Keeping Kids Healthy

Adolescent Well-Care Visits: A quality of care indicator that measures the percentage of members 12-21 years of age who had at least one well-care visit with a PCP in the measurement year. A well-care visit is a routine, preventive exam with a doctor to help ensure that adolescents are up-to-date with health screenings and immunizations.

Childhood Immunization Status – Combo 3: A quality of care indicator that measures the percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HIB); three hepatitis B (HepB), one chicken pox (VZV), and four pneumococcal conjugate (PCV) vaccines by their second birthday.

Children & Adolescents’ Access to PCPs – 12 – 24 months: A quality of care indicator that measures the percentage of members ages 12 – 24 months who had a visit with a PCP during the measurement year.

Children & Adolescents’ Access to PCPs – 25 months – 6 years: A quality of care indicator that measures the percentage of members ages 25 months – 6 years who had a visit with a PCP during the measurement year.

Children & Adolescents’ Access to PCPs – 7 – 11 years: A quality of care indicator that measures the percentage of members ages 7 – 11 years who had a visit with a PCP during the measurement year or the year prior to the measurement year.

Children & Adolescents’ Access to PCPs – 12 – 19 years: A quality of care indicator that measures the percentage of members ages 12– 19 years who had a visit with a PCP during the measurement year or the year prior to the measurement year.

Chlamydia Screening in Women, Ages 16-20 years: A quality of care indicator that measures how often women are screened for the sexually transmitted disease Chlamydia. It measures the percentage of sexually active females, ages 16 through 20 years, who have had at least one test for Chlamydia during the measurement year.

Immunizations for Adolescents – Combo 1: A quality of care indicator that measures the percentage of adolescents 13 years of age who had one dose of meningococcal conjugate vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) by their 13th birthday.

Lead Screening in Children: A quality of care indicator that measures the percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday.

Well-Child Visits, First Fifteen Months of Life, Six or More Visits:  A quality of care indicator that measures the percentage of members who turned 15 months of age during the measurement year and who had six or more well-child visits with a PCP during their first 15 months of life.. A well-child visit is a routine, preventive exam with a pediatrician to help ensure that children are up-to-date with health screenings and immunizations.

Well-Child Visits, Ages 3-6 Years:  A quality of care indicator that measures the percentage of members 3-6 years of age who had one or more well-child visits with a PCP during the measurement year. A well-child visit is a routine, preventive exam with a pediatrician to help ensure that children are up-to-date with health screenings and immunizations.

Keeping Adults Healthy

Adult BMI Assessment: A quality of care indicator that measures the percentage of members 18 – 74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.

Adults’ Access to Preventive Health Services: A quality of care indicator that measures the percentage of members 20 years and older who had an ambulatory or preventive care visit during the measurement year.

Breast Cancer Screening: A quality of care indicator that measures the percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer during the measurement year or the year prior. Early detection and treatment increase the survival rate of breast cancer patients.

Cervical Cancer Screening: A quality of care indicator that measures the percentage of women 21-64 years of age who were screened for cervical cancer during the measurement year.

Chlamydia Screening in Women, Ages 21-24 years: A quality of care indicator that measures the percentage of sexually active females, ages 21 through 24 years, who have had at least one test for Chlamydia during the measurement year.

Chlamydia Screening in Women (combined age groups): A quality of care indicator that measures the percentage of sexually active females, ages 16 through 24 years, who have had at least one test for Chlamydia during the measurement year.

Living With Illness

Controlling High Blood Pressure: A quality of care indicator that measures the percentage of adults 18 through 85 years of age, diagnosed with high blood pressure, who had their blood pressure adequately controlled (systolic pressure under 140 mm and diastolic pressure under 90 mm) during the measurement year. Persons with uncontrolled high blood pressure have a greater risk of stroke and heart disease.

Diabetes Care: HbA1c Testing: A quality of care indicator that measures the percentage of members 18 – 75 years of age with diabetes (type 1 and type 2) who had a blood sugar (glucose) screening in the measurement year.

Diabetes Care: HbA1c – Good Control: A quality of care indicator that measures the percentage of members 18 – 75 years of age with diabetes (type 1 and type 2) who had a blood sugar (glucose) screening in the measurement year and whose most recent blood sugar (glucose) level was <8.0%. A value below 8.0% indicates that the member’s blood sugar (glucose) level is under control.

Diabetes Care: Eye Exam: A quality of care indicator that measures the percentage of members 18 − 75 years of age with diabetes (type 1 and type 2) who received an eye exam in the measurement year. Diabetes is the leading cause of adult blindness in the U.S., which makes it important that diabetics have their eyes examined regularly so that appropriate treatment can be initiated at the first sign of a problem.

