Molina Healthcare of New York Quality Incentive Program

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1 Molina Healthcare of New York Quality Incentive Program MolinaHealthcare.com NY0218

2 Molina Healthcare of New York - Quality Incentive Program Purpose Molina Healthcare and the providers that make up our network all share a common goal providing quality health care. It is our number one priority; Molina s care and services focus on promoting health, wellness, and improved patient outcomes. The Molina Quality Incentive Program (MQIP) is set up to offer incentive payments to our providers and help maintain and improve health outcomes of our members. The program also helps to boost our overall performance as a New York State health insurance plan. The measures are aligned with areas that we believe are crucial in monitoring and maintaining our shared population s overall health. Within the MQIP, providers earn payment while promoting the best quality of health care that we all strive for. Overview The MQIP (Molina Quality Incentive Program) is designed to measure the care physicians (and health care professionals) provide to Molina Healthcare members as well as those members satisfaction with their experience of care. For community practices, provider groups will be identified by Tax ID Number (TIN) and results will reflect the aggregated performance of all physicians linked to that TIN. Provider groups are evaluated on select quality measures consistent with those set and monitored by New York State Department of Health (NYSDOH) and the Center for Medicaid and Medicare Services (CMS) in order for Molina Healthcare to receive incentive payments under the NYSDOH Medicaid Incentive Program and the CMS Star Rating system for Medicare Advantage Plans (CMS Star Program). Only provider groups that meet the membership requirements for eligibility will have the opportunity to earn quality bonuses (i.e., incentives) for their performance on MQIP measures. Eligibility Molina Healthcare membership will be used to determine eligibility for MQIP (Molina Quality Incentive Program). A provider/provider group must have at least 50 Molina Healthcare Medicaid and Child Health Plus members to be eligible for the Program. Final membership eligibility will be determined at the last date of the performance year. OB/GYN practitioners are also eligible to participate in this program without any minimum member threshold requirement. However, to trigger the measure they will require at least 5 members in denominator for that measure. Providers must register in the provider portal. A provider portal training will be provided by the Provider Relations Team upon request by the practice.

3 Overall Quality Rating Opportunity Provider groups that meet certain criteria will have the opportunity to earn an incentive on their valid Overall Quality Rating. Provider groups can earn ratings of 2 to 5 Stars for each of the 22 measures included in the MQIP for Medicaid Overall Quality Rating calculation, with 2 being the lowest and 5 being the highest. 2 stars align with less than 50% 3 stars align with 50% 4 stars align with 75% 5 stars align with 90% The ratings are determined using percentiles ( cutpoints ), as set by NYS Medicaid Incentive Program and adjusted as necessary by Molina Healthcare. A measure will only be included in a provider group s Overall Quality Rating calculation if it meets the minimum denominator requirement by the end of the measurement period. Additionally, a provider group must have at least five (5) members under the denominator for each qualified measure in order to meet the minimum denominator requirement. Once the minimum denominator requirement is met, the Overall Quality Rating calculation must be considered valid to be eligible for the incentive payments. For a complete list of measures included in the Overall Quality Rating for the MQIP for Medicaid program, please see Appendix A. Additional Information For the 2018 MQIP, the deadline for new claim and lab/encounter data is February 28, Claims submitted after this date will not be considered when calculating incentive payments. The deadline for the submission of corrected claims is February 1, 2019 which is earlier than the regular claims deadline. Please keep this in mind when submitting claims for correcting previously submitted claims information. Provider Portal The Provider Portal is a web-based tool that gives providers access to a multitude of quality data and health information. In the portal, providers can view their personal data across multiple physicians, as well as lines of business (Medicaid Managed Care and Child Health Plus). Each provider group eligible for the portal should have at least one person that is able to access it at all times. Molina encourages multiple staff members to have access to it and utilize it to its full potential. For more information about the Provider Portal and how it will benefit your office, please contact our Provider Services Department at

4 Quality Appeals Any provider offices that are participating in the MQIP are encouraged to report any discrepancies or inaccuracies with their quality reports or scoring. These are required to be reported to their Provider Relations Representative or Quality Specialist, if applicable. A quality appeal will be accepted in a certified, formal letter to the Director of Provider Relations. Once the letter is received, it will be reviewed within 30 days. Not all measures will be eligible for appeal, and some may also be denied if the basis of the appeal does not meet the criteria outlined by Molina. A decision will be made promptly after the letter submission (30 days) and a follow-up letter will be sent containing the appeal status. Appeal can be sent to: Attention to: Molina Healthcare of New York, Inc. Director, Provider Relations 5232 Witz Drive North Syracuse, New York 13212

