This documentation presents (1) a description of each of the Special Needs Plan (SNP) HEDIS measures that CMS collected for 426 SNP plan benefit packages (PBPs) for health care provided in calendar year 2014 to Medicare SNP beneficiaries and (2) the location of the rates associated with each SNP HEDIS measure within the HEDIS workbook (HEDIS2015_SNP.XLS). CMS took the description and additional information for each measure from HEDIS 2015 Volume 2: Technical Specifications. This release contains only those rates, percentages, or averages for each measure and not the numerator or denominator used to create those measures.
CMS requires that all managed care organizations undergo an audit on all HEDIS measures. The summary data file includes all submitted data following the audit.
The HEDIS measure descriptions reprinted here are done so with the permission of the National Committee for Quality Assurance (NCQA). HEDIS is a registered trademark of NCQA, and a copyright for HEDIS 2015 is held by the National Committee for Quality Assurance, 1100 13th Street, NW, Suite 1000, Washington, DC 20005. All rights reserved.
The reporting unit for SNP HEDIS is the PBP. Each Medicare Advantage contract must have at least one PBP; many contracts offer more than one. SNP PBPs limit enrollment to special needs individuals, i.e., those who are dual-eligible, institutionalized, or have one or more severe or disabling chronic conditions. In 2015, CMS collected data from 211 Medicare Advantage contracts for health care delivered by 426 SNP PBPs in 2014.
The "Service_Area" sheet in the SNP HEDIS workbook identifies the state(s) and counties where services are offered for that PBP.
The description and related information provided for each measure in this documentation are taken from the HEDIS 2015 Technical Specifications, which are the specific instructions for calculating HEDIS measures that NCQA provides to Medicare managed care plans. For each measure, the Technical Specifications detail the precise method for sampling (when appropriate), identification of the numerator and denominator, measure calculation, and any other important considerations specific to that measure. The Technical Specifications also contain general guidelines that apply to all measures, such as the use of medical records and when a plan should not report a measure because its eligible membership is too small. Some measures require more detailed specifications than others.
The HEDIS guidelines distinguish between three different types of missing values in the rate field: Not Applicable (NA), No Benefit (NB) and Not Reportable (NR). Health plans report NA when they: do not have a large enough population to calculate a representative rate (e.g., many measures require that rates be based on at least 30 members) or are not eligible for a measure (e.g., a health plan cannot calculate outpatient drug utilization if it does not offer an outpatient drug benefit; a health plan cannot calculate a measure requiring a year of continuous enrollment if its first enrollment began mid-way through the reporting year.) A value of NB is recorded when the health plan did not offer the health benefit required by the measure (e.g., Mental Health/Chemical Dependency). Health plans report NR when: they choose not to calculate and report a rate, or the health plans HEDIS Compliance Auditor determines that a rate is materially biased (applicable only to audited measures).
For measures reported as a percentage, material bias is defined as a deviation of more than five percentage points from the true rate. For other measures (e.g., procedures per 1,000 member years), material bias exists if the number of counted procedures deviates by more than ten percent from the true number of procedures.
Under the Privacy Act, CMS cannot publish or otherwise disclose the data in a form raising unacceptable possibilities that an individual could be identified (i.e., the data must not be beneficiary-specific and must be aggregated to a level where no data cells have 10 or fewer beneficiaries). To ensure that no beneficiary can be identified, CMS has chosen not to report certain measures, specifically enrollment by age category, and has suppressed an extremely small number of rates. CMS has replaced suppressed rates with an NA.' Please see the section on missing values above for an explanation of missing value designations.
CMS includes our record of enrollment as of December of the measurement year in the "GENERAL" sheet in the HEDIS workbook. The HEDIS reported value is adjusted for individuals with partial-year enrollment and reflects the entire contract's enrollment as well as the PBP enrollment.
We have included the Post Balanced Budget Amendment Naming of plan types as well as indicators if the contract offered a Special Needs benefit package or a Part D drug benefit in 2014. These values and others can be found on the sheet named "GENERAL". The full list of fields included on this sheet is described later in this document.
There is a separate sheet called "Service Area" in the SNP HEDIS workbook which contains the contract, state(s) and counties served by the PBPs reporting HEDIS. There is an additional field "EGHP" which indicates if the county is available only to beneficiaries in Employer Groups.
