Linkage between performance measures and service duties

CO | CT | DC | HI | IL | IN | IA | IABH | KS | KY | MD | MABH
MN | NV | NJ | NM | NC | OH | ORMH | TX | WV | WI

"XVI. QUALITY ASSURANCE…
C. Quality and Utilization Measures
1. The Contractor shall accurately calculate and submit specified measures from the Health Plan Employer Data and Information Set (HEDIS). The Department will collaborate with the Quality Improvement Committee, made up of quality assurance leaders from contracting Medicaid managed care organizations, to designate the required measures. The designated measures shall be submitted to the Department, in a format defined by the Department, on June 30 of each Contract Year for the previous reporting year.

2. The Contractor shall work with the Department to analyze and respond to results indicated in the HEDIS measures. The Contractor is required to fund auditing of the HEDIS measures according to guidelines and a timeline negotiated by the Contractor and the Department.

3. Such audits shall support the publishing of measures and allow the Department to determine compliance with the calculation of measures.

4. A failed audit which nullifies more than three (3) required HEDIS measures is considered non-compliance with this standard and the Department may impose sanctions upon the Contractor pursuant to this Contract." Colorado Contract, pages 54, 56-57.

"3.19 Prenatal Care...
b. Performance Measure: Early access to prenatal care: Percentage of women with live births who were enrolled during the first trimester of pregnancy who had a first prenatal visit prior to 13 weeks gestation from last menstrual period.

c. Performance Measure: Adequacy of prenatal care: Percentage of women with live births who were continuously enrolled during pregnancy who had more than 80% of the recommended prenatal visits, adjusted for gestational age at enrollment and delivery…" Connecticut Contract, page 33.

"3.20 Dental Care...
b. Performance Measure: The MCO shall ensure that no less than eighty (80) percent of continuously enrolled members 2 to 20 years of age shall receive on screening and dental cleaning per twelve month period. On a quarterly basis, the DEPARTMENT shall, through the encounter data submitted by MCO, review the MCO's performance under children's dental access.

c. Performance Measure: The MCO shall ensure that no less than 80% of continuously enrolled members 21 years of age and over shall receive one screening and dental cleaning per twelve month period. On a quarterly basis, the DEPARTMENT shall, through the encounter data submitted by MCO, review the MCO's performance under adult dental access…" Connecticut Contract, page 34.

"4.11 Incentives...
B. Early and Periodic Diagnosis, Screening and Treatment (EPSDT)
1. Using encounter data submitted by the MCO pursuant to section 3.37.h, the DEPARTMENT will establish a baseline measure of EPSDT participation and screening of members for the period of October 1, 1998 through September 30, 1999 using the methodology then in effect as promulgated by the Health Care Financing Administration (HCFA) for the HCFA 416 report.
2. Using the encounter data submitted by the MCO, the DEPARTMENT will measure EPSDT participation and screening ratios, as defined by the HCFA 416 methodology, for the last twelve months of the contract. Such measurement will not occur until three months after the last day of the contract...

C. Dental Access
1. Using encounter data submitted by the MCO, the DEPARTMENT will establish baseline measures of dental access over the first twelve months of this contract. This would include services rendered by dental hygienists acting within the scope of their practice under state law.
2. The measures of dental access shall be the same as those proposed by HCFA for the HCFA 416 and adopted by the DEPARTMENT for utilization reporting by the MCOs, as follows:
i. Percent of members between 4 and 21 years of age receiving any dental service;
ii. Percent of members between 4 and 21 years of age receiving preventive dental services;
iii. Percent of members between 4 and 21 years of age receiving dental treatment services…

E. Behavioral Health
1. Using encounter data submitted by the MCO pursuant to section 3.37.h and the results of a special behavioral health outcome study, the DEPARTMENT will construct measures of behavioral health outcomes.
2. One measure will be based on the special behavioral health outcome study and three others will be constructed from encounter data using NCQA HEDIS specifications for 'administrative data'…" Connecticut Contract, pages 59-63.

"7. EPSDT Performance Standards
a. Provider shall meet the EPSDT participation ratio, as defined by the HCFA State Medicaid Manual, Section 5360.B (November 1993) for Provider's enrollees according to the following schedule:
(1) 75% for 1998, and
(2) 80% for 1999.

b. If Provider fails to meet or show progress toward meeting the EPSDT performance standards in paragraph 'a' of this section or ensure that children have their age-appropriate screens updated for missed opportunities, the District shall take any or all of the following actions (depending on the extent of the failure to comply or to demonstrate progress with the standards):
(1) require the Provider to develop and implement a corrective action plan, that is approved by the District and is designed to increase Provider's EPSDT participation ratio;
(2) require the Provider to utilize the Department's EPSDT case management program; or
(3) withheld an amount from the Provider's payment, pursuant to Article XI, section A.3 at a rate of $45 for each enrollee that is required to be added to the numerator in Provider's EPSDT participation ratio to comply with the performance standards in paragraph 'a' of this section." District of Columbia Contract, page 32.

"46.300 Quality Assurance Reporting
The QA reporting requirements provide: ... 2) performance measures. The objectives of the performance measures are: 1) to standardize how the plan specifies, calculates and reports information; and 2) to trend a plan's performance over time and to identify areas in need of improvement.
* The plan shall provide the following reports and information: ...
* Performance Measures

The health plan is responsible for submitting Medicaid Health Plan Employer Data and Information Set (HEDIS) reports as specified in the most current HEDIS document in effect at the start of the contract period. (See the Medicaid HEDIS document in the documentation Library.) HEDIS reports will be follow HEDIS specifications except that the reports will be based on the State's fiscal year and is due to DHS by December 31." Hawaii RFP, pages 68-69.

"EXHIBIT A
Quality Assurance (QA)

1. All services provided by or arranged by Contractor to be provided shall be in accordance with prevailing professional community standards. Contractor shall establish a program that systematically and routinely collects data to review which includes quality oversight and monitoring performance and patient results. The program shall include provision for the interpretation of such data to Contractor's practitioners. Contractor shall have in effect a program consistent with the utilization control requirements of 42 CFR Part 456. This program will include, when required by the regulations, written plans of care and certifications of need of care…" Illinois HMO Contract, Appendix A, page A-1.

