Performance measures are indicators or metrics that are used to gauge program performance. They provide the information needed to measure the extent to which VT Medicaid is achieving its intended results/outcomes.
The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 90+ measures across 16 domains of care.
VT Medicaid runs the full set of HEDIS administrative measures, and in 2023 is producing 5 hybrid measures. Hybrid measures combine administrative claims data with data abstracted from member records during a medical record review. The 5 hybrid measures are:
- Controlling High Blood Pressure (CBP)
- Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (9.0%) (HPCMI)
- Hemoglobin A1c Control for Patients with Diabetes (HBD)
- Prenatal & Postpartum Care (PPC)
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
The VT Medicaid program reports many of the HEDIS measure results to our internal and external partners and stakeholders. Some of these measures are part of measure sets that we are required to report to Vermont’s Agency of Human Services (AHS) and the Centers for Medicaid & Medicare Services (CMS). For more information, see the links and other information below.
Cotiviti is the medical record retrieval contractor for VT Medicaid and will contact providers and request medical records to support the Medical Record Review (MRR). Please note that providers are required to participate (at no cost) as stated in your signed Provider Enrollment Agreement: Article VI. Audit Inspection. The Department of Vermont Health Access (DVHA) may enforce a 10% withholding of all VT Medicaid payments for all providers that do not submit the required medical records within ten (10) business days (at no cost).
Please pay close attention to the HEDIS Measure Requirements and Dates of Service on both the Member Request and/or the Member List Request forms and only submit the type of record requested within the stated timeframe.
Examples of the 2023 MRR record request retrieval letter and forms:
Centers for Medicare & Medicaid Services (CMS) Reporting Requirements:
The Centers for Medicare & Medicaid Services (CMS) published an Initial Adult Core Set of Measures via Federal Register Notice in 2012 signifying an important step toward better understanding, at both the State and national level, the quality of health care delivered to Medicaid-covered adults. This measure set is now updated annually by CMS.
The Children's Health Care Quality Measures for Medicaid and CHIP originated from the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009. Ultimately, the goals of this core measure set are to provide a national estimate of the quality of health care for children; facilitate comparative analyses across various dimensions of pediatric health care quality; and help identify racial, ethnic, and socioeconomic disparities.
A sub-set of the Adult Core Set consisting of the behavioral health measures and the Child Core Set will be mandatory for states to report to CMS starting in the year 2024. DVHA is currently reviewing all available resources, particularly for hybrid measure reporting to create a longer-term strategic reporting plan.