Diabetes Care: Nephropathy: A quality of care indicator that measures the percentage of members 18 − 75 years of age with diabetes (type 1 and type 2) who were screened or treated for kidney disease (diabetic nephropathy) during the measurement year. Diabetes affects multiple organs in the body including the kidneys. Kidney failure can be prevented if detected and addressed in the early stages.

Mental Health Care

ADHD Medications Follow-Up – Initiation Phase: A quality of care indicator that measures the percentage of children ages 6 – 12 years who had one follow-up care visit within 30 days of when the first newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication was dispensed.

Antidepressant Medication Management – Acute: A quality of care indicator that measures 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 for at least 12 weeks.

Follow-Up After Hospitalization for Mental Illness – 7 Day: A quality of care indicator that measures 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 a follow-up visit with a mental health practitioner within 7 days after discharge.

Follow-Up After Hospitalization for Mental Illness – 30 Day: A quality of care indicator that measures 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 a follow-up visit with a mental health practitioner within 30 days after discharge.

Pregnancy-related Care

Frequency of Ongoing Prenatal Care - ≤ 81% of expected visits: A quality of care indicator that measures the percentage of Medicaid deliveries on or between November 6 of the year prior to the measurement year and November 5 of the measurement year that had 81% or more of expected prenatal visits.

Postpartum Care: A quality of care indicator that measures the percentage of deliveries who had a postpartum visit on or between 21 and 56 days after delivery.

Prenatal Care:  A quality of care indicator that measures the percentage of deliveries that received a prenatal care visit in the first trimester, on the enrollment start date or within 42 days of enrollment. Prenatal care is a form of preventive medicine that helps to reduce low weight births and provides help for new mothers.

HEDIS

Healthcare Effectiveness Data & Information Set (HEDIS):   A set of measures that are used to report the performance of health plans. The measures evaluate the organizational structure and systems of the HMO and the performance in delivering care. HEDIS measures ensure that results are comparable across health plans. HEDIS was created by the National Committee for Quality Assurance (NCQA).

Consumer Assessment of Healthcare Providers and Systems (CAHPS):  A survey that assesses the member satisfaction with the performance of the health plan. The CAHPS survey makes it possible for consumers and purchasers to view understandable and usable comparative information across plans and over time. CAHPS was developed by the Agency for Healthcare Research and Quality (AHRQ) and the NCQA.

Percentage of respondents reporting it is usually or always easy to get needed care (vs. sometimes or never):  Score shows percent responding "Usually" & "Always." The score for this item is the average score for the following questions:

• How often did you get an appointment to see a specialist as soon as you needed?
• How often was it easy to get the care, tests, or treatment you needed?

Percentage of respondents reporting it is usually or always easy to get care quickly (vs. sometimes or never):  Score shows percent responding "Usually" & "Always."  The score for this item is the average score for the following questions:

• When you needed care right away, how often did you get care as soon as you needed?
• Not counting the times you needed care right away, how often did you get an appointment for check-up or routine care at a doctor's office or clinic as soon as you needed?

Percentage of respondents reporting doctors usually or always communicate well (vs. sometimes or never):  Score shows percent responding "Usually" & "Always."  The score for this item is the average score for the following questions:

• How often did your personal doctor explain things in a way that was easy to understand?
• How often did your personal doctor listen carefully to you?
• How often did your personal doctor show respect for what you had to say?
• How often did your personal doctor spend enough time with you?

Percentage of respondents reporting they usually or always get the help/information needed from their plan’s customer service staff (vs. sometimes or never): *   Score shows percent responding "Usually" & "Always."  The score for this item is the average score for the following questions:

• How often did your health plan’s customer service give you the information or help you needed? 
• How often did your health plan’s customer service staff treat you with courtesy and respect? 

Percentage of respondents reporting plans usually or always process claims quickly and correctly (vs. never or sometimes): *  Score shows percent responding "Usually" & "Always."  The score for this item is the average score for the following questions:

• How often did your health plan handle your claims quickly?
• How often did your health plan handle your claims correctly?

Percentage of respondents rating their plan an 8, 9, or 10 on a scale of 0 (worst) – 10 (best):  "Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan?"  Score shows percent responding "8", "9", or "10"

Percentage of respondents rating the number of doctors to choose from as excellent or very good (vs. good, fair, or poor):  "How would you rate the number of doctors you had to choose from?"  Score shows percent responding "Very Good" or "Excellent."