"11. The findings, conclusions, recommendations, actions taken, and results of the actions taken as a result of QA activity, shall be documented and reported to appropriate individuals within the organization and through the established QA channels. Contractor shall document coordination of QA activities and other management activities.

a. QA information shall be used in recredentialing, recontracting and/or annual performance evaluations.

b. QA activities shall be coordinated with other performance monitoring activities, including utilization management, risk management, and resolution and monitoring of member complaints and grievances.

c. There shall be a linkage between QA and the other management functions of the Plan such as:
• network changes;
• benefits redesign;
• medical management systems (e.g., pre-certification);
• practice feedback to physicians licensed to practice medicine in all its branches; and
• patient education.

In the aggregate, without reference to individual physicians licensed to practice medicine in all its branches or Beneficiary identifying information, all Quality Assurance findings, conclusions, recommendations, actions taken, results or other documentation relative to QA shall be reported to Department on a quarterly basis or as requested by the Department. The Department shall be notified of any physician licensed to practice medicine in all its branches terminated from a subcontract with Contractor for a quality of care issue." Illinois HMO Contract, pages A7-A8.

"4.6.9 Quality Improvement and Utilization Review Program
The MCO must monitor, evaluate, and take effective action to identify and address any needed improvements in the quality of care delivered to members by all providers in all types of settings, in accordance with the provisions specified in Section 4.6.9.1 of this RFP. In addition, the MCO must have a utilization review program in place that meets the requirements specified in Section 4.6.9.2 of this RFP.

4.6.9.1 Quality Improvement Program and Reporting Standard...
* The MCO must have procedures to measure various quality indicators. A listing of quality improvement indicators is provided in Appendix V-G of this RFP. These indicators may be modified or vary at the discretion of the Quality Improvement Committee or Clinical Advisory Committee. The MCO must have in place a quality improvement process that uses at least these indicators to refine and develop MCO policies and procedures.

* The MCO must have procedures in place to conduct performance feedback to providers that discusses clinical and facility indicators and ways to improve performance.." Indiana RFP, pages 4-33, 4-34, 4-39.

"4.18 Quality Improvement (QI) Program...
During the first Contract year, the HMO shall establish a baseline performance level using the appropriate performance indicators(s). By May 1 of the first Contract year, the HMO shall submit to the Department the results of the baseline assessment with the QI Plan for each QAPI project. Upon the Department's approval of the QI Plan in writing, the HMO shall implement the QI plan during the second and third Contract year. QI activities must include, but are not limited to patient and Provider education as related to the best practices." Iowa Contract, pages 35-36.

IABH

"PERFORMANCE INDICATORS CARRYING MEDICAID FINANCIAL INCENTIVES for the IOWA PLAN FOR BEHAVIORAL HEALTH...

Unless specified otherwise, all performance indicators relate only to Medicaid mental health services.

For the attainment of each designated performance indicator for the time period January 1, 1999 through June 30, 2000, the contractor shall be paid $125,000 in incentive pay...

Measure

Consumer Involvement
The consumer shall participate in 96% of all joint treatment planning conferences

Community Tenure
The average time between hospitalization shall not fall below 60 days.

Involuntary Hospitalization
The percent of involuntary admissions to 24-hour inpatient settings for mental health treatment shall not exceed 20% of all children's admissions and 15% of all adult admissions

Access
Based on claims data during the contract year, the Contractor shall provide services to at least 15% of Iowa Plan enrollees.

Service Array
At least 2.5% of mental health service expenditures will be used in the provision of integrated services and supports including natural supports, consumer-run programs, services delivered in the home of the enrollee

Quality of Care
The number of emergency room presentations shall not exceed 8.5 visits per 1000 enrollee moths (annualized)

Quality of Care
90% of persons discharged form inpatient care will receive other treatment services within 7 days of discharge date

90% of all discharged plans written for enrollees being released from inpatient hospitalizations shall be implemented" Iowa Behavioral Health Contract, pages 65- 66.

"Quality Management...
The HMO shall: …
• Develop and carry out a process of review of: 1) outcome indicators associated with specific conditions/diagnoses important to the Medicaid population, and 2) treatment protocols for specific conditions/diagnoses important to the Medicaid population. This process must include at a minimum: ...
o Periodic written reports as requested to SRS updating the status of ongoing studies for immunizations, pregnancy related health concerns and KAN Be Healthy (EPSDT). Quality improvement may also be requested by SRS if the HMO is not internally measuring Medicaid health outcomes or if SRS has identified a particular area of concern." Kansas Contract, pages 25-29.

"E. QUALITY IMPROVEMENT
1. Quality Improvement System
The Contractor shall maintain and operate a continuous, internal Quality Improvement System in accordance with Sections 7.5.1 and 7.5.2 and Attachments VI and XVI of the RFA...

5. Health Care Outcomes, Indicators and Benchmarks
The Contractor shall comply with the requirements of Section 7.5 and Attachment VI of the RFA regarding health care outcomes. The Department specifically agrees to payment of the incentive amounts specified in Attachment D should the Contractor achieve in a given year the benchmarks established by the Department in collaboration with the Contractor, as specified in Attachment VI of the RFA, for that year in a specified category..." Kentucky Contract, page 23.

"7.5.1 Quality Improvement System...
(a) The Quality Improvement Plan shall contain: ...
(9) Mechanisms for assessing and taking corrective actions, when performance measures or benchmarks are not achieved or study findings deem corrective action to be appropriate…If the Department determines benchmarks have not been achieved, a corrective action plan shall be submitted to the Department by The Partnership within two months of notification. Improvement shall be shown by the partnership within three months following initiation of the corrective action plan...
(b) The Scope of work shall include:
(1) Monitoring and evaluation required and financially-incented regional benchmarks related to health care outcomes, including the members' risk factors, functional status, morbidity, mortality, readmissions to health care facilities, adverse incidents and complications, satisfaction with care and effect of educational programs. Certain screening and outcome benchmarks shall be required by years two and three of operation of a Partnership. Other outcome benchmarks may be fiscally-incented for any year of Partnerships operation. The required screening and outcome benchmarks shall be adjusted in collaboration with each Partnership based on the health status of recipients in The Partnership's region. During the second year of operation Partnership shall meet adjusted screening benchmarks. During Year three, Partnerships shall meet adjusted outcome benchmarks.

The specific requirements include:
(i) The Reporting Set Measures contained in the most recent version of HEDIS 3.0 published by and available from the national Committee for Quality Assurance.
(ii) The required health indicators and benchmarks developed by the Commissioners of Kentucky's Departments for Public Health and Mental health/mental Retardation for Kentucky's Health Care Partnership Program...
(iv) The EPSDT screening and special services requirements..." Kentucky RFA, pages 34-37.

