PATH MEDICARE ADVANTAGE
HEDIS IMPROVEMENT PROGRAM
2015 TERMS AND CONDITIONS
These PATH Medicare Advantage HEDIS Improvement Program Terms and Conditions (“Terms and
Conditions”) govern the PATH Medicare Advantage HEDIS Improvement Program (“MA-HIP” or “PATH
MA-HIP”). As a precondition for the Provider to participate in MA-HIP pursuant to these Terms and
Conditions and to be eligible for the MA-HIP Bonus described below, one of the following must have occurred:
(a) Care Improvement Plus (“CIP”) presented an MA-HIP Participation Acknowledgement
(“Acknowledgment”) to Provider and Provider signed and returned the Acknowledgement to CIP in accordance
with the deadline established by CIP, or (b) CIP notified Provider of Provider’s enrollment in MA-HIP via a
unilateral amendment to Provider’s participation agreement with CIP.
A Provider that participates in MA-HIP will receive an MA-HIP Bonus from CIP if all of the requirements and
conditions described in these Terms and Conditions are met.
1. Definitions: Capitalized terms in these Terms and Conditions have the meanings given to them in the list of
defined terms in Paragraph 9 of these Terms and Conditions.
2. Eligibility: With respect to a given MA-HIP Term, Provider will be eligible to receive the MA-HIP Bonus
if both the Threshold Criteria and the Performance Criteria are met as follows:
A.
Provider must meet the following Threshold Criteria with respect to the MA-HIP Term:
i.
Provider has at least one Customer with an Annual Care Visit with a date of service during
the current MA-HIP Term.
ii.
Provider must have accessed its PCOR at least once each month after publication on
www.CIPhealthcareonline.com.
B.
Provider must meet the following Performance Criteria with respect to the MA-HIP Term:
i.
Provider achieves or exceeds the specified HEDIS Compliance Percentage Target for at
least one of the eleven MA-HIP Measures set forth in the following table, as calculated
by CIP pursuant to Paragraph 3.
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2015 Medicare Advantage HEDIS Improvement Program Effective January 1, 2015
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MA-HIP Measures Table*
2014
CMS ID
2015
Star ID
CMS STAR
Weighting
C01
DMC22
1
C02
C01
Measure Name
Breast Cancer
Screening
1
Colorectal Cancer
Screening
Osteoporosis
Management in
women w/ fracture
C14
C13
1
C15
C14
1
C16
C15
1
Diabetes Care – Eye
Exam
Diabetes Care Kidney disease
monitoring
Description
Period
HEDIS
COMPLIANCE
RATE
SUPERIOR
COMPLIANCE
RATE
One mammogram every two
years
Current or prior calendar year
74%
83%
One or more screenings: Yearly
fecal occult blood test (FOBT),
or Every 5 years flexible
sigmoidoscopy, or Every 10
years colonoscopy
FOBT: Current calendar year
Flex Sig: Current calendar year
to previous 4 calendar years
Colonoscopy: Current calendar
year to previous 9 calendar
years
58%
65%
Current calendar year
60%
76%
Current calendar year
64%
77%
Urine microalbumin for
nephropathy
Current calendar year
85%
94%
Current calendar year
78%
88%
Given a bone mineral density
test, OR Prescribed a drug to
treat or prevent osteoporosis in
the six months after the
fracture
Eye exam (retinal or dilated)
performed
C20
C19
1
Rheumatoid Arthritis
Management
Diagnosed with rheumatoid
arthritis AND dispensed at least
one ambulatory Rx for a
disease-modifying antirheumatic drug
D11
D09
3
High Risk Medication
2 or more prescription fills for a
drug with a high risk of serious
side effects in the elderly
Current calendar year
9%
7%
D12
D10
3
Diabetes Treatment
Dispensed medication for
diabetes and a medication for
hypertension whose treatment
included a RAS antagonist
Current calendar year
86%
90%
3
Medication
Adherence for
Diabetes
Medications
Diabetes medication
prescription fills to cover
80% or more of the time
supposed to be taking the
medication (excludes insulin)
Current calendar year
77%
81%
3
Medication
Adherence for
Hypertension (RAS
antagonists)
Blood pressure medication (RAS
antagonists) prescription fills to
cover 80% or more of the time
supposed to be taking the
medication
Current calendar year
81%
85%
Cholesterol medication (Statins)
prescription fills to cover 80% or
more of the time supposed to
be taking the medication
Current calendar year
76%
83%
D13
D14
D15
D11
D12
D13
3
Medication
Adherence for
Cholesterol (Statins)
* The MA-HIP Measures shown in the table above are subject to change from time to time at CMS’ discretion. The
table shows the star thresholds for the 2015 star ratings effective January 1, 2015. For final evaluation of the MA-HIP
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Measures, CIP will use the most recently published CMS plan star thresholds for each measure, as of the time CIP
calculates Provider’s HEDIS Compliance Percentage.
