Total Care for General Population (TCGP)

Value Based Payment Quality Measure Set
Measurement Year 2025

  • Measure Set is also available in Portable Document Format (PDF)

January 2025                     NYS Medicaid Value Based Payment

INTRODUCTION

The Measurement Year (MY) 2025 Total Care for General Population (TCGP) Quality Measure Set was created in collaboration with the Primary Care (Physical Health), Maternity Care, Behavioral Health/Health and Recovery Plans (HARP), People Living with HIV/AIDs, and Clinical Advisory Groups (CAGs), as well as the New York State Department of Health (the Department) CAG Strategy team. The goal of this measure set is to align with measures put forth in the NYS Quality Assurance Reporting Requirements (QARR), the Healthcare Effectiveness Data and Information Set® (HEDIS)1 Technical Specifications for Health Plans, the Centers for Medicare & Medicaid Services (CMS) Core measure set, the Merit-based Incentive Payment System (MIPS), and the Medicaid Managed Care (MMC) Quality Incentive program, where applicable. The measure set is designed to encourage providers to meet high standards of patient-centered clinical care and coordination across multiple care settings.

MEASURE SELECTION AND FEASIBILITY

Beginning in MY2020, to encourage a broader diversity of quality measures appropriate to member populations being served by a TCGP arrangement, the Department recommended all measures in the TCGP measure set be grouped into domains and added the following requirement to the Value Based Payment (VBP) Roadmap2.

Managed Care Organizations (MCOs) (excluding Managed Long-Term Care) that execute a TCGP VBP arrangement must base shared savings and risk distribution on quality measures that include at least one, Category 1 Pay-for-Performance (P4P) measure from each of the following domains:

  • Primary Care
  • Mental Health
  • Substance Use Disorder
  • HIV/AIDS
  • Maternity
  • Children's

TCGP VBP arrangements that exclude pregnant women, children, or persons living with HIV/AIDS are not required to include quality measures from these respective quality measure set domains. However, TCGP arrangements that carve out HARP members are still required to include quality measures from the primary care, mental health, and substance use disorder quality measure domains, in addition to the maternity, children, and HIV/AIDS domains, if these latter populations are included.

These requirements carry through to TCGP Arrangements for MY2025. For MY2025, 24 measures have remained the same, one measure has been added, one measure has been removed, and ten measures' reporting specifications/requirements have been revised, culminating in a total of 35 TCGP Category 1 measures.

VBP ARRANGEMENT REQUIREMENTS FOR MY2025 - HEALTH EQUITY

In MY2022, NCQA added race and ethnicity stratification to several HEDIS measures to help promote transparency in health plan performance. Because high-quality care requires equitable care, NCQA hopes to better identify where disparities exist so they can be addressed. They also hope to identify and learn from top performers in areas where disparities don't exist. To align with this initiative, in July 2022, NYS required payers and providers to incorporate race and ethnicity measure stratification in VBP arrangements. For MY2025, there are 26 HEDIS stratified measures. Twenty-two of these are included in various New York Medicaid VBP arrangement measure sets for payers and providers to add to their VBP contracts. Please refer to the following section for VBP contracting stratification specifications for MY2025.

Stratification Specifications:

  1. Payers are required to include at least one of the following measures in all level 1 or higher VBP contracts and stratify results by race and ethnicity categories as outlined in the HEDIS MY2025 specifications.3
NQCA Measure Name Measure Inclusion by Arrangement Type
TCGP HARP/BH Maternity HIV/AIDs Children's
Adult Immunization Status (AIS-E) ✓        
Asthma Medication Ratio (AMR) ✓ ✓   ✓ ✓
Breast Cancer Screening (BCS-E) ✓ ✓   ✓  
Cervical Cancer Screening (CCS; CCS-E) ✓ ✓   ✓  
Child and Adolescent Well–Care Visits (WCV) ✓       ✓
Childhood Immunization Status (CIS; CIS-E) ✓       ✓
Colorectal Cancer Screening (COL-E) ✓ ✓   ✓  
Controlling High Blood Pressure (CBP) ✓ ✓   ✓  
Eye Exam for Patients with Diabetes (EED) ✓ ✓   ✓  
Follow-Up After Emergency Department Visit for Mental Illness (FUM) ✓ ✓     ✓
Follow–Up After Emergency Department Visit for Substance Use (FUA) ✓ ✓      
Follow-Up After Hospitalization for Mental Illness (FUH) ✓ ✓      
Glycemic Status Assessment for Patients with Diabetes (GSD) (Formerly Hemoglobin A1c - HBD) ✓ ✓   ✓  
Immunizations for Adolescents - Combo 2 (IMA, IMA-E) ✓       ✓
Initiation and Engagement of Substance Use Disorder Treatment (IET) ✓   ✓ ✓  
Kidney Health Evaluation for Patients with Diabetes (KED) ✓ ✓   ✓  
Pharmacotherapy for Opioid Use Disorder (POD) ✓ ✓      
Postpartum Depression Screening and Follow-Up (PDS-E)     ✓    
Prenatal and Postpartum Care (PPC) ✓   ✓    
Prenatal Depression Screening and Follow-Up (PND-E)     ✓    
Prenatal Immunization Status (PRS-E) ✓   ✓    
Well-Child Visits in the First 30 Months of Life (W30) ✓       ✓