"Expansion and or Changes in the network
If at any time, a Partnership determines that its Provider Network is not adequate to comply with the access standards specified above, The Partnership shall notify the Department for Medicaid Services of this situation and submit a corrective action plan to remedy the deficiency. The corrective action plan shall describe the deficiency in detail, including the geographic location and specific regions where the problem exists, and identify specific action steps to be taken by The Partnership and time frames to correct the deficiency." Kentucky RFA, page 51.

"10.09.65.03...
L. An MCO shall complete 100 percent of HEDIS reporting for the following performance measures beginning in year one:
(1) Well-child care, referring to the MCO's EPSDT periodicity schedule;
(2) Prenatal care; and
(3) Pediatric asthma.

M. An MCO shall, at a minimum, meet the following standards for the annual systems performance review:
HCQIS Standards: Minimum Compliance Rates...

N. An MCO shall, at a minimum, meet the following standards for its annual clinical care review:
(1) In the first year, for each clinical care area reviewed, the MCO shall meet or exceed a compliance rating of 70 percent for:
(a) Medical records review, and
(b) Clinical care focused studies, to include special populations and other clinical care areas as designated by the Department; and
(2) In each subsequent year of the clinical care review, the MCO shall, within each clinical care area reviewed, demonstrate a compliance rating improvement of at least 5 percent, until achieving and maintaining a compliance rating of at least 90 percent." Maryland COMAR 10.09.65.03.

MABH

"SECTION 5: REIMBURSEMENT...
C. Risk Sharing...
5. Performance Incentives and Sanctions
a. General Provisions
(1) All provisions for performance incentives and sanctions described under this section shall also constitute independent requirements under this Contract in addition to operating as standards for the purpose of determining whether the Contractor has earned an incentive or may be subject to sanctions.

(2) If the Contractor fails to meet the following performance standards, the Division shall provide written notification to the Contractor.

(3) Within 15 business days of the date of the Division's notification of failure to meet a performance standard, the Contractor shall submit a corrective action plan and a timetable for implementation of the corrective action plan to the Division for its review and approval, and any modifications thereto.

(4) Subsequent to the Division's review and approval of the corrective action plan and the timetable for its implementation, the Contractor shall implement the corrective action plan within fourteen calendar days.

(5) The Division shall have the sole authority for determining whether the Contractor has met, exceeded or fallen below any and all of the requirements set forth in this subsection.

(6) The Division shall notify the Contractor when performance has returned to acceptable levels.

(7) Failure to meet the performance standards listed in this section may result in imposition of sanctions and penalties listed in Section 5 of Appendix A to this Contract.

(8) The Division shall make its determination as to whether the Contractor has complied with the performance standards listed below on a Contract Year basis, to be completed no later than three (3) months after the end of the first Contract Year, except as otherwise provided in subsection j. herein; and provided, however, that if the Division has not received sufficient material information from the Contractor to make such a determination, it shall not be required to comply with this section...

(13) In determining Contractor compliance and achievement against the performance standards listed below, performance measurements will not be rounded. For example, if the Contractor is required to achieve a performance level of 105%, the target will not have been achieved if the Contractor's performance is 104.99%.

(14) Except as otherwise expressly stated, for any performance standard for which compliance is determined by reference to a baseline, the baseline will be established by the Division, in its sole discretion, utilizing relevant MHMA, Inc. data for calendar year 1995.

(15) For the first Contract Year, for purposes of imposing sanctions and/or paying incentives in accordance with the provisions of Sections 5.1.C.5.b.-j. of Appendix A of the Contract, the Division shall measure the Contractor's performance only for the period November 1, 1996 through June 30, 1997.

b. Performance Standard for Outpatient Visits: The Contractor shall ensure that combined discharges from inpatient hospitals, freestanding detoxification facilities, and acute residential treatment facilities (‘inpatient facilities') shall be followed by an outpatient visit within three (3) days of discharge, unless transfer is made to another inpatient facility...

(1) If the annual compliance rate for timeliness of outpatient visits is less than 105% of the baseline but greater than or equal to 100%, the Division may elect to impose a penalty of up to $100,000.

(2) If the annual compliance rate for timeliness of outpatient visits is less than 95% but not greater than 100% of the baseline, the Division may elect to impose a penalty of up to $200,000.

(3) If the annual compliance rate for timeliness of outpatient visits is equal to or greater than 105% of the baseline, the Division shall pay the Contractor $333,333.

c. Performance Standard for Readmissions: The Contractor shall ensure that the combined inpatient readmission rate to inpatient hospitals, freestanding detoxification facilities and acute residential treatment facilities (‘inpatient facilities') within seven (7) days of discharge from any one of the three settings, shall not exceed 5% during the first Contract Year... Cases where the discharge was against medical advice shall be removed from the sample.

(1) If the combined inpatient readmission rate exceeds 5% but is less than or equal to 10%, the Division may elect to impose a penalty of up to $100,000.

(2) If the combined inpatient readmission rate is greater than 10%, the Division may elect to impose a penalty of up to $200,000.

(3) If the combined inpatient readmission rate equals or is less than 5%, the Division shall pay the Contractor $333,333...

g. Performance Standard for Continuation of Care: The Contractor shall provide a prior approval decision within twenty four (24) hours of receiving a request with all necessary clinical information from a Provider for continuation of care beyond the initial pre-approved period, for all Enrollees for the following services: inpatient psychiatric services, Level IV detoxification services, holding beds, crisis stabilization beds, acute residential treatment services, acute partial hospital treatment services, day program services, Level III detoxification services, and short-term addiction residential treatment program services...

(1) If the annual compliance rate for the continuation of care authorization decision and notification process is less than 95% and greater than 90%, the Division may elect to impose a penalty of up to $100,000.

(2) If the annual compliance rate for the continuation of care authorization decision and notification process is 90% or less, the Division may elect to impose a penalty of up to $200,000.

(3) If the annual compliance rate for the continuation of care authorization decision and notification process is equal to 95% or more, the Division shall pay the Contractor $333,333...

i. Performance Standard for Claims Processing: The Contractor shall review, process, and remit a check for Clean Claims submitted to the Contractor by the Provider within thirty days of receipt of the Clean Claims...

(1) If the annual compliance rate for claims processing is less than 95% and more than 90%, the Division may elect to impose a penalty of up to $100,000.

(2) If the annual compliance rate for claims processing is 90% or less, the Division may elect to impose a penalty of up to $200,000.

(3) If the annual compliance rate for claims processing is equal to or greater than 95%, the Division will pay the Contractor $333,333.

j. Performance Standard for Report Submission: The Contractor shall submit the reports required pursuant to Section 5 of Appendix A and Section 8 of Appendix B to this Contract in the format and timeframes specified therein with the exception of quarterly and annual reports requiring analysis which will be due within 45 days of the end of the quarter...