.
3. HEDIS Compliance Percentage. To improve the quality of the health care it delivers, Provider will
strive to achieve performance levels for each of the MA-HIP Measures that are at or above the
applicable HEDIS Compliance Percentage Targets shown in the MA-HIP Measures Table in Paragraph
2.B. to these Terms and Conditions. If, for a given MA-HIP Term, Provider has met the Threshold
Criteria, CIP will determine whether Provider has met the Performance Criteria for each MA-HIP
Measure for the period ending on the last day of the MA-HIP term based on the “% Adherent” column
of the Group Level Summary Report contained within the Final PCOR. The Final PCOR will be the
sole source of information and data used to determine whether Provider has met the HEDIS Compliance
Percentage for a given MA-HIP Measure. If there are no Customers identified on the Final PCOR as
eligible for a particular MA-HIP Measure for the Review Period, then such measure will be excluded
from consideration for purposes of meeting the eligibility requirements and payment of any incentive
payment hereunder.
4. MA-HIP Bonus. If, for a given MA-HIP Term, Provider meets the Threshold Criteria and the
Performance Criteria, CIP will calculate Provider’s MA-HIP Bonus as the amount equal to the bonus
amount indicated on the Bonus Table below multiplied by the Total Eligible Patients for that MA-HIP
Term. The applicable Bonus Amount is determined by the number of MA-HIP measures that provider
met pursuant to Paragraph 3. CIP will pay the incentive amount to Provider no later than 150 days after
the end of the Review Period. Notwithstanding anything to the contrary in Terms and Conditions, if
Provider is no longer a contracted provider in CIP’s network(s) for Medicare Advantage Benefit Plans
under the Agreement (or under a similar successor agreement with CIP) at the time such payment is due,
then Provider will not be eligible for or entitled to the MA-HIP Bonus.
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Bonus Table:
# of Measures
Met
Bonus
Amount
11
10
9
8
7
6
5
4
3
$100*
$90*
$80*
$55*
$50*
$30*
$25*
$20*
$15*
2
$10*
1
$5*
*The applicable MA-HIP Bonus is this amount listed above plus an
additional $5 for each MA-HIP Measure, if any, where Provider’s HEDIS
Compliance Percentage met or exceeded the corresponding Superior
Compliance Percentage Level set forth in the MA-HIP Measures Table.
5. Termination. CIP and Provider each shall have the right to terminate Provider’s participation in the
MA-HIP Program for any reason, effective for the next MA-HIP Term, by giving written notice to the
other no more than 60 days after the Terms & Conditions for the next MA-HIP Term have been
communicated/published. Such termination will not affect the MA-HIP Bonus determination (if any)
pursuant to the terms of these Terms and Conditions for the MA-HIP Term in effect prior to such
termination.
Further, CIP and Provider each shall have the right to terminate Provider’s participation in MA-HIP
immediately upon notice to the other in the event of the other party’s failure to comply with any
requirement of these Terms and Conditions.