Stratification Requirements:

  1. Any measure(s) from the preceding table can be selected for stratification of race and ethnicity provided the two groups approve on the contracting elements around other performance of the measure.
  2. Payers are required to include the following details in the Provider Contract Statement and Certification form (DOH-4255)4 and Contract language:
    1. Indicate what measure(s) are included for race and ethnicity stratification.
    2. Indicate how the stratified measure results for applicable measures will be shared with the VBP contractor.
  3. Plans are required to include the race and ethnicity data when submitting to NYS using the following method:
    1. Race and ethnicity fields will be added to the annual VBP member attribution submission file specifications. This will allow the Department to stratify measure performance by race and ethnicity categories for applicable performance measures at the VBP contract and VBP Contractor levels.

All new contracts must meet this requirement to be approved by the Department. As of April 1, 2023, all other existing contracts were to be updated/amended at the end of the contract's current measurement period and before the contract's next measurement period began.

MEASURE CLASSIFICATION

In previous years, measures have been designated by the Department as Category 1, 2, or 3 with associated recommendations for implementation and testing for future use in VBP Arrangements.

For MY2025 the TCGP Measure Set consists of 35 Category 1 measures. The following measure domains were incorporated into the TCGP Measure Set for MY2025: Primary Care, Mental Health, Substance Use Disorder, HIV/AIDS, Maternity, and Children's.

Category 1

Category 1 quality measures as identified by the CAGs and accepted and deemed reportable by the Department are to be reported by VBP Contractors to the MCOs. These measures are also intended to be used to determine the amount of shared savings for which VBP contractors are eligible.5

For MY2025 the TCGP Measure Set consists of 35 P4P and 3 P4R measures, as defined below.

  • P4P measures are intended to be used to determine shared savings amounts for which VBP Contractors are eligible. Measure performance can be considered in both the determination of the target budget and in the calculation of shared savings for VBP Contractors.
  • P4R measures are intended to be used by the MCOs to incentivize VBP Contractors to report data to monitor the quality of care delivered to members under a VBP contract. Incentives for reporting should be based on timeliness, accuracy, and completeness of data.

Not all Category 1 measures will be reportable for the measurement year, as reporting on some of these measures will be phased in over the next few years. Please refer to the 2025 Value-Based Payment Reporting Requirements Technical Specifications Manual (MY2025) for details on which measures must be reported for the measurement year. This manual will be updated annually, in line with the release of the final VBP measure set for the subsequent year.

MY2025 TCGP QUALITY MEASURE SET

The measures provided on the following pages are recommendations for MY2025. Note that measure classification is a Department recommendation, and implementation is to be determined between the MCO and VBP Contractor.

Measure sets and classifications are considered dynamic and will be reviewed annually. Updates will include measure additions, deletions, recategorizations, and/or reclassifications from P4R to P4P or vice versa, based on experience with measure implementation in the prior year. Please see Appendix A for a full list of these changes.

Category 1

The table below displays the Category 1, MY2025 TCGP Quality Measure Set, arranged alphabetically within domains and includes the measure title, measure steward, and the Department recommended measure classification. The measure set is redlined to highlight changes made between MY2024 and MY2025; please refer to the key at the end of this table for an explanation of redlined formatting.