Percentage of respondents reporting they definitely or probably would recommend their health plan to family & friends: *  "Would you recommend your health plan to your family or friends?"  Score shows percent responding "Probably Yes" or "Definitely yes."

Percentage of respondents reporting they definitely or probably would select their current plan again: *  "If today you could select any health plan company in your area, would you select your current plan again?"  Score shows percent responding "Probably Yes" or "Definitely yes."

Percentage of respondents who reported there is shared decision making between the provider and respondent (Yes vs. No): * Score shows percent responding "Yes." The score for this item is the average score for the following questions:

• Did you and a doctor or other health provider talk about the reasons you might want to take a medicine?
• Did you and a doctor or other health provider talk about the reasons you might not want to take a medicine?
• When you talked about starting or stopping a prescription medicine, did a doctor or other health provider ask you what you thought was best for you?

Health Maintenance Organization (HMO):  An organized system for providing comprehensive, prepaid health care. HMOs provide care in a defined geographic area; provide or ensure delivery of an agreed-upon set of basic and supplemental health maintenance and treatment services; provide care to a voluntarily enrolled group of persons; require their enrollees to use the services of designated providers; and receive a predetermined, fixed, periodic prepayment made by or on behalf of the member. HMOs are licensed and reviewed by government agencies such as the Agency for Health Care Administration (AHCA) to ensure compliance with state and federal regulations.

Exclusive Provider Organization (EPO): EPOs are individual providers or groups of providers who have entered into written agreements with an insurer to provide health care services to subscribers. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but you cannot go outside of the network for care. EPO members usually do not receive any reimbursement or benefit if they choose to visit medical care providers outside of the established network, except for certain emergency cases. EPOs are also licensed and reviewed by government agencies including the Agency.

Preferred Provider Organization (PPO): The PPO plan gives you the choice of obtaining health care services from any network (the plan's select group of health care providers) or any non-network health care provider. In most PPO plans, your primary care physician does not control your use of specialists. PPO plans usually require that you pay co-insurance or make a co-payment at the time services are rendered. If you choose to receive services out of the network, it may result in higher out-of-pocket costs for you. PPO plans are not regulated by the Agency, but are regulated by the Florida Department of Financial Services.

Point of Service (POS):  This plan adds an out-of-network benefit to HMOs. The POS plan allows you to decide whether to use a network or non-network health care provider at the time care is needed. If you use a non-network health care provider, the plan may only pay 50 to 80 percent of your health care expenses and you may be responsible for paying a deductible and co-insurance charges.

Commercial:  This is health care coverage paid for by employers or individual consumers.

Florida Healthy Kids:  A public-private initiative designed to improve access to comprehensive health insurance for the state's uninsured children. Healthy Kids acts as a single payer financing mechanism to pay premiums to commercial health plans who assume the insurance risk. This program is unique because it is designed to provide affordable access to health insurance coverage for working families for whom the payment of the full premium would be out of reach.

Florida Medicaid: Medicaid is a state-administered medical assistance program that provides access to health care for low-income families and individuals. Medicaid also assists aged and disabled people with the costs of nursing facility care and other medical expenses. The Florida Medicaid program offers the following types of managed care health plans:

• Health Maintenance Organizations (HMOs): Corporations that contract with a network of health care providers, such as physicians, hospitals, and laboratories, to provide prepaid health services and place emphasis on preventive health care through effective quality and cost controls.
• Provider Service Networks (PSNs): Health care delivery systems, owned and operated by hospitals, physician groups, or other providers. PSNs have a network of providers and facilities, which provide health care to enrollees.
• Children’s Medical Services Network (CMS Network or CMSN): A program operated by the Department of Health that provides services for children from birth through age 21 with special health care needs.

Medicare: A federal health insurance program that serves people age 65 and older or disabled persons, regardless of income.

Accreditation Status:  The accreditation status summarizes how well a plan performs overall. Plans with higher levels of accreditation can generally be expected to provide better care and service than plans with lower levels of accreditation. The highest level of accreditation is "Full". The second highest level is labeled "One-Year" by AAAHC and NCQA, while the second highest level is labeled "Conditional" by URAC.

Accreditation Association for Ambulatory Health Care (AAAHC):  A private, not-for-profit accreditation organization that reports on the quality of managed care plans.

National Committee for Quality Assurance (NCQA):  A private, not-for-profit accreditation organization that reports on the quality of managed care plans.

Utilization Review Accreditation Commission (URAC):  A private, not-for-profit accreditation organization that reports on the quality of managed care plans.