5 Molina Healthcare Measures Appendix A Quality Incentivized Measures Access to Care Rating Min Den Target Rate Incentive Payment New Member Visit (within 45 days) NA NA NA 1 NA $30 Non-user Population: Decrease total number by 20% (at end of calendar year)*** Pediatric Prevention NA NA NA NA NA $200 Childhood Immunizations (Combo 3) 77% 82% 83% 5 83% $25 Well-Child Visit: 15 months (5+ visits) 81% 84% 89% 5 89% $50 Well-Child Visit: 3-6 years 82% 85% 87% 5 87% $50 Adult Prevention Breast Cancer Screening 68% 70% 73% 5 73% $75 Cervical Cancer Screening* 71% 76% 78% 5 78% $60 Chlamydia Screening (16-24 years)* 71% 77% 80% 5 80% $30 Colorectal Cancer Screening 55% 57% 64% 5 64% $35 Chronic Care Management Comprehensive Diabetes Screening: Received All 3 Tests 57% 60% 62% 5 62% $125 Diabetes Care: Eye Exam NA NA 5 $50 Diabetes Care: HbA1c Testing NA NA 5 $25 Diabetes Care: Nephropathy NA NA 5 $25 Diabetes Screening for Schizophrenia/Bipolar on Antipsychotics 42% 44% 45% 5 45% $50 Metabolic Monitoring for Children and Adolescents on Antipsychotics 42% 48% 49% 5 49% $50 Medication Management for People with Asthma 75% (5-64 years) 46% 48% 51% 5 51% $75 Use of Spirometry Testing in Assessment and Diagnosis of COPD 45% 54% 55% 5 55% $75 OB/GYN Pregnancy Notification Form NA NA NA 5 NA $50 Postpartum Visit (3-8 weeks PP) 69% 72% 74% 5 74% $50

6 *When screening has not been done in another office during calendar year; no duplicate payments will be made; first claim dropped will receive incentive payment. ***Non-user population bonus is an aggregate amount to be incentivized. For a decrease of 20% for total non-user population, the physician may receive $200.

7 Appendix B Display Measures (Non-incentivized) Display Measures Rating Measure Name Total Care of General Population Antidepressant Medication Management 42% 45% 45% Controlling High Blood Pressure 63% 65% 71% Flu Shots for Adults 40% 44% 47% Immunizations for Adolescents-Combo 2 25% 30% 39% Initiation and Engagement of Alcohol and other Drug Dependence Treatment (Composite) 35% 40% 41% Medical Assistance with Tobacco Cessation (Composite) 63% 65% 67% Statin Therapy for Patients with Cardiovascular Disease-Statin Adherence 80% 64% 66% 70% Weight Assessment and Counseling for Children and Adolescents (Composite) 76% 84% 86% Behavioral Health Adherence to Antipsychotic Medications for Individuals with Schizophrenia 61% 63% 68% Follow-up after Discharge from the Emergency Department for Alcohol or Other Drug Dependence-7 day rate Follow-up after Discharge from the Emergency Department for Mental Health- 7 day rate 27% 35% 37% 62% 65% 74% Follow-up after Hospitalization for Mental Health-7 day rate 61% 67% 70% Follow-up for Children Newly Prescribed ADHD Medication (Composite) 61% 69% 70% HIV Viral Load Suppression 77% 83% 84%

8 New Member Visits The New Member Incentive that encourages providers to see new members as soon as they become enrolled in a Molina Healthcare Plan. Providers can earn $30 per new member seen in a timely fashion; the definition of timely depends on each member s effective date. New members can be identified in the member roster shared with Provider s office each month. To earn $30 per new member visit, providers must: Perform well-care evaluations for new members within 45 days of their effective date. If the date of claims submission exceeds 45 days from the member s effective date, that visit will no longer qualify for the bonus. Bill using preventive medicine codes and (Please note that providers should submit all codes applicable to the visit, not just the preventive medicine codes for the new member bonus. However, only the codes outlined above will count towards the incentive). Submit all applicable claims by the deadlines outlined in the 2018 MQIP Final Program Documents. Visit claims must be submitted to Molina Healthcare by February 28, 2019 to receive credit, regardless of member effective date. *If a member leaves the plan and rejoins, that member will not be counted for this incentive unless the member was never seen by his/her PCP during their initial enrollment period. Non-User Population In any given year, a large number of Medicaid recipients may not see their primary care providers or any other specialists until they get sick. Often times this results in ER visits and/or inpatient/outpatient admissions. In an effort to get these members to visit their providers, Molina Healthcare will need assistance from the community providers. Hence, we are introducing this new measure. In order to qualify and earn $200 for this measure, providers must: Receive a list of non-users from the health plan. Upon receiving the non-user list, the provider needs to request that members complete a preventive or well-care office visit. Providers must reconcile the non-user report each quarter generated by the health plan, and inform the plan of any member discrepancies they have seen. At the end of the year, the health plan will quantify the percentage of membership seen on the initial report and compare with the year-end report. If the non-user population drops by 20% at year-end for the primary care provider, the provider will be eligible for the bonus. All claims for non-user population must be submitted by February 1, All the visits must be completed by December 31, 2018.