(1) If the Division determines that the Contractor is one (1) to seven (7) days late in submitting any such report, the Division may elect to impose a penalty of up to $5,000.

(2) Thereafter, the Division may elect to impose a penalty of up to $500 for each additional business day after the seventh day following the report's due date until the date on which the report is delivered to the Division.

(3) If the annual compliance rate for report submission meets or exceeds the Division's specifications for report submission, the Division will pay the Contractor $333,333.

6. Performance Improvement Bonuses
a. General Provisions

(1) The Division shall make its determination as to whether the Contractor has complied with the performance improvement standards listed below on a Contract Year basis, to be completed no later than three (3) months after the end of the first Contract Year, except as otherwise provided in subsection j. herein; and provided, however, that if the Division has not received sufficient information from the Contractor to make such a determination, it shall not be required to comply with this section.

(2) If the Contractor meets or exceeds each of the performance improvement standards listed in subsections 5.1.C.6.b and 5.1.C.6.c, as determined by the Division, the Division shall pay the Contractor a $500,000 performance improvement bonus for each performance improvement.

(3) The Division shall have the sole authority for determining whether the Contractor has met, exceeded or fallen below any and all of the requirements set forth in this subsection.

b. Continuing Care Rate Performance Improvement Standard
The percentage of Enrollees discharged from an inpatient hospital unit who, subsequent to discharge, attend a minimum of one outpatient appointment per month for four months, shall be required to increase 10%...

c. Discharge Information Performance Improvement Standard
The percentage of inpatient hospital charts with evidence of completed discharge information at the time of discharge shall be required to increase by 7.5%..." Massachusetts MH/SAP Contract, Appendix A, pages 36, 42-50.

"2.06 Network Management
The Contractor shall: ...

2.06.03 Design and submit to the Division for its prior review and approval, prior to the tenth month of the first Contract Year, a plan to manage the Provider Network, which shall include, but not be limited to, a clearly defined strategy for managing through the Provider Network the issues of access, quality and cost-effectiveness, and shall also include, at a minimum, the following: ...
b. a system for the Contractor and Provider to identify and establish improvement goals and periodic measurements to track the Provider's progress or lack of progress towards the improvement goals;
c. a list of improvement goals and measures by Provider type; a reporting schedule; regularly scheduled management meetings by Provider type and by Region; and a mechanism to establish, prioritize, set and measure achievement of Provider improvement goals…" Massachusetts MH/SAP Contract, Appendix B, page 19.

"6.04 Service Outcomes
The Contractor shall: ...

6.04.03 Use outcome measures based on behavioral health care industry standards after receiving prior review and approval from the Division; or develop outcome measures in collaboration with the Division and Network Providers that are specific to each type of service and ensure that such outcome measures include, at a minimum:
a. recidivism;
b. adverse occurrences;
c. treatment drop-out;
d. length of time between admissions; and
e. treatment goals achieved." Massachusetts MH/SAP Contract, Appendix B, pages 51-52.

"D. SECTION 5: REIMBURSEMENT...
6. Section 5.1.C.5. Of Appendix A shall be amended by deleting subsections d, e, f, and h and replacing them, respectively, with the following subsections:

d. Performance Standard for Timeliness of Inpatient Admissions: The Contractor shall ensure that inpatient hospital disposition occur within two hours of receiving clinical assessment information from a credentialed Provider or ESP...
1) If the annual compliance rate for timeliness of inpatient admissions is less than 90% and greater than or equal to 80%, the Division may elect to impose a penalty of up to $100,000.
2) If the annual compliance rate for timeliness of inpatient admissions is less than 80% but greater than 70%, the Division may elect to impose a penalty of up to $200,000.
3) If the annual compliance [sic] for timeliness of inpatient admissions is equal to or greater than 90%, the Division shall pay the contractor $333,333.

e. Performance Standard for Referrals to DMH: The Contractor shall issue corrective action plans to up to 22 inpatient hospital providers with less than a 95% rate of Continuing Care Eligibility (CCE) determination by DMH and/or endorsement by the Contractor...
1) If the annual compliance rate exceeds 95% but is not 100%, the Division may elect to impose a penalty of up to $100,000.
2) If the annual compliance rate is 90% but less than 95%, the Division may elect to impose a penalty of up to $200,000.
3) If the annual compliance rate for issuing corrective action plans is equal to 100%, the Division shall pay the Contractor $333,333.

f. Performance Standard for Inpatient Prior Approval: The Contractor shall provide a prior approval decision for all DMA Inpatient Services within one and a half hours of receiving clinical assessment information from a credentialed ESP or Provider...
1) If the annual compliance rate for the inpatient prior approvals is less than 90%, the Division may elect to impose a penalty of up to $100,000.
2) If the annual compliance rate for inpatient prior approval is 85% or less, the Division may elect to impose a penalty of up to $200,000.
3) If the annual compliance rate for inpatient prior approvals is greater than or equal to 90%, the Division shall pay the Contractor $333,333 ...

h. Performance Standards for Prior Approval of Outpatient Services: The Contractor shall provide notification of prior approval and continued care approval decisions for Outpatient Services within ten business days of receiving a verbal or written request, or both complete with all necessary clinical information from the Provider...
1) If the annual compliance rate for prior approval and continued care approval decisions and notification for outpatient services is less than 95% and more than 90%, the Division may elect to impose a penalty of up to $100,000.
2) If the annual compliance rate for the prior approval and continued care approval decisions and notification for outpatient services is less than 90%, the Division may elect to impose a penalty of up to $200,000.
3) If the annual compliance rate for prior approval and continued care approval decisions and notification for outpatient services is greater than or equal to 95%, the Division shall pay the Contractor $333,333." Massachusetts MH/SAP Contract, Amendment 1, pages 5-7.

"5.1.IC.5: PERFORMANCE INCENTIVES AND PENALTIES; INITIATIVES
a. General Provisions...
Unless otherwise cited below, all Performance Standards and Initiatives shall be measured for the period August 1, 1997 through June 30, 1998.
b. Incentive and Penalties

1) Aftercare Planning: Disabled Adults
The Contractor shall measure the percentage of charts for disabled adults discharged from an inpatient psychiatric hospital with evidence of completed aftercare planning...
a) If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000.
b) If the actual measure is equal to or greater than the compliance target, the Contractor shall receive a bonus of $400,000.

