Florida Medicaid Quality in Managed Care
Florida Medicaid is committed to ensuring that health care services delivered through managed care plans are held to high standards of quality and excellence. All vendors contracted with the Agency to provide managed care services must meet specific requirements for ensuring quality both in services provided and in administrative processes involved in oversight of the plan's operations.
By accessing the information below, you may learn about the Agency's overall quality strategy and you will find additional information sources to learn more about Florida's quality initiatives.
Performance Measure Specifications Manual
The following files provide the list of required performance measures for Medicaid HMO and PSNs and specifications for Agency-defined measures. These documents should be used for the July 1, 2010, performance measure submission which will represent services for calendar year 2009.
Medicaid HMO and PSN Performance Measures - Version 2011 – Revised 12/11 [359KB] Updated 4/30/2012
Medicaid HMO and PSN Performance Measure Specification Manual 12/11 Version [210KB] Updated 4/30/2012
Antiretroviral Formulations [385KB] Updated 4/30/2012
Performance Measures 2012 Report Template [43KB] Updated 4/30/2012
Performance Measure Data Submissions for Medicaid
Medicaid beneficiaries can find information to help compare the performance of Medicaid Health Plans. The Agency monitors the Medicaid Reform health plan performance through the HEDIS performance measures and Agency defined measures. The Medicaid Reform health plan contract specifies the performance measures that were to be collected and reported to the Agency annually on July 1st.
HEDIS measures are developed by the National Committee for Quality Assurance (NCQA), which is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. NCQA develops quality standards and performance measures for a broad range of health care entities. These are the measures and standards that AHCA, like most organizations and individuals, uses to help identify opportunities for improvement.
If you would like to send us questions, comments, or suggestions please Contact Us.
| CY 2010 New 4/30/2012 |
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| Reform | Non-Reform | ||
| Ratings [144KB] |
Scores [114KB] |
Ratings [167KB] |
Scores [137KB] |
| 2009 | |||
| Reform | Non-Reform | ||
| Ratings | Scores | Ratings | Scores |
| 2008 | 2007 | |||||
| Reform | Non-Reform | Reform | ||||
| Ratings | Scores | Ratings | Scores | Ratings | Scores | |
| Health Plans | ||||||
| Indicator Descriptions |
Performance Measures Policy Transmittals
Year 1 - HMO - 06-06: Health Plan Performance Measures [493KB]
Year 2 - HMO 08-02 and PSN 08-05: Health Plan Performance Measures [374KB]
Year 3 - HMO and PSN 09-01: Health Plan Performance Measures [1.84MB ]
Quality Assessment and Improvement Strategies
The Federal Centers for Medicare and Medicaid Services require that each state have a written strategy for assessing and improving the quality of managed care services. Florida completed its initial quality strategy in 2006. The Quality Assessment and Improvement Strategy will be updated annually and will include input from recipients and interested stakeholders. Please follow the link below to access Florida's Initial Quality Assessment and Improvement Strategy.
Initial Quality Assessment & Improvement Strategies, Florida Medicaid Managed Care Programs [395KB]
The 2007 update to the Quality Assessment and Improvement Strategy was submitted to CMS in January 2008 and can be viewed by clicking on the link below.
The Agency for Health Care Administration would like to receive any comments you have about our Quality Assessment & Improvement Strategies. Please email comments to qualityinmc@ahca.myflorida.com.
Managed Care Quality Assessment & Improvement Strategies 2008/2009 Update [1.5MB]
Medicaid Reform Performance Measure Selection
As part of Florida's Medicaid Reform initiative, the Agency sought to review and amend the performance measures historically required for health plans contracting with the Agency to better assess the quality and effectiveness of the health care services. Public input was sought and received from interested parties, including health care advocates, providers, and State of Florida sister agencies, culminating in the final list of adopted measures.
The links below provide documents distributed at public workshops held on October 6, 2006, and October 26, 2006. Also provided is a compilation of stakeholder comments the Agency received during the performance measures development process.