9 Appendix C HEDIS Measures & Incentive Codes Common codes utilized for Pediatric Measures: Measure ICD-10 Codes CPT/HCPCs Codes Adolescent Well-Care Visits (AWC) Z00.121, Z00.129, Z , 99385, 99394, Z02.0-Z02.6, Z02.9 Well-Child Visits in First 15 Months of Life (W15) Well-Child Visits 3-6 years of Life (W34) Z00.110, Z00.111, Z00.121, Z00.129, Z02.9 Z00.121, Z00.129, Z00.8, Z02.0-Z02.6, Z , 99382, 99391, , 99383, 99392, Child Immunization Status (CIS) Z23 Common Immunizations: DTaP: 90698, 90700, IPV: 90698, 90713, MMR: 90707, Influenza: 90630, 90657, 90658, 90661, 90673, 90685, 90687, 90662, Varicella: HiB: 90644, 90647, 90648, 90698, Hepatitis B: 90740, 90744, 90747, Pneumococcal Conjugate: Hepatitis A: Rotavirus: 90681(2 dose), (3 dose) Weight Assessment & Counseling for Nutrition & Physical Activity for Children (WCC) Medication Management for People with Asthma (MMA) Z68.51, Z68.52, Z68.53, Z68.54 J45.901, J45.902, J45.909, J45.990, J45.991, J45.20-J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J Nutritional Counseling: , G0447 Use applicable E/M code

10 Common codes utilized for OBGYN Measures: Measure ICD-10 Codes CPT/HCPCs Codes Cervical Cancer Screening (CCS) Breast Cancer Screening (BCS) Chlamydia Screening in Women (CHL) Prenatal Care (PPC) Z12.4, Z01.411, Z01.419, C53.0-C53.9, D06.0-D06.9 R92.0, R92.1, R92.2, R92.8, Z12.31, Z12.39 A56.0-A56.8, A74.0, A74.8, A74.9 O09-O16, O20-O26, O28-O36, O40-O48, O60.00-O60.03, O71, O88, O91, O92, O98, O99, O9A, Z03.71-Z03.79, Z33, Z34, Z , 88147, 88148, 88150, 88152, 88153, 88164, 88165, 88166, 88167, 88174, 88175, 87624, , 77059, 77063, 77065, 77066, , 87270, 87320, , Ultrasounds: 76801, 76805, 76811, 76813, , Visits: , , , Postnatal Care (PPC) Z39.1, Z , 58300, 59430, Cervical Cytology: , 88147, 88150, , , 88174, Long Acting Reversible Contraceptives Z30.013, Z30.430, Z30.431, Z30.432, Z , 11980, 11981, 11982, 11983, 58300, 58301

11 Appendix D Access and Availability Guidelines Access Standards Molina Healthcare monitors compliance and conducts ongoing evaluations regarding the availability and accessibility of services to Members. Please ensure adherence to these regulatory standards: Urgent Care APPOINTMENT TIME Non-Urgent sick visit Emergency Care Routine Care (non-urgent) Adult Baseline and Routine Physicals Well-Child Care Initial PCP office visit for Newborn Initial Prenatal Visit Initial Family Planning Visits Routine Care (non-urgent) In-Plan, Non-Urgent Care Mental Health or Substance Abuse Visits In-Plan Mental Health or Substance Abuse Follow-Up Visits WAIT TIME STANDARDS Within twenty-four (24) hours of the request. Within forty-eight (48) to seventy-two (72) hours of request. Primary Care Provider (PCP) or Prenatal Care Immediately upon presentation at a service delivery site. Within four (4) weeks of the request. Within twelve (12) weeks from enrollment. Within four (4) weeks of request. Within two (2) weeks of hospital discharge. Within three (3) weeks during first trimester, two (2) weeks during the second trimester, and one (1) week thereafter. Within two (2) weeks of request. Specialty Care Provider (SCP) Within four (4) to six (6) weeks of the request. Mental/Behavioral Health Within two (2) weeks of request. Visits (pursuant to an emergency or hospital discharge): within five (5) days of request, or sooner as clinically indicated. All physicians must have back-up coverage after hours or during absence/unavailability. Molina Healthcare requires providers to maintain a 24-hour telephone service, 7 days a week.

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