2) Family Member/Guardian Involvement: Children and Adolescents
The Contractor shall measure the percentage of charts for children and adolescents discharged from an inpatient psychiatric hospital or mental health acute residential treatment program with documentation of family member/guardian participation or invitation to participate in meetings on the inpatient unit...
a) If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000.
b) If the actual measure is equal to or greater than the compliance target, the Contractor shall receive a bonus of $400,000.

3) Continuing Care: Children and Adolescents
The Contractor shall measure the percentage of children and adolescents discharged from inpatient psychiatric treatment participating in aftercare appointments...
a) If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000.
b) If the actual measure is equal to or greater than the compliance target, the Contractor shall receive a bonus of $450,000.

4) Continuing Care: Adults
The Contractor shall measure the percentage of adults discharged from inpatient psychiatric treatment who receive outpatient treatment within three (3) business days of discharge...
a) If the actual measure is less than the compliance target, the Division may impose a penalty of up to $300,000.
b) If the actual measure is equal to or greater than the compliance target, the Contractor shall receive a bonus of $400,000.

5) Continuing Care: Medication Monitoring
The Contractor shall measure the percentage of members across all rating and age categories discharged from inpatient psychiatric treatment who attend within 21 days of discharge: an outpatient medication evaluation; a medication monitoring appointment; an initial evaluation by a physician or Clinical Nurse Specialist; or a medication group appointment...
a) If the actual measure is less than the compliance target, the Division may impose a penalty of up to $500,000.
b) If the actual measure is greater than or equal to the compliance target but less than a 25% increase above the first contract year performance level, the Contractor shall receive a bonus of $500,000; or
c) If the actual measure is greater than or equal to a 25% increase above the first contract year performance level, the Contractor shall receive a bonus of $700,000.

6) Readmission Rates: Disabled Adults
The Contractor shall measure the percentage of disabled adult members discharged from inpatient psychiatric treatment who are readmitted within 30 days of discharge...
a) If the actual measure is less than the compliance target, the Division may impose a penalty of up to $350,000.
b) If the actual measure is greater than or equal to the compliance target, the Contractor shall receive a bonus of $400,000.

7) Continuity of Care in Readmission for Children and Adolescents
The Contractor shall measure the percentage of medically necessary readmissions occurring within one year of the initial admission (excluding situations where family choice and bed availability otherwise prevail) for children and adolescents readmitted to the same inpatient mental health treatment facility that was the site of the prior admission...
a) If the actual measure is less than the compliance target, the Division may impose a penalty of up to $300,000.
b) If the actual measure is greater than or equal to the compliance target and less than 90% of readmissions, the Contractor shall receive a bonus of $200,000; or
c) If the actual measure is greater than or equal to 90% of readmissions, the Contractor shall receive a bonus of $400,000.

c. Incentives Only
1) Primary Care Clinician Linkage
The Contractor shall measure the percentage of disabled adult members admissions to inpatient psychiatric facilities where there is evidence of telephonic or written notification by the inpatient facility to the member's Primary Care Clinician, as identified by the member or DMA; provided, however, that such measure shall include only those admissions of disabled adult members who have provided written consent to their treating facility to contact their PCC...This measure shall apply for the period September 1, 1997 through June 30, 1998.
a) If the actual measure is greater than or equal to 25% but less than 30% of all admissions described above, the Contractor shall receive a bonus of $150,000; or
b) If the actual measure is greater than or equal to 30% but less than 35% of all admissions described above, the Contractor shall receive a bonus of $250,000; or
c) If the actual measure is greater than or equal to 35% but less than 40% of all admissions described above, the Contractor shall receive a bonus of $400,000; or
d) If the actual measure is 40% of all admissions described above or greater, the Contractor shall receive a bonus of $600,000.

2) Crisis Intervention Capacity for Children and Adolescents
The Contractor shall
(i)ensure compliance with the child/adolescent service capacity provisions of the Contractor's subcontracts with Emergency Services Programs and
(ii) assist ESPs in developing protocol agreements with key Department of Social Services and DMH children's residential providers in their service area
a) If 70% of ESP providers document compliance with the ESP subcontract provisions, the Contractor shall receive a bonus of $200,000; or
b) If 80% of ESP providers document compliance with the ESP subcontract provisions, the Contractor shall receive a bonus of $300,000; or
c) If 90% of ESP providers document compliance with the ESP subcontract provisions, the Contractor shall receive a bonus of $400,000; and/or
d) If every contracted ESP executes a protocol agreement with at least two key residential providers in the ESP's service area, the Contractor shall receive a bonus of $200,000.

3) Member Involvement in Aftercare Planning
The Contractor shall measure the percentage of disabled adults discharged from a psychiatric inpatient unit who participate in the development of their discharge/aftercare plans, as evidenced by the documentation of the member's (a) attendance at discharge planning meetings or (b) refusal to participate...This measure shall apply for the period October 1, 1997 through June 30, 1998.
a) If the actual measure is greater than or equal to the compliance target and less than 25% over the first quarter FY98 baseline, the Contractor shall receive a bonus of $150,000; or
b) If the actual measure is greater than or equal to 25% over the first quarter FY98 baseline, the Contractor shall receive a bonus of $350,000.

4) Intensive Case Management/Consumers who are Dually- Diagnosed
The Contractor shall target an increase in enrollment in the Intensive Case Management (ICM) program of at least 100 individuals, at least 75 of whom must be members with a dual-diagnosis (substance abuse and psychiatric) and include both disabled adults and adolescents. All dually diagnosed individuals must be newly enrolled in the ICM subsequent to June 30, 1997. If additional ICM days for dually-diagnosed members are greater than or equal to 13,687 by June 30, 1998, the Contractor shall receive a bonus of $400,000.

5) Expanded MassHealth Benefit Advocacy: DMH Consumers
The Contractor shall provide outreach to DMH Acute Care Consumers not already determined MassHealth eligible by sending MassHealth application material to and following-up with the consumer or his/her DMH case manager. For consumers who are eligible for DMH services as of July 1, 1997 (‘Known Consumers'), the Contractor shall target to complete such outreach activities within 90 days of the inception of MassHealth Expansion. For all new DMH acute care consumers (‘New Consumers'), the Contractor shall target to complete such outreach activities within 45 days of the Contractor's receipt of the consumer's DMH eligibility information.
a) If within the time period described above, the Contractor completes the outreach activities described above for 90% or more of ‘New Consumers', the Contractor shall receive a bonus of $200,000; and/or
b) If within the time period described above, the Contractor completes the outreach activities described above for 95% or more of ‘Known Consumers', the Contractor shall receive a bonus of $450,000.

