2022 Quality Incentive Report

A Report on the Quality Incentive Program in New York State

  • Report also available in Portable Document Format (PDF)
various health related photos

QARR Report Series                               health.ny.gov

Table of Contents

New York's Medicaid Managed Care Quality Incentive Program began in early 2001. In 2002, the program was expanded to provide increased incentives for improvement. Plans became eligible to receive bonuses added to the premium based on composite scores from quality measures and satisfaction measures. The Quality Incentive Program continues to evolve and includes new components and measures as well as a refined methodology to calculate current performance relative to peers.

The data sources used in the Quality Incentive Program include measures from the following sources:

  • New York's Quality Assurance Reporting Requirements (QARR), which is largely comprised of the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®)
  • State-specific performance measures
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS®)

Rates of performance in Medicaid managed care have increased steadily over the last decade. New York State Medicaid plans have demonstrated a high level of care compared to national averages, and for many domains of care the gap in performance between commercial and Medicaid managed care has been decreasing since the Quality Incentive Program was implemented. The use of financial incentives has proven successful in engaging Medicaid managed care plans in developing infrastructure, programs, and resources to promote high-quality care. Incorporating financial incentives that tie payment directly to quality is an important approach to improving the quality of care, holding health plans accountable for the care they provide, and rewarding those who invest in processes that improve care. State Medicaid programs have steadily increased the use of financial incentives or pay-for-performance (P4P) mechanisms in their payment systems.

Currently, the Quality Incentive Program has a defined methodology to determine the percentage of the potential financial incentive that a plan receives. Plans earn up to 100 percentage points from the categories of Quality of Care (80%) and Experience of Care (20%). Points are subtracted from the plan's total points if the plan had statements of deficiency in the Compliance category. A maximum of 10 points could be subtracted from the plan's total points for statements of deficiency associated with specific compliance areas.

Summary of the current Quality Incentive structure components and possible points:

Component Number of Measures Points
Quality – QARR (HEDIS® and NYS-specific) 36 100 points
Satisfaction – CAHPS® Health Plan Survey 3 20 points
Total Points Sum of 80% of Quality points and Satisfaction points
Compliance (Subtracted from Total) 7 Up to 10 points
Final Score Up to 100 points

In past incentive programs, plans have been grouped into one of five tiers to determine the incentive award. The five tiers are based on the percentage of points earned by the plans. Plans must achieve or exceed the threshold for the respective tier to be eligible for their award. Quality incentive payments are subject to the availability of State funding as determined by the Annual Budget process. A plan's performance in the Quality Incentive affects the auto-assignment algorithm. Plans achieving Tier 1 - Tier 4 of the Quality Incentive award receive the quality preference in the auto-assignment algorithm. The quality preference in the algorithm directs a proportion of auto-assignees only to plans that qualified for the preference. The quality preference for auto-assignment is not adjusted by the tier of the Quality Incentive award; rather, all tiers other than Tier 5 receive the same quality preference and share in the distribution of auto-assignees equally. Tier 1 indicates scores at 68.48 or higher, Tier 2 indicates scores between 58.86-68.47, Tier 3 indicates scores between 39.41-58.85, Tier 4 indicates scores between 33.03-39.40, and Tier 5 indicates scores at 33.02 or lower. The 2022 Quality Incentive awards became effective for capitation rates and for auto-assignment preference on April 1, 2024.

In this section, a detailed description of the three Quality Incentive components and the calculation process are presented to explain how the points were assigned to each measure within each component.

The following three Quality Incentive components were used to determine the 2022 Quality Incentive results:

  • Quality of Care: 2022 Quality Assurance Reporting Requirements
  • Consumer Satisfaction: The most recent CAHPS® survey for Medicaid, which was administered in the fall of 2022 and results released in reports dated May 2023
  • Compliance: Regulatory compliance information from 2021 and 2022

Quality of Care: (100 points possible)

The methodology for awarding points for quality measures in the Quality Incentive is outlined below.

  • The Quality Measures included align with the measures selected for the State's Value-Based Payment arrangements. Quality measures from Primary Care, Mental Health, Substance Use, Maternity, Children's Health, and HIV were included. This approach allows a more comprehensive view of quality and aligns with other uses of the data. It also minimizes the impact of one problematic area in the overall performance of the plan.
  • For some measures with more than one indicator, we used a weighted average method (see equation below) to average each measure's individual indicator rates and calculate a measure score.