CMS has calculated and included a weighted national average for all of the Effectiveness of Care (EOC) measures. These rates are reported on a separate sheet called "National Rates" in the SNP HEDIS workbook. The rate for each of the EOC measures was calculated using the following formula:
((En1/TotE)*Sn1)+((En2/TotE)*Sn2)+ +((Enx/TotE)*Snx)=National Enrollment Weighted Average Score
Where: TotE
= Total enrollment for all PBPs with a valid numeric rate in the measure
En1 = Enrollment in the first PBP with a valid numeric rate
Sn1 = Reported rate for the first PBP with a valid numeric rate
Enx = Enrollment in the last PBP with a valid numeric rate
Snx = Reported rate for the last PBP with a valid numeric rate
DESCRIPTION - General organization Information. These fields are not explicitly identified in the HEDIS Technical Specifications.
General-0010 Type of Organization (Local CCP, 1876 Cost, etc.)
General-0011 Type of Plan (Post Balanced Budget Amendment Naming)
General-0014 Offers Special Needs Plans to beneficiaries (Yes or No)
General-0015 Offers Part D benefits (Yes or No)
General-0020 Line of Business (HMO, POS, etc.)
General-0050 12/2011 Enrollment as reported by the Medicare Advantage Prescription Drug (MARx) system
General-0060 CMS Region Number
General-0070 CMS Region Name
General-0080 Patient Population
General-0085 Submitted summary level HEDIS 2008 data to NCQA
General-0087 Included in HOS data from NCQA
DESCRIPTION - The area where the contract provides services to Medicare care beneficiaries. This data comes from the Health Plan Management System (HPMS) as reported by the contract.
SA-0030 Social Security Administration (SSA) State/County Code
SA-0040 American National Standards Institute (ANSI) State/County Code INCITS 31-2009 (formerly Federal Information Processing Standard [FIPS] State/County codes)
SA-0050 State Abbreviation (United States Postal Service (USPS) State Code)
SA-0060 County Name
SA-0070 County serves only beneficiaries in an Employer Group Health Plan (Y = Yes, N = No)
CMS has calculated and included a weighted national average for all of the Effectiveness of Care (EOC) measures. These rates are reported on a separate sheet called "National Rates" in the HEDIS workbook. The rate for each of the EOC measures was calculated using the following formula:
((En1/TotE)*Sn1)+((En2/TotE)*Sn2)+...+((Enx/TotE)*Snx)=National Weighted Average Score
Where:
TotE = Total enrollment for all contracts with a valid numeric rate in the measure
En1 = Enrollment in the first contract with a valid numeric rate
Sn1 = Reported rate for the first contract with a valid numeric rate
Enx = Enrollment in the last contract with a valid numeric rate
Snx = Reported rate for the last contract with a valid numeric rate
NR-0010 The HEDIS Year of the data (the measurement year is one year prior)
NR-0020 Measure from the HEDIS Public Use File for which the national rate has been calculated
NR-0030 Field from the HEDIS Public Use File for which the national rate has been calculated
NR-0040 The National Rate for this measure and field
NR-0050 The number of contracts that submitted a numeric HEDIS rate for this measure and field
NR-0060 The total number of enrollees in the contracts that submitted a numeric HEDIS rate for this measure and field
DESCRIPTION - The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported:
The percentage of discharges for which the member received follow-up within 30 days of discharge.
The percentage of discharges for which the member received follow-up within 7 days of discharge.
(HEDIS 2015, Volume 2: Technical Specification, Pg. 177)
EOC010-0011 Rate - 7 Days
EOC010-0012 Rate - 30 Days
EOC010-0021 Upper Confidence Interval - 7 Days
EOC010-0022 Upper Confidence Interval - 30 Days
EOC010-0031 Lower Confidence Interval - 7 Days
EOC010-0032 Lower Confidence Interval - 30 Days
DESCRIPTION - The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported.
Effective Acute Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
Effective Continuation Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).
(HEDIS 2015, Volume 2: Technical Specifications, Pg. 168)
EOC030-0010 Rate - Effect.Continuation Phase Treat.
EOC030-0020 Lower Confidence Interval - Effect.Continuation Phase Treat.
EOC030-0030 Upper Confidence Interval - Effect.Continuation Phase Treat.
