 yrs As needed to divert hospitalization, emergency room visits, or prevent placement Healthy Behavior Reward Program healthy community reward program 0 21 yrs As outlined in health plan literature submitted in ITN Professional consultation between primary care provider and specialist or medical team conference without patient/family present case consultation 99367 or 99368 0 21 yrs Limited to 2 per year for team
Family Training family support and education S5110 0 21 yrs 12 visits a year. social determinant of health benefits counseling SE 0 21 yrs Not covered 3 sessions annually. Partial hospitalization Partial hospitalization or S9480 (Mental Health), H0015 (Substance Use Disorder), Use of Revenue codes (0172, 0173, 0175, 0176), 0 21 yrs Covered as needed in lieu of inpatient hospitalization Detoxification or withdrawal management in an ambulatory or residential setting Withdrawal management H0010, H0011, H0012, H0014, 0 21 yrs Covered as needed in lieu of inpatient hospital detoxification Drop-in Center Drop-in Center H2030 or H2031 16 21 yrs Covered as needed in lieu of clubhouses
Non-medical transport Transportation A0090, A0100, A0110, A0120, A0130, A0170, T2003 0 21 yrs Covered as needed for community integration Nutritional Counseling Nutritional Counseling, diet S9470 0 21 yrs Covered as medically necessary for children with diabetes, Phenylketonuria (PKU) and metabolic conditions, eating disorders, Obesity, and children at risk of metabolic disorders under EPSDT For wellness counseling for at-risk children Supports for Wellness healthy living coaching 7 yrs 13 yrs 12 visits a year.
Education/Supports for Wellness Miscellaneous therapeutic items and supplies, retail purchases, not otherwise classified; identify product in “remarks” T1999 Covered up to $200 per year Housing Supports Pest control Pest Control S5121 0 21 yrs Only available on Project Aids Care Waiver $25 a job/$150 a year. $500 max annually. Social Determinant of Health Financial Counseling Financial counseling T2013 SE 0 21 yrs Not covered 6 sessions annually.
Criteria #20 – Online Provider Directory Respondent will describe the provider search function for the online provider directory, including submission of: A description outlining the transparency and accessibility of the online provider directory, including the parameters upon which enrollees may search. Include whether or not the online provider directory is mobile friendly. Screen shots for each mouse click required from the start of the Respondent’s home page to actual search results for a provider, using durable medical equipment providers and zip code as the search elements. A list of performance indicators the Respondent will include for each provider type listed in its provider directory. A description of the Respondent’s process for verification of provider information in the online provider directory, including delegated subcontractor provider information, and the method(s) the Respondent uses to ensure the weekly network file submission to the Department is accurate. Reply: Evaluation Criteria: The extent of the Respondent’s search functions for the Respondent’s online directory and ease of access for enrollees’ navigation of the online provider directory, including whether or not the online directory is mobile friendly. The extent to which the number of clicks it takes recipients to access the search results, as indicated by the screen shots provided, is less than five. The extent and relevance of the performance indicators available in the Respondent’s provider directory for each provider type listed. The extent of the Respondent’s efforts to ensure information in the Respondent’s online provider directory is accurate, including type and frequency of monitoring activities, and delegated subcontractor provider information. Include the frequency of outreach efforts to remediate incorrect provider demographic information and accepting new patient status. The extent to the Respondent’s online provider directory updates are performed daily and the extent to which the updates are communicated to the Department as required ensuring the information the Respondent displays on its website align with the Department’s information. Score: This section is worth a maximum of 10 raw points with each of the above components being worth a maximum of 2 points each.