Indicators with larger denominators contributed more to the scoring than indicators with smaller denominators. The attached list of measures identifies the measures with multiple indicators where the scores were calculated as weighted averages. The weighted average equation is as follows:

formula for scoring

Where X is the final measure score that is the weighted average, xi is the indicator score, and ni is the indicator denominator.

  • The allotted 100 points for quality were distributed evenly for all measure scores, and for measures with more than one indicator, each measure score was counted as one measure. For example, if there were 30 measures in the quality section, each measure was worth up to 3.33 points.
  • If a measure has less than 30 members and more than 1 in the denominator, we considered it to be a Small Sample Size (SS), and we suppressed those results. There was no reweighting for SS. If plan results were SS, there was an overall reduction of base quality points. For example, with 30 measures worth 100 possible points, if the plan only has 29 measures, the base was reduced by the maximum value for that one measure.
  • Measures were classified as Pay for Reporting (P4R) or Pay for Performance (P4P).
  • For measures classified as P4R, full points were awarded for valid reporting of that measure regardless of the measure score. Hybrid measures reported administratively received full P4R points. Valid reporting of the measure requires a minimum denominator of 30. Denominators with sizes of 1 to 30 are SS. If there is a denominator of 0 then there will be 0 points awarded and there will be no reweighting.
  • For measures classified as P4P, plans were awarded 50 percent of possible points for a measure result at or above the 50th percentile, but less than the 75th percentile; 75 percent of possible points for a measure result at or above the 75th percentile, but less than the 90th percentile; and 100 percent of possible points for the measure at or above the 90th percentile.
  • The determination of the 50th, 75th, and 90th percentiles, for both P4P and P4R measures, were based on the same measurement year of the results. To determine the plans achieving the percentiles the results were rounded to two decimal points prior to the percentile determination.
  • Each plan's quality points were totaled and then divided by their base points. The resulting quality percentage points were weighted to be worth 80% of the final score. This weighting of quality percentage points allows this section of the Quality Incentive to continue to retain a similar weight in the makeup of the overall scores.
  • NYS DOH reserves the ability to convert a P4P measure to a P4P if the measure has major updates that impact performance within the measurement year.

Quality Measure Benchmarks for the 2022 Medicaid Quality Incentive

Measure Name 90th Percentile 75th Percentile 50th Percentile Points Possible
Primary Care
Adult Immunization Status Influenza (Ages 19-65) 21.03 20.53 18.83 2.78
Antidepressant Medication Management-84 days and 180 days (Composite) 52.53 51.40 49.69 2.78
Asthma Medication Ratio (Ages 5-64) 71.92 69.77 62.47 2.78
Breast Cancer Screening 67.31 66.74 63.38 2.78
Cervical Cancer Screening 71.47 69.68 68.54 2.78
Chlamydia Screening (Ages 16-24) 80.05 75.68 70.11 2.78
Colorectal Cancer Screening (Ages 50-75) 54.13 53.60 51.83 2.78
Controlling High Blood Pressure 73.13 71.35 67.64 2.78
Diabetes Screening for People w/ Schizophrenia or Bipolar Disorder Using Antipsychotic Meds 81.30 79.35 76.79 2.78
Eye Exam for Patients With Diabetes 65.63 64.17 60.91 2.78
Hemoglobin A1c Control for Patients With Diabetes Poor HbA1c Control * 27.93 29.85 33.17 2.78
Initiation and Engagement in SUD Dependence Treatment (Composite) 36.61 31.74 29.84 2.78
Kidney Health Evaluation for Patients With Diabetes (Total) 44.77 42.95 41.15 2.78
Use of Spirometry Testing in the Assessment and Diagnosis of COPD 38.33 36.62 32.98 2.78
COVID-19 Immunization Status: Primary Series and Booster Series (Composite) 63.27 53.44 43.99 2.78
Children's Health
Adolescent Immunization (Combo 2) 53.41 45.74 42.58 2.78
Annual Dental Visit (Ages 2-18) 60.93 57.18 54.73 2.78
Child and Adolescent Well-Care Visits (Total) 72.83 71.03 68.25 2.78
Childhood Immunization Status (Combo 3) 76.40 75.62 73.18 2.78
Developmental Screening in the First Three Years of Life 43.97 34.15 20.42 2.78
Weight Assessment and Counseling for Children/Adolescents (Nutrition and Physical) 83.93 83.64 81.20 2.78
Well-Child Visits in the First 30 Months of Life (First 30 Months) 78.11 77.20 75.16 2.78
Mental Health
Adherence to Antipsychotic Medications for Individuals with Schizophrenia 63.24 62.30 60.91 2.78
Follow-Up After Emergency Department Visit for Mental Illness Within 7 days 75.36 60.34 54.36 2.78
Follow-Up After Hospitalization for Mental Illness Within 7 Days 73.69 63.50 62.44 2.78
Follow-up for Children Prescribed ADHD Medication-Initiation and Continuation (Composite) 65.95 65.70 59.35 2.78
Metabolic Monitoring for Children and Adolescents on Antipsychotics 51.12 45.89 38.70 2.78
Depression Screening and Follow-Up (Composite) 13.85 2.00 0.41 2.78
Substance Use
Follow-Up After High-Intensity Care for Substance Use Disorder Within 7 Days 47.26 46.44 42.72 2.78
Follow-up After Emergency Department Visit for Substance Use Within 7 Days 31.89 30.04 27.63 2.78
Initiation of Pharmacotherapy Upon New Episode of Opioid Use Disorder 55.55 51.39 44.35 2.78
Pharmacotherapy for Opioid Use Disorder 37.14 36.06 32.98 2.78
Maternity
Postpartum Care 85.00 84.41 83.83 2.78
Prenatal Immunization Status Combination 31.53 29.39 25.11 2.78
Timeliness of Prenatal Care 90.38 89.96 87.47 2.78
HIV
Viral Load Suppression 79.91 78.85 74.91 2.78