6) Expanded MassHealth Benefit Advocacy: Emergency Services Programs
The Contractor shall receive an amount equal to 15% of the per application incentive which shall be provided to Emergency Services Program providers for completion of the MassHealth Benefit Request.

7) Substance Abuse Capacity
In conjunction with the Department of Public Health's Bureau of Substance Abuse Services, the Contractor shall provide a minimum of two in-service training sessions on substance abuse identification and intervention in each of the three Partnership regions (Western, Central, Eastern)... If 80% or more of ESP clinical staff attend both training sessions by June 30, 1998, the Contractor shall receive a bonus of $400,000.

8) Cultural Competency
The Contractor shall provide a minimum of two in-service training sessions for network providers on cultural and linguistic competency in behavioral health treatment covering network providers in each of the six Partnership subregions. There shall be discrete workshops at these training sessions which shall address specifically the needs of at least the four largest minority groups served by the Contractor. If the Contractor provides ten or more training sessions by June 30, 1998, the Contractor shall receive a bonus of $400,000.

9) Administrative Efficiency
For the final nine months of the second contract year, the Contractor intends to have 85% or more of all initial provider claims which are adjudicated, submitted to the Contractor electronically via diskette, modem, or magnetic tape. If 85% or more of provider claims are submitted as described, the Contractor shall receive a bonus of $350,000.
d. Penalties Only

1) Network Procurement
Procurement or recontracting of the provider network (including outpatient, Emergency Services Program, and inpatient providers) shall be completed, as measured by written notification of status mailed to all provider applicants by September 26, 1997. If letters are not mailed to all applicants by September 26, 1997, the Division may impose a penalty of up to $300,000.

2) Timely and Adequate Reporting
All required reports shall be delivered to the Division within forty- eight (48) hours of the scheduled date/time. All requests for new reports and revisions to existing reports shall be delivered at the agreed upon schedule. If the Contractor falls to comply with this standard, the Division may impose a penalty of up to $5,000 per failure up to a maximum of $300,000.

3) Provider Quality Forums
The Contractor shall convene two statewide provider Quality Improvement Forums, one by December 31, 1997 and the other by June 30, 1998 in a central Massachusetts location. The Contractor shall convene a Quality Management Workshop for providers to be held in each of two different areas of the state by June 30, 1998. If the Contractor fails to comply with any component of this requirement, the Division may impose a penalty of up to $300,000.

4) Child/Adolescent Inpatient Access
Inpatient capacity for children and adolescents shall be available to 85% of members within 45 miles or 60 minutes of their place of residence provided that such a facility exists. If the Contractor fails to comply with this requirement, the Division may impose a penalty of up to $300,000.

e. Initiatives with Administrative Costs Only

1) Flexible Financing
By April 30, 1998, at least one case rate program or one capitation contract for one provider type or level of care shall be developed and implemented. If at least one case rate program or one capitation rate contract is implemented by April 30, 1998, the Division shall reimburse the Contractor for actual incremental administrative costs up to $225,000.

2) Automated Eligibility Process: Phase II
By June 30, 1998, the Contractor shall through MHS, add PCP information, demographic and TPL changes received from DMA, test the merge process and through automation, recycle the reject file. If the systems specifications are reviewed and approved by DMA and the merge process is tested, the Division will reimburse the Contractor for actual incremental administrative costs up to $124,500.

3) Expanded Intensive Case Management Program
The Contractor shall increase enrollment in the Intensive Case Management (ICM) program by at least 100 individuals. If additional ICM enrollee days total at least 18,250 by June 30, 1998, the Contractor shall receive reimbursement of actual incremental administrative costs up to a maximum of $210,000.

4) Expanded MassHealth Benefit Advocacy: DMH Consumers
The Contractor shall provide outreach to DMH Acute Care Consumers not already determined eligible by sending MassHealth application material to and following-up with the consumer or his/her DMH case manager. If outreach activities occur for at least 70% of ‘Known Consumers', the Contractor shall receive funding of actual incremental administrative costs up to $122,000.

5) Administrative Efficiency
For the last nine months of the second contract year, if at least 78% of all initial provider claims adjudicated are submitted electronically via diskette, modem, or magnetic tape the Contractor shall receive reimbursement of actual incremental administrative costs up to $25,000." Massachusetts MH/SAP Contract, Amendment 1, pages 14-20.

"APPENDIX A: ...
2. Section 5.1.1.C.5.b.4, entitled 'Continuing Care: Adults,' shall be amended by deleting the introductory paragraph in its entirety and inserting in lieu thereof the following:
'The Contractor shall measure the percentage of adults discharged from inpatient psychiatric treatment who receive subsequent outpatient treatment as follows: The Contractor will measure the percentage of adults discharged from inpatient psychiatric treatment who either
(A) attend an outpatient aftercare appointment within three business days of their inpatient discharge or
(B) receive a Bridge Consultation, as defined below, during the course of the inpatient admission, and receive an outpatient aftercare appointment with their Primary Outpatient Provider, as defined below, within 5 business days of the date of such discharge. The compliance target for such measure shall be to increase the percentage of such discharges by at least 15 percentage above the first Contract Year performance level.'" Massachusetts MH/SAP Contract, Amendment 3, page 1.

"Section 5 of Appendix A of the contract is amended by inserting the following new Section 5.1.3.G...
Section 5.1.3.G.: Performance Incentives, Penalties, and Initiatives: Provisions and Standards...

A. STANDARDS WITH AN INCENTIVE AND A PENALTY REHABILITATION, RECOVERY, AND EMPOWERMENT...

SERVICE/SYSTEM INTEGRATION
5. Medication Monitoring - The Contractor shall measure the percentage of adult mental health inpatient discharge events followed by a medication appointment within 14 business days of discharge. The initial compliance target for this standard will be 78% of adult mental health discharge events between July 1, 1999 and March 31, 2000...

6. Seven Day Aftercare - The Contractor shall increase the percentage of members discharged from inpatient mental health treatment who receive aftercare within seven calendar days. The initial compliance target for this standard shall be a rate greater than 80% for such discharges between July 1, 1999 and March 31, 2000...

PSYCHOPHARMACOLOGY
7.Medication Protocol for Enhanced Residential Care Program (ERC) Participants - The Contractor shall collaborate with ERC programs and with recognized experts in child/adolescent psychopharmacology to develop a psychopharmacological evaluation/treatment protocol for ERC programs and participants. The Contractor shall monitor ERC program compliance with the established protocol and shall ensure the completion of psychopharmacological treatment plans that reflect use of the protocol… The goal of this initiative is to provide more coordinated medication therapy for this group of children/adolescents...