TCGP Measure Measure Steward Classification
2025 TCGP Primary Care Domain
Adult Immunization Status - Electronic (Influenza)(AIS-E)^ NCQA P4P
Antidepressant Medication Management - Effective Acute Phase Treatment & Effective Continuation Phase Treatment (AMM)* NCQA P4P
Asthma Medication Ratio (AMR) NCQA P4P
Breast Cancer Screening (BCS-E) NCQA P4P
Cervical Cancer Screening (CCS; CCS-E)* NCQA P4P
Chlamydia Screening in Women (CHL)^ NCQA P4P
Colorectal Cancer Screening (COL-E) NCQA P4P
Controlling High Blood Pressure (CBP) NCQA P4P
COVID-19 Immunization Measure (CVS)^ NYS P4P
Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)* NCQA P4R
Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) NCQA P4P
Eye Exam for Patients with Diabetes (EED)^ NCQA P4P
Glycemic Status Assessment for Patients with Diabetes (GSD) NCQA P4P
Initiation and Engagement of Substance Use Disorder Treatment (IET) NCQA P4P
Kidney Health Evaluation for Patients with Diabetes (KED) NCQA P4P
Social Need Screening and Intervention (SNS-E) NCQA P4R P4P
2025 TCGP Mental Health Domain
Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA) CMS P4P
Depression Remission or Response for Adolescents and Adults (DRR-E) NCQA P4P
Follow-Up After Emergency Department Visit for Mental Illness (FUM) NCQA P4P
Follow-up After Hospitalization for Mental Illness (FUH) NCQA P4P
Potentially Preventable Mental Health Related Readmission Rate 30 Days (PPR-MH) NYS P4P
2025 TCGP Substance Use Domain
Follow-Up After Emergency Department Visit for Substance Use (FUA) NCQA P4P
Follow-Up After High-Intensity Care for Substance Use Disorder (FUI) NCQA P4P
Initiation of Pharmacotherapy upon New Episode of Opioid Dependence (POD-N) NYS P4P
Pharmacotherapy for Opioid Use Disorder (POD) NCQA P4P
2025 TCGP HIV/AIDS Domain
HIV Viral Load Suppression (VLS) HRSA P4P
2025 TCGP Maternity Domain
Prenatal & Postpartum Care (PPC) NCQA P4P
Prenatal Immunization Status (PRS-E)^ NCQA P4R P4P
2025 TCGP Children's Domain
Child and Adolescent Well-Care Visits (WCV) NCQA P4P
Childhood Immunization Status - Combination 3 (CIS; CIS-E)* NCQA P4P
Developmental Screening Using Standardized Tool, First Three Years of Life (DEV-N)^ OHSU/NYS P4R P4P
Immunizations for Adolescents - Combination 2 (IMA, IMA-E)* NCQA P4P
Oral Evaluation, Dental Services (OED) NCQA P4R
Topical Fluoride for Children (TFC) NCQA P4R
Well-Child Visits in the First 30 Months of Life (W30)^ NCQA P4P

^ Measure Revised for MY2025
Retired/Removed for MY2025
*Revised for MY2025 - ECDS (HEDIS Electronic Clinical Data Systems) Reporting ONLY
*New Measure for MY2025

Appendix A

The tables below identify the changes to the Category 1 measures for the MY2025 TCGP Quality Measure Set.

Category 1 Measure Changes from 2024 to 2025

Measure Name Change Rationale for Change
Adult Immunization Status - Electronic (Influenza)(AIS-E) Classification change Second year measure; changed to P4P
Adult Immunization Status - Electronic (Influenza)(AIS-E) Specification Change Added a hepatitis B immunization indicator
Antidepressant Medication Management - Effective Acute Phase Treatment & Effective Continuation Phase Treatment (AMM) Measure removed Retired by NCQA
Cervical Cancer Screening (CCS) Reporting Specification Change ECDS* reporting only
Childhood Immunization Status – Combination 3 (CIS) Reporting Specification Change ECDS* reporting only
Chlamydia Screening in Women (CHL) Name Change Gender inclusive measurement
COVID-19 Immunization Measure (CVS) Specification Change Enrollment/anchor dates, measurement period, and CDC vaccine codes updated.
Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) Measure Added To align with MMC Quality Incentive program.
Developmental Screening Using Standardized Tool, First Three Years of Life (DEV-N) Classification change Second year measure; changed to P4P
Eye Exam for Patients with Diabetes (EED) Specification Change Removed hybrid data collection method
Immunizations for Adolescents – Combination 2 (IMA) Reporting Specification Change ECDS* reporting only
Prenatal Immunization Status (Combination)(PRS-E) Classification change Second year measure; changed to P4P

*ECDS: HEDIS Electronic Clinical Data Systems

__________________________________________________________

1. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).1
2. New York State Roadmap for Medicaid Payment Reform website 2
3. HEDIS® Measurement Year 2025 Volume 2 Technical Specification for Heath Plans, General Guidelines section 28. 3
4. DOH 4255 has been updated, Section C 2e, to include a Quality Measure Race and Ethnicity Stratification section 4
5. New York State Department of Health, Medicaid Redesign Team, A Path Toward Value-Based Payment: Annual Update, May 2022. 5