EOC030-0040 Rate - Effect.Acute Phase Treatment
EOC030-0050 Lower Confidence Interval - Effect.Acute Phase Treatment
EOC030-0060 Upper Confidence Interval - Effect.Acute Phase Treatment
DESCRIPTION - The percentage of members 1885 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria:
Members 1859 years of age whose BP was <140/90 mm Hg.
Members 6085 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg.
Members 6085 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg.
Note: Use the Hybrid Method for this measure. A single rate is reported and is the sum of all three groups
(HEDIS 2015, Volume 2: Technical Specification, Pg. 132)
EOC035-0100 Rate - Total
EOC035-0110 Lower Confidence Interval tot
EOC035-0120 Upper Confidence Interval tot
DESCRIPTION - The percentage of members 5075 years of age who had appropriate screening for colorectal cancer. (HEDIS 2015, Volume 2: Technical Specification, Pg. 86)
EOC040-0010 Reported Rate
EOC040-0020 Lower Confidence Interval
EOC040-0030 Upper Confidence Interval
DESCRIPTION - The percentage of women 6785 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture. (HEDIS 2015, Volume 2: Technical Specification, Pg. 160)
EOC045-0010 Reported rate
EOC045-0020 Lower Confidence Interval
EOC045-0030 Upper Confidence Interval
DESCRIPTION - The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge. (HEDIS 2015, Volume 2: Technical Specification, Pg. 138)
EOC055-0010 Reported rate
EOC055-0020 Lower Confidence Interval
EOC055-0030 Upper Confidence Interval
DESCRIPTION - The percentage of Medicare members 66 years of age and older who received at least one high-risk medication.
The percentage of Medicare members 66 years of age and older who received at least two different high-risk medications.
For both rates, a lower rate represents better performance.
(HEDIS 2015, Volume 2: Technical Specification, Pg. 214)
EOC070-0010 Rate - one prescription
EOC070-0020 Lower Confidence Interval - one prescription
EOC070-0030 Upper Confidence Interval - one prescription
EOC070-0040 Rate - at least 2 prescriptions
EOC070-0050 Lower Confidence Interval - at least 2 prescriptions
EOC070-0060 Upper Confidence Interval - at least 2 prescriptions
DESCRIPTION - The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. For each product line, report each of the three rates separately and as a total rate.
Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB).
Annual monitoring for members on digoxin.
Annual monitoring for members on diuretics.
Total rate (the sum of the three numerators divided by the sum of the three denominators).
(HEDIS 2015, Volume 2: Technical Specification, Pg. 202)
EOC075-0010 Reported rate - ACE inhibitors or ARBs
EOC075-0020 Lower Confidence Interval - ACE inhibitors or ARBs
EOC075-0030 Upper Confidence Interval - ACE inhibitors or ARBs
EOC075-0040 Reported rate - Digoxin
EOC075-0050 Lower Confidence Interval - Digoxin
EOC075-0060 Upper Confidence Interval - Digoxin
EOC075-0070 Reported rate - Diuretics
EOC075-0080 Lower Confidence Interval - Diuretics
EOC075-0090 Upper Confidence Interval - Diuretics
EOC075-0160 Rate - Total
EOC075-0170 Lower Confidence Interval - Total
EOC075-0180 Upper Confidence Interval - Total
DESCRIPTION - The percentage of members 40 years of age and older with a new diagnosis of COPD or newly active COPD, who received appropriate spirometry testing to confirm the diagnosis. (HEDIS 2015, Volume 2: Technical Specification, Pg. 114)
EOC080-0010 Reported rate
EOC080-0020 Lower Confidence Interval
EOC080-0030 Upper Confidence Interval
DESCRIPTION - The percentage of Medicare members 65 years of age and older who have evidence of an underlying disease, condition or health concern and who were dispensed an ambulatory prescription for a potentially harmful medication, concurrent with or after the diagnosis.
Report each of the three rates separately and as a total rate.
A history of falls and a prescription for anticonvulsants, nonbenzodiazepine hypnotics, SSRIs, antiemetics, antipsychotics, benzodiazepines or tricyclic antidepressants.
Dementia and a prescription for antiemetics, antipsychotics, benzodiazepines, tricyclic antidepressants, H2 Receptor Antagonists, nonbenzodiazepine hypnotics or anticholinergic agents.