HOMELESSNESS
8.Discharge Planning - The Contractor shall continue to collaborate with the homeless advocacy community to identify strategies and resources to facilitate appropriate discharge dispositions for homeless adults… The Contractor shall utilize established tracking mechanisms to monitor performance relative to the identified strategies, and take appropriate network management action with respect to those inpatient mental health providers whose discharge planning performance fails to comply with the contractor's discharge planning protocol. The compliance target for this standard...

9. Internet Technology and Resources for Services to Homeless Members - The Contractor shall collaborate with the homeless advocacy and health care provider community to develop and construct a discrete web site that will contain aftercare planning best practices, including referral information for both behavioral health and physical health resources, specifically for providers of services to homeless members. Such information shall be organized regionally, as well as by type of resource. The compliance targets for this standard shall be the development and construction of a discrete web site, the compilation of information on aftercare planning best practices, including referral information for both behavioral health and physical health resources specifically for providers of services to homeless members, and the availability of the information on the web site...

CHILDREN'S SERVICES
10. Enhanced Residential Care (ERC)-The Contractor shall work in collaboration with the Departments of Social Services and Mental Health to implement the ERC pilot program. The goal of this program is to enhance the milieu and clinical capacity of a minimum of five selected residential providers in order to reduce the number of children and adolescents in acute care settings awaiting discharge, for whom there is no available placement. The compliance targets for this standard shall be...

11.Community-Based Assessment for Certain Children and Adolescents in the Northeast - The Contractor shall, in collaboration with a workgroup of Department of Mental Health, Department of Social Services, Division and biological/foster family member representatives, develop a comprehensive community-based assessment protocol. The protocol shall use a strength-based approach to assessment and shall be developed utilizing established assessment tools for children and adolescents…

The compliance targets for this standard shall be:
1) development of a comprehensive community-based assessment protocol, including the establishment of a rate for the assessment and standards for the credentialing of providers to perform the assessment; and
2) field testing of the protocol with one or more providers...

FAMILIES
12.Preventive Services-Family Support - The Contract shall implement an educational and support model curriculum for MassHealth families. Including families whose primary language spoken at home is Spanish, of children who are receiving or have received mental health services through the Contractor and may be at-risk for a decrease in level of functioning… The compliance target shall be the provision of an educational and support model to 100 families, a certain percentage of whose primary language spoken at home is Spanish, including a minimum of 65 non-foster families...

SUBSTANCE ABUSE SERVICES
13. Payment of LAMM/Methadone Case Rate - The Contractor shall work with the Department of Public Health's Bureau of Substance Abuse Services and the substance abuse provider community to develop and conduct a process to: reimburse providers for Levomethadyl Acetate Hydrochloride (LAMM) as an alternative opiate replacement therapy… The compliance targets for this standard shall be…" Massachusetts MH/SAP Contract, Amendment 6, pages 2-8.

"Section 7.5. Performance Improvement. The HEALTH PLAN shall provide the following:
Section 7.5.1. An annual report, due to the STATE before April 15, 1999, detailing the HEALTH PLAN's progress toward meeting the federal EPSDT (Child and Teen Check-ups) requirement of 80% participation for well-child visits, as it pertains to the Enrollees covered by this Contract during 1998.

Section 7.5.2. A progress report, detailing the efforts made to date, due to the STATE by August 31, 1999, detailing the HEALTH PLAN's performance improvement efforts and results in the area of access to mental health services by children and adults, and in the area of preventive dental visits for children, as they relate to the Enrollees covered by this Contract...

Section 7.7. Financial Performance Incentives. The HEALTH PLAN will be eligible for a financial performance incentive payment in an amount based on the HEALTH PLAN's reported participation rate for C&TC/EPSDT screenings as reported in encounter data under Section 3.5.1." Minnesota Contract, page 76.

"ATTACHMENT D.1. QUALITY ASSURANCE STANDARDS AND REPORTING GUIDE:
Overview:
The current Medicaid population encompasses the Temporary Assistance for Needy Families (TANF) and Child Health Assurance Program (CHAP) assistance groups. Traditionally, the Medicaid population is a high-risk, high-volume user of health care services…

Contractor baselines/benchmarks will be established over a period of time. The common goal of the managed care program is a successful partnership with quality health plans to provide care to Medicaid participants, while focusing on continuous quality improvement.

QUALITY MEASUREMENTS: ...
2. Comprehensive Well Child Periodic and Interperiodic Health Assessments/Early Periodic Screening Diagnosis and Treatment (EPSDT)/Healthy Kids:
Standard
The Contractor shall take affirmative steps to increase participant utilization of the EPSDT program to a minimum participation rate of 80% of all enrolled participants eligible for EPSDT screenings...

3. Family Planning-
Standard
The Contractor shall take affirmative steps to ensure family planning services are provided to Medicaid eligible participants (both male and female) of child bearing age. Child bearing age is defined as approximately 10 years of age through 55 years of age. Family planning services and education are an integral part of preventive health services for this Contract population.
Refer to Attachment B of this contract for detail on family planning services. A managed care participant has the right, by federal regulation, to receive family planning services from any qualified provider, even if the provider is not part of the Contractor's provider network. The Contractor may not require prior authorization of family planning services.

Measurement & Methodology
The Contractor will ensure age appropriate family planning services, including family planning education, are appropriately and adequately provided to Medicaid participants.

4. Mental Health-
Standard
The Contractor shall take affirmative steps to ensure adequate, quality, mental health services are provided to participants. Mental health is an integral part of holistic health care. The measurement methodology below demonstrates elementary steps toward continuing review of the quality of mental health care." Nevada Contract, pages 52-56.

"'The Contractor shall take affirmative steps to increase participant utilization of the EPSDT program to a minimum 80% of Nevada Check Up eligible children who have been enrolled for twelve (12) months must have an age appropriate periodic screening. Well childcare promotes healthy development and disease prevention, in addition to possible early discovery of disease and appropriate treatment.'" Nevada Amendment #1, page 11.

"PROVIDER NETWORK REQUIREMENTS...
F. Accessibility Measures/Appointment Scheduling Standards...
Performance Standard
Type of Care/ Standard Met
1. Emergency Care/ 100%
2. Urgent Care/ 95%
3. Routine Care/ 75% first contract year, 80% second year, 85% third year, 90% thereafter" New Jersey Contract, pages 199-200.

