The data sources used for quality improvement measurement, analysis of barriers, and determining appropriate interventions include, but are not limited to, encounters, claims, utilization review, pharmacy, laboratory, enrollment, behavioral health, medical records, and appeals data. Additionally, provider and member complaints, applicable case management and disease management databases, and telephone response data are also utilized. Other sources of data include HEDIS®/QARR data, Quality Compass®, national and regional epidemiological, demographic, and census data about EmblemHealth’s membership, and practitioner, provider and member surveys. Provider surveys include, but are not limited to, provider satisfaction surveys, GeoAccess studies, and Access and Availability surveys. Member surveys include, but are not limited to, the following: CAHPS®, EES, Health Outcomes Survey (HOS), new member surveys, member satisfaction with and assessment regarding the network, member loyalty surveys, disease management surveys, and case management surveys.
Integrated data systems collect member, practitioner and provider information, utilization, population-based and/or specific member information, and practitioner/provider specific information. Software includes, but is not limited to, claims systems, NCQA-approved HEDIS® software, credentialing and re-credentialing software, Microsoft products, and other systems to support both clinical and service interventions.
CMS Stars Ratings Data Sources: EmblemHealth complies with the annual Medicare HEDIS®, HOS, and CAHPS® reporting requirements, and other administrative measures required by CMS. This information forms the basis of the CMS Star Ratings used to assess the quality of Medicare Advantage plans.
HEDIS® Reporting Requirements
EmblemHealth submits audited summary-level HEDIS® data to NCQA and to the Centers for Medicare & Medicaid Services-designated contractor. The data collection methodologies are either administrative or hybrid types. The administrative method is from transactional data for the eligible populations, and the hybrid method is from medical record or electronic medical record and transactional data for the sample.
Because of the critical importance of ensuring accurate data, EmblemHealth is required to participate in an external audit of the HEDIS® measures before public reporting. EmblemHealth contracts with an NCQA-licensed organization for the Compliance Audit. Following receipt of the Final Audit Report, EmblemHealth makes available a copy of the complete final report to CMS.
Medicare HOS Survey Process Requirements
EmblemHealth is required to report results for a baseline HOS and a follow-up survey. EmblemHealth contracts with an NCQA-certified vendor for administration of both the baseline and follow-up surveys. Each year, baseline cohorts are drawn and the CMS identifies a number of randomly selected members per contract to be surveyed. Additionally, each year the cohort measured two years previously at baseline is resurveyed. The results of this re-measurement are used to calculate a change score for the physical health and emotional well-being of each respondent.
Individual member level data is not provided to EmblemHealth until approximately a year after the entire baseline/followup cohort study is completed. CMS provides EmblemHealth with a HOS Baseline Report and HOS Performance Measurement Report and Data containing the results of the follow-up survey. The survey vendor provides EmblemHealth with details of the survey administration.
Medicare CAHPS® Requirements
EmblemHealth is required to report results of the CAHPS® Survey. EmblemHealth contracts with an approved MA & PDP CAHPS® vendor for survey administration. This vendor adheres to CMS requirements for fielding, collecting, and reporting CAHPS® data, thereby ensuring valid and reliable results.
Children’s Health and Behavioral Health Medicaid Benefit
The Plan’s Children’s Health and Behavioral Health Medicaid Benefit integrates physical health and behavioral health for children under 21 years of age to create better quality of care and lay the groundwork for better health outcomes for adults. This includes addressing the needs of Medically Fragile Children, children with behavioral health diagnosis(es), and children in Foster Care (FC) with developmental disabilities. This benefit also includes Home and Community Based Services to address the membership’s complex needs.
Reporting Requirements for Children’s Health and Behavioral Health Medicaid Benefit:
- Children’s Consumer Perception Survey
- The Plan will participate in a consumer perception survey for the children’s population under 21 years of age, including those in the following subpopulations: Medically Fragile Children with physical, emotional, or developmental disabilities diagnosis; behavioral health diagnosis(es), and children in voluntary foster agencies in adherence to New York State guidance. The Plan will also report results according to New York State guidance.
- Home and Community Based Services (HCBS)
- The Plan will comply with the federal HCBS quality assurance performance measure reporting requirements for children under 21 years of age receiving HCBS as defined by New York State.
- Outcome Measures
- The Plan will report on required outcome measures for the children’s population under 21 years of age, including those in the following subpopulations: Medically Fragile Children with physical, emotional, or developmental disabilities diagnosis; behavioral health diagnosis(es); and children in voluntary foster agencies, as specified by New York State.
- Performance Improvement Project
- The Plan will participate in an internal performance improvement project as defined by New York State on a topic affecting the children’s population under 21 years of age, including those in the following subpopulations: Medically Fragile Children with physical, emotional, or developmental disabilities diagnosis; behavioral health diagnosis(es); and children in voluntary foster agencies.
- Quality Assurance Reporting Requirements (QARR)
- The Plan will continue to submit reports to New York State as specified in the Quality Assurance Reporting Requirements (QARR) within the time frames provided by the Medicaid Managed Care Model Contract.