Chronic kidney disease and prescription for Cox-2 Selective NSAIDs or nonaspirin NSAIDs.
Total rate (the sum of the three numerators divided by the sum of the three denominators).
Members with more than one disease or condition may appear in the measure multiple times (i.e., in each indicator for which they qualify). A lower rate represents better performance for all three rates.
(HEDIS 2015, Volume 2: Technical Specification, Pg. 209)
EOC090-0010 Rate - DDI Falls + Anticonvulsants, Nonbenzodiazepine hypnotics, SSRIs, Antiemetics, Antipsychotics, Benzodiazepines or Tricyclic Antidepressants
EOC090-0020 Lower Confidence Interval - DDI Falls + Anticonvulsants, Nonbenzodiazepine hypnotics, SSRIs, Antiemetics, Antipsychotics, Benzodiazepines or Tricyclic Antidepressants
EOC090-0030 Upper Confidence Interval - DDI Falls + Anticonvulsants, Nonbenzodiazepine hypnotics, SSRIs, Antiemetics, Antipsychotics, Benzodiazepines or Tricyclic Antidepressants
EOC090-0040 Rate - DDI Dementia + Antiemetics, Antipsychotics, Benzodiazepines, Tricyclic Antidepressants, H2 Receptor Antagonists, Nonbenzodiazepine hypnotics or Anticholinergic Agents
EOC090-0050 Lower Confidence Interval - DDI Dementia + Antiemetics, Antipsychotics, Benzodiazepines, Tricyclic Antidepressants, H2 Receptor Antagonists, Nonbenzodiazepine hypnotics or Anticholinergic Agents
EOC090-0060 Upper Confidence Interval - DDI Dementia + Antiemetics, Antipsychotics, Benzodiazepines, Tricyclic Antidepressants, H2 Receptor Antagonists, Nonbenzodiazepine hypnotics or Anticholinergic Agents
EOC090-0070 Rate - DDI Chronic Kidney disease + Cox-2 Selective NSAIDs or Nonaspirin NSAIDs
EOC090-0080 Lower Confidence Interval - DDI Chronic Kidney disease + Cox-2 Selective NSAIDs or Nonaspirin NSAIDs
EOC090-0090 Upper Confidence Interval - DDI Chronic Kidney disease + Cox-2 Selective NSAIDs or Nonaspirin NSAIDs
EOC090-0100 Rate - Total
EOC090-0110 Lower Confidence Interval - Total
EOC090-0120 Upper Confidence Interval - Total
DESCRIPTION - The percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED visit on or between January 1November 30 of the measurement year and who were dispensed appropriate medications. Two rates are reported:
1. Dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event.
2. Dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event.
Note: The eligible population for this measure is based on acute inpatient discharges and ED visits, not on members. It is possible for the denominator to include multiple events for the same individual.
(HEDIS 2015, Volume 2: Technical Specification, Pg. 116)
EOC105-0010 Reported rate - Systemic corticosteroid
EOC105-0020 Lower 95% confidence interval - Systemic corticosteroid
EOC105-0030 Upper 95% confidence interval - Systemic corticosteroid
EOC105-0040 Reported rate - Bronchodilator
EOC105-0050 Lower 95% confidence interval - Bronchodilator
EOC105-0060 Upper 95% confidence interval - Bronchodilator
DESCRIPTION - The percentage of adults 66 years and older who had each of the following during the measurement year:
Advance care planning.
Medication review.
Functional status assessment.
Pain assessment.
(HEDIS 2015, Volume 2: Technical Specification, Pg. 94)
EOC115-0010 Reported Rate - Advance Care Planning
EOC115-0020 Lower Confidence Interval - Advance Care Planning
EOC115-0030 Upper Confidence Interval - Advance Care Planning
EOC115-0040 Reported Rate - Medication Review
EOC115-0050 Lower Confidence Interval - Medication Review
EOC115-0060 Upper Confidence Interval - Medication Review
EOC115-0070 Reported Rate - Functional Status Assessment
EOC115-0080 Lower Confidence Interval - Functional Status Assessment
EOC115-0090 Upper Confidence Interval - Functional Status Assessment
EOC115-0100 Reported Rate - Pain Assessment
EOC115-0110 Lower Confidence Interval - Pain Assessment
EOC115-0120 Upper Confidence Interval - Pain Assessment
DESCRIPTION - The percentage of discharges from January 1December 1 of the measurement year for members 66 years of age and older for whom medications were reconciled on or within 30 days of discharge. (HEDIS 2015, Volume 2: Technical Specification, Pg. 206)
EOC120-0010 Reported Rate
EOC120-0020 Lower Confidence Interval
EOC120-0030 Upper Confidence Interval
DESCRIPTION - The percentage of the following physicians whose board certification is active as of December 31 of the measurement year.