"ATTACHMENT I
EPSDT PROTOCOL…

Performance Standards for EPSDT Services

Service/Standard Met 1st year/Standard Met 2nd year/Standard Met 3rd Year
EPSDT exam-age appropriate/75%/85%/90%
Completed immunizations for age/75% /85% /90%
Lead screening /75% /85% /90%" New Jersey Contract, Attachment I, pages 172, 175.

"2.A.3 Standards for Internal Quality Management and Improvement...
2.A.3g QI Program Effectiveness Evaluation
The CONTRACTOR annually shall evaluate the overall effectiveness of its QI program and demonstrate improvements in the quality of clinical care and the quality of service to its members. The MCO will submit its annual written evaluation of the QI program to HSD. This evaluation will include at least the following: ...
2.A.3.g.ii Trending of measures to assess performance in quality of clinical care and quality of service..." New Mexico Contract, pages 9-11.

"7.1 Internal Quality Assurance/Quality Improvement System…
a. The Plan shall have a written description of its Quality Assurance (QA)/Quality Improvement (QI) program. The description shall contain QA/QI objectives with timetables for implementing and accomplishing objectives…" North Carolina Contract, page 14.

"Program Objectives
Assuring access to medically-necessary health services as well as the quality of care delivered to Medicaid members enrolled in managed care plans are of primary concern to ODHS. Plan performance is monitored through: …
* the use of individual 'Performance Improvement Agreements' developed with each plan to target and encourage superior plan performance beyond basic program requirements…" Ohio RFP, pages 5-6.

ORMH

"E. Quality Assurance/Quality Improvement(QA/QI) Requirements...
3. Measurable Objectives and Benchmarks
Contractor shall develop and monitor progress toward Measurable Objectives and Benchmarks in the above mentioned domains. Contractor shall demonstrate that findings are used to improve access and remove barriers to Covered Services; improve Capacity to provide Covered Services in a timely manner; improve the quality of care provided and the coordination of benefits, and strengthen and expand prevention, Early Intervention and Education Services." Oregon Mental Health Contract, page 27.

"6.8 TEXAS HEALTH STEPS (EPSDT)…
6.8.11 Compliance with THSteps Performance Benchmark. TDH will establish performance benchmarks against which HMO’s full compliance with the THSteps periodicity schedule will be measured. The performance benchmarks will establish minimum compliance measures which will increase over time. HMO must meet all performance benchmarks required for THSteps services.

6.8.12 Validation of Encounter Data. Encounter data will be validated by chart review of a random sample of THSteps eligible enrollees against monthly encounter data reported by HMO. Chart reviews will be conducted by TDH to validate that all screens are performed when due and as reported, and that reported data is accurate and timely. Substantial deviation between reported and charted encounter data could result in HMO and/or network providers being investigated for potential fraud and abuse without notice to HMO or the provider." Texas Contract, pages 41, 43- 44.

"EXHIBIT F
Standard of Internal Quality Assurance for Managed care Organization...
Domain I: Quality Assessment and Performance Improvement (QAPI) Program...

I-1 Required Levels of Performance
Each Mountain Health Trust health maintenance organization must meet certain required levels of performance when providing health care and related services to enrollees. The MCO must achieve minimum performance levels established by the Bureau for Medical Services with respect to the measures listed below. Each MCO must also meet any goals for performance improvement on specific measures that may be established by BMS. These minimum performance levels will be established by examining historical performance levels as well as benchmarks (beat practices) of other health plans and delivery systems. Performance levels for each quality review period will be provided to the MCOs by BMS. Each MCO must measure its performance in these areas using standard measures, as defined by HEDIS3.0/1998 or subsequent version.

Measures of preventive care or the care and treatment of certain health conditions:
Performance Indicator
Adolescent Immunization...
Childhood Immunization...
Maternal and Child Health...
Indicators Pertaining to the Treatment of Specific Health Conditions...

Measures of access and appropriate utilization of services:
Performance Indicator
Access to Care...
Frequency of Selected Procedures...
Implant and Outpatient Utilization...
Measures of member satisfaction
Performance Indicator…" West Virginia Contract, Exhibit F, pages 1-2.

"Standard XI: Standards for Availability and Accessibility
The plan has established standards for access (e.g. to routine, urgent and emergency care; telephone appointments; advice; and member service lines). Performance on access standards are assessed on a routine basis." West Virginia RFA, Appendix E, page E13.

"2.1.2 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services...
The federal government, through Health Care Financing Administration (HCFA), has announced that states will be required to demonstrate an 80 percent compliance rate for EPSDT screening schedules by 1995…" West Virginia RFA, page 7.

"Y. QUALITY IMPROVEMENT (QI)...
3. Monitoring and Evaluation
a. The QI program must monitor and evaluate the quality of clinical care and service in institutional settings, non-institutional settings, and specialty areas (e.g., mental health and substance abuse) on an ongoing basis… The quality indicators must be linked to performance goals and appropriate data collection methodologies must be used to analyze and improve clinical care and services...

13. Priority Areas...
d. Preventive Care Objectives - The HMO must develop and implement programs which address the speck preventive care initiatives described below. In addition, the HMO must measure and report activity in the four Preventive Care areas...

1) Immunization Preventive Care Objective
The objective for the year 2000 is to increase to 90% the proportion of children who are two years of age who are fully immunized...

2) Dental Preventive Care Objective
The objective for calendar years 1998 and 1999 is that Medicaid HMO enrollees will receive preventive dental services at a rate greater than or equal to 110% of the preventive dental services rate for Medicaid fee-for-service (FFS) enrollees...

3) Lead Toxicity Preventive Care Objective
The objective for calendar year 1998 is 65% of all Medicaid enrollees with their first or second birthday during the reporting period who were enrolled in the HMO for any 6 months of the reporting year (not continuously) and prior to their first or second birthday had one blood lead test...

4) Mental Health Follow Up Care Objective
The objective for calendar years 1998 and 1999 is to increase the rate of ambulatory follow-up treatment within 30 days of hospital discharge for treatment of selected mental health disorders, by 10 percentage points each year...

5) Substance Abuse Follow-up Care Objective
The objective for calendar years 1998 and 1999 is to increase the rate of ambulatory follow-up treatment within 30 days of discharge for individuals with specific substance abuse disorders, by 10 percentage points each year...

6) Births and Average Length of Stay, Newborn Objective
This objective measures the percentage of well newborns and newborns with medical problems during the reporting year and the average length of stay for the newborns hospitalization…" Wisconsin Contract, pages 21, 23, 30-32.