* A low rate is desirable

CAHPS Experience of Care Survey: (20 points possible)

Three CAHPS Experience of Care survey measures were included in the Quality Incentive. Twenty points were available and distributed based on whether a plan was at or above the statewide average for the most recent CAHPS survey. CAHPS is administered every year for Medicaid alternating adult and child surveys. For the 2022 Quality Incentive, the CAHPS scores from the survey conducted in fall 2022 with children in Medicaid were used. Plans were awarded points based on their scores within the measurement year. Plans earned 6.66 points for measures with results significantly better than the statewide average, 3.33 points for measures with results not significantly different from the statewide average, and no points for measures with results significantly lower than the statewide average. If a plan had less than 30 people answer at least one of the questions used in a composite measure, then the measure is suppressed and noted with a SS. If a plan results were SS, there was an overall reduction of base satisfaction points. Each plan's satisfaction points were totaled and then divided by their base points to achieve a satisfaction score of up to 100%. The resulting satisfaction percentage points were weighted to be worth 20% of the final score.

CAHPS Measure Satisfaction Points
Rating of Health Plan 6.66 points
Getting Care Needed 6.66 points
Customer Service and Information 6.66 points
Total 20 points

Compliance: (10 points for subtraction)

The Compliance section includes seven areas: Statements of Deficiency (SOD) for the Medicaid Managed Care Operating Report (MMCOR), Quality Assurance Reporting Requirements, plan network, provider directory, member services, behavioral health parity, and claims payment and/or denials. The Quality Reporting Requirement area for 2022 includes submission requirements for Care Management data, Performance Improvement Project reports, performance matrices action plans, and focused clinical studies. In the 2022 Quality Incentive, points from issues with Compliance were subtracted from the total points prior to calculating the final percentage scores. The number of points that may be subtracted is detailed below:

Category Measure Description Timeframe Points
Medicaid Managed Care Operating Report Any SOD for timeliness, completeness, or failure to meet reserve requirements of MMCOR reports submitted for the measurement year (2022). MMCOR reports submitted for 2022 2 points for any SOD timeliness, completeness, or failure to meet reserves. No more than 2 points were moved for this category.
Any SOD for timeliness, completeness, or failure to meet reserve requirements of MMCOR reports submitted the year prior to the measurement year (2021). MMCOR reports submitted for 2021
Quality Reporting Requirements Any SOD for failure to submit required complete quality data for Care Management (CMART) data and QARR data (including the required member-level file and the birth file) by the established deadlines for the measurement year (2022). Quality Reporting Requirements for 2022 data 2 points for a SOD. No more than 2 points were removed for this category.
Any SOD related to the Performance Improvement Projects or the quality performance matrix process. Quality reporting requirements for 2022
Any statement of deficiency related to a Focused Clinical Study (FCS). FCS reporting requirements for 2022
Plan Network Any SOD issued for the measurement year (2022) for failure to manage access to care to maintain a network with at least 75% compliance with required appointment timeframes based on the Access and Appointment Availability survey conducted for the department. Access and Availability survey results for 2022 1 point for any SOD. No more than 1 point was removed for this item in the category.
Any SOD for timeliness, incomplete, or inaccurate Provider Network Directory System (PNDS) or Panel Submission for measurement year (2022). PNDS Quarterly submission for 2022
Provider Directory Any SOD for incomplete or inaccurate provider listings and/or failure to maintain at least 75% provider participation rate for the measurement year (2022). Provider Directory Information and Participation results for 2022 1 point for any SOD for either directory information or for provider participation. No more than 1 point was removed for this item in the category.
Member Services Any SOD or statement of findings for member services during the measurement year (2022) for failure to: maintain a functional member services phone line; provide correct information to callers; provide specific information upon written request. Member services for 2022 1 point for any SOD or statement of findings for any of the three-member service items. No more than 1 point was removed for this category.
Behavioral Health Parity Reporting Requirement Any SOD for timeliness, completeness, and/or accuracy or failure to meet requirements on Behavioral Health Parity reports submitted for the measurement year (2022). Parity reports submitted for 2022 1 point for any SOD for timeliness, completeness or for accuracy. No more than 1 point was removed for this category.
Claims Payment and/or Denials Any statement of deficiency or statement of findings related to claims payment and/or denials issues for the year (2022). Claims payment and/or denials data for 2022 2 points for a statement of deficiency or statement of findings. No more than 2 points were removed for this category.
Total     10 points
Quality Incentive Tiers:

A percentage of total quality measure points and a percentage of satisfaction points is calculated for each plan. From those results, a blended final percentage is calculated weighting the final percentage 80% for quality points and adding the CAHPS Satisfaction points. Plans were grouped into one of five tiers based on the final percentage of the total score to determine the incentive award. Plans must achieve or exceed the threshold for the respective tier to be eligible for their award. Tier 1 indicates scores at 68.48 or higher, Tier 2 indicates scores between 58.86-68.47, Tier 3 indicates scores between 39.41-58.85, Tier 4 indicates scores between 33.03-39.40, and Tier 5 indicates scores at 33.02 or lower. Quality incentive payments are subject to the availability of State funding as determined by the annual Budget process.

For 2022, the twelve NYS Medicaid Managed Care plans were grouped into five tiers based on their Quality Incentive scores. The table below shows the tier assigned to each plan. The 2022 Quality Incentive awards become effective for capitation rates and for auto-assignment preference on April 1, 2024.

MMC QUALITY INCENTIVE 2022
INCENTIVE PREMIUM AWARD (%) PLAN NAME Quality Score
(100 points)		 Weighted Quality Score
(80%)		 Satisfaction Score
(20 Points)		 Sum of Quality and Satisfaction Scores Compliance points
(Up to - 10 points)		 Total
TIER 1 Independent Health 67.42 53.93 16.65 70.58 -1 69.58
TIER 1 Healthfirst PHSP, Inc. 74.37 59.49 9.99 69.48 -1 68.48
TIER 2 MetroPlus Health Plan 63.94 51.15 9.99 61.14 -2 59.14
TIER 3 CDPHP 56.99 45.59 14.99 60.58 -2 58.58
TIER 3 Excellus BlueCross BlueShield 47.26 37.81 14.99 52.8 -1 51.8
TIER 3 Highmark Western and Northeastern New York, Inc. 46.57 37.25 13.32 50.57 -2 48.57
TIER 3 Empire BlueCross BlueShield HealthPlus 45.87 36.7 9.99 46.69 -1 45.69
TIER 3 Fidelis Care New York, Inc. 43.09 34.47 9.99 44.46 -2 42.46
TIER 3 HIP (EmblemHealth) 45.18 36.14 6.66 42.8 -2 40.8
TIER 4 MVP Health Care 37.53 30.02 9.99 40.01 -2 38.01
TIER 5 UnitedHealthcare Community Plan 35.45 28.36 6.66 35.02 -2 33.02
TIER 5 Molina Healthcare 34.06 27.24 6.66 33.9 -1 32.9

If you have questions regarding the incentive premium award, please contact the Bureau of Managed Care Reimbursement at bmcr@health.ny.gov.

We welcome suggestions and comments on this publication. Please contact us at:

Bureau of Quality Measurement and Evaluation
Office of Health Services Quality and Analytics
Corning Tower, Room 1938 Empire State Plaza
Albany, New York 12237

Telephone: (518) 486-9012
Fax: (518) 486-6098
E-mail: nysqarr@health.ny.gov