Family medicine physicians
Internal medicine physicians
Pediatricians
OB/GYN physicians
Geriatricians
Other physician specialists
Board certification refers to the various specialty certification programs of the American Board of Medical Specialties and the American Osteopathic Association. Report each product separately as of December 31 of the measurement year.
(HEDIS 2015, Volume 2: Technical Specification, Pg. 382)
PDI801-0010 Family Medicine Board Cert Pct
PDI801-0030 Oth Specialists Board Cert Pct
PDI801-0050 Geriatricians Board Cert Pct
PDI801-0060 Internal Medicine Board Cert Pct
PDI801-0070 OB/GYN Provs Board Cert Pct
PDI801-0080 Pediatrician Board Cert Pct
DESCRIPTION - For members 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories:
1. Count of Index Hospital Stays (IHS) (denominator).
2. Count of 30-Day Readmissions (numerator).
3. Average Adjusted Probability of Readmission.
(HEDIS 2015, Volume 2: Technical Specification, Pg. 318)
UOS524-0010 Count of Index Stays (Denominator) 65-74
UOS524-0020 Count of 30-Day readmissions (Numerator) 65-74
UOS524-0025 Observed Readmission (Num/Den) 65-74
UOS524-0030 Average Adjusted Probability 65-74
UOS524-0035 Total Variance 65-74
UOS524-0040 Count of Index Stays (Denominator) 75-84
UOS524-0050 Count of 30-Day readmissions (Numerator) 75-84
UOS524-0055 Observed Readmission (Num/Den) 75-84
UOS524-0060 Average Adjusted Probability 75-84
UOS524-0065 Total Variance 75-84
UOS524-0070 Count of Index Stays (Denominator) 85+
UOS524-0080 Count of 30-Day readmissions (Numerator) 85+
UOS524-0085 Observed Readmission (Num/Den) 85+
UOS524-0090 Average Adjusted Probability 85+
UOS524-0095 Total Variance 85+
UOS524-0100 Count of Index Stays (Denominator) Total Total
UOS524-0110 Count of 30-Day Readmissions (Numerator) Total Total
UOS524-0120 Observed Readmission (Num/Den) Total Total
UOS524-0130 Average Adjusted Probability Total Total
UOS524-0140 Total Variance Total Total
UOS524-0150 Observed-to-Expected Ratio
UOS524-0160 Lower Confidence Interval
UOS524-0170 Upper Confidence Interval
UOS524-0510 Count of Index Stays (Denominator) 18-44
UOS524-0520 Count of 30-Day readmissions (Numerator) 18-44
UOS524-0525 Observed Readmission (Num/Den) 18-44
UOS524-0530 Average Adjusted Probability 18-44
UOS524-0535 Total Variance 18-44
UOS524-0540 Count of Index Stays (Denominator) 45-54
UOS524-0550 Count of 30-Day readmissions (Numerator) 45-54
UOS524-0555 Observed Readmission (Num/Den) 45-54
UOS524-0560 Average Adjusted Probability 45-54
UOS524-0565 Total Variance 45-54
UOS524-0570 Count of Index Stays (Denominator) 55-64
UOS524-0580 Count of 30-Day readmissions (Numerator) 55-64
UOS524-0585 Observed Readmission (Num/Den) 55-64
UOS524-0590 Average Adjusted Probability 55-64
UOS524-0595 Total Variance 55-64
UOS524-0600 Count of Index Stays (Denominator) Total Total
UOS524-0610 Count of 30-Day readmissions (Numerator) Total
UOS524-0620 Average Adjusted Probability Total Total
UOS524-0630 Observed Readmission (Num/Den) Total Total
UOS524-0640 Total Variance Total Total
UOS524-0650 Observed-to-Expected Ratio
UOS524-0660 Lower Confidence Interval
UOS524-0670 Upper Confidence Interval