October 6, 2006 Medicaid Reform Performance Measures Presentation [126KB]
Stakeholder Comments (as of 10/25/06)
October 26, 2006 Medicaid Reform Performance Measures Workshop Presentations [100KB]
Medicaid Reform Performance Measures 10/26/06 [47KB]
Pfizer Health Solutions Reporting Overview 10/26/06 [471KB]
External Quality Review
In compliance with federal requirements, Florida contracts with an external quality review organization to provide a quality review of its Medicaid managed care programs. The purpose of External Quality Review is to assess and improve managed care organizations and prepaid inpatient health plans' strengths and weaknesses with respect to the quality, timeliness, and access to Medicaid health care services.
Health Systems Advisory Group, Inc. (HSAG), Florida's contracted External Quality Review vendor, provides 11 categories of activity that include:- validation of performance improvement projects;
- validation of performance measures;
- review of compliance with access, structural and operations standards;
- strategic reports on consumer-reported satisfaction surveys;
- strategic reports of HEDIS Analysis;
- technical assistance on enrollee race/ethnicity and primary household language information;
- value-based purchasing methodologies;
- evaluation of AHCA's quality strategy;
- implementation of focused studies (such as adolescent well-care and identification of special health care needs);
- dissemination of information to keep key stakeholders within and outside of Medicaid involved and informed of External Quality Review work projects and tasks; and
- development of an annual technical report for submittal to the Federal Centers for Medicare and Medicaid.
These activities impact HMOs, Provider Service Networks, Prepaid Mental Health Plans, the Child Welfare Prepaid Mental Health Plan, and Nursing Home Diversion Plans.
For more information about HSAG and external quality review activities, see HSAG's Florida website at: www.myfloridaeqro.com
Children’s Quality Demonstration Grant (CHIPRA grant)
The Children’s Health Insurance Program Reauthorization Act of 2009 Section 401 (D) allows the federal Centers for Medicare and Medicaid Services (CMS) to award states grant money to improve child health outcomes over the next five years. The State of Florida with the State of Illinois submitted a proposal to federal CMS and was awarded a grant with a reduced budget. During the first nine months of the grant, the states are required to revise their Final Implementation Plan while working within their reduced budgets. Workgroups are being formed to gather expert advice for the Final Implementation Plan.
Please review the Florida-Illinois proposal package [214KB] submitted to CMS for detailed information. Please note that this proposal does not include the final implementation plan and is not reflective of the reduced budget. It is subject to change upon federal CMS approval.
Please review the CHIPRA project summary [448KB] for general information.
New information for providers interested in medical home projects. This work is authorized under 401(d) of the Florida Children’s Health Insurance Program Reauthorization Act. Information Calls FAQs [180KB]
Cultural Competency
The Agency for Health Care Administration supports ongoing training for cultural competency in the delivery of services for all its health plans and providers. Georgetown University's National Center for Cultural Competence offers a valuable resource to organizations and individuals developing, implementing and/or evaluating a cultural competency plan.
http://www11.georgetown.edu/research/gucchd/nccc/index.html
Florida Health Finder
On this website you can find information to help you compare the quality and cost performance of hospitals, ambulatory surgery centers, health plans, nursing homes, and prescription drugs. The website also lists Florida health care facilities; information on health insurance; medical care resources for the uninsured; resources for seniors; and much more.
The main topic areas to view on the Florida Health Finder website include:
Health Plans: Compare health plans on quality of care, member satisfaction, coverage areas by county, accreditation status, and claims payment performance. You can also compare monthly health plan premium rate options and find additional resources on many health insurance topics.
Hospitals and Ambulatory Surgery Centers: View performance and outcome data on selected medical conditions and procedures in these types of health care facilities.
Emergency Room Care: Read educational information about when and how to use an emergency room, what to do in a medical crisis, alternatives to emergency room care and other helpful information.
Prescription Drugs: View comparative prices at Florida pharmacies for the top 100 most prescribed drugs in Florida. You choose the county where you live and a drug you want to price. The website displays the current price for most pharmacies in your county.
For more information about Florida Health Finder, please visit the website at: http://www.floridahealthfinder.gov.
Related Links
Medicaid Health Maintenance Organization (HMO)
Nursing Home Diversion Program (Department of Elder Affairs) (Currently under construction)
Provider Service Network (PSN)
For more information on Florida Medicaid Quality in Managed Care, please contact:
qualityinmc@ahca.myflorida.com