6. Amendment of the MA-HIP Terms and Conditions. CIP, in its sole discretion, may amend these
Terms and Conditions for any future MA-HIP Term by providing to Provider a copy of and/or
electronic access to the new Terms and Conditions no later than 30 days prior the first day of the MAHIP Term to which the new Terms and Conditions will apply. If Provider does not wish to continue
participation in the MA-HIP Program after review of the new Terms and Conditions, Provider has the option
to terminate participation in the MA-HIP Program as set forth in Paragraph 5 above.
7. Agreement. When Provider and CIP are parties to an Agreement, CIP and Provider agree and
acknowledge that these Terms and Conditions supplement the Agreement. The terms of the Agreement
remain binding on the parties, and none of the rights and obligations of Provider and of CIP under the
Agreement shall be modified or impaired by these Terms and Conditions, except in the event of a
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2015 Medicare Advantage HEDIS Improvement Program Effective January 1, 2015
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conflict between these Terms and Conditions and the Agreement, in which case the specific conflicting
term(s) of these Terms and Conditions will govern with respect to MA-HIP.
When Provider and CIP are not parties to an Agreement when Provider begins participating in MA-HIP,
Provider agrees and acknowledges that it is subject to the additional Terms and Conditions in Paragraph
10 of these Terms and Conditions. Further, Provider acknowledges that each of Provider’s Provider
Physicians is subject to the terms of the participation agreement or provider contract under which the
Provider Physician participates in CIP’s network for Medicare Advantage Benefit Plans.
8. Record Reviews. With regard to MA-HIP described in these Terms and Conditions, and without
limiting any other data access rights set forth elsewhere in the Agreement, Provider and Provider
Physicians will permit CIP or its designee to conduct chart reviews of Provider’s/Provider Physicians’
records pertaining to MA-HIP Customers evaluated as part of MA-HIP free of charge upon reasonable
notice at any time during the 12 months following the end of the Review Period.
9. Defined Terms. As used in these Terms and Conditions, these capitalized terms have the following
meanings:
Agreement: The participation agreement or provider contract to which Provider and CIP are parties
and under which Provider has agreed to participate in CIP’s network for Medicare Advantage Benefit
Plans.
Benefit Plan: A certificate of coverage, summary plan description, or other document or
agreement, whether delivered in paper, electronic, or other format, under which a CIP is
obligated to provide coverage of Covered Services for a Customer.
Covered Services: A health care service or product for which Customer is entitled to receive
coverage from CIP, pursuant to the terms of the Customer’s Benefit Plan with CIP.
Customer: A person eligible and enrolled to receive coverage from a CIP for Covered Services.
Final PCOR: The PCOR that covers HEDIS activity and dates of service through the last day of the
Review Period.
HEDIS Compliance Percentage: The ratio (expressed as a percentage) of (i) the number of MA-HIP
Customers that CIP has identified as eligible for the MA-HIP Measure, to (ii) Number of MA-HIP
Customers that CIP shows as having met the MA-HIP Measure. Each HEDIS Compliance Percentage
will be rounded up or down to the nearest whole number.
HEDIS Compliance Percentage Target: The level of performance for a particular MA-HIP Measure
that Provider must meet or exceed in order to achieve the MA-HIP Measure for a given MA-HIP Term
for purposes of meeting the Performance Criteria, as set forth in the MA-HIP Measures Table in
Paragraph 2.B.
MA-HIP Bonus: For a given MA-HIP Term, the payment available to Provider if all of the
requirements described in these Terms and Conditions are met with respect to that MA-HIP Term.
MA-HIP Customer: Each Customer eligible for and enrolled in a Medicare Advantage Benefit Plan
who is attributed, for a given MA-HIP Term, by CIP to one of Provider’s Provider Physicians for the
MA-HIP described in these Terms and Conditions.
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2015 Medicare Advantage HEDIS Improvement Program Effective January 1, 2015
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MA-HIP Measures: The specific measures that will be evaluated with respect to a given MA-HIP
Term, as set forth in the MA-HIP Measures Table in Paragraph 2.B.
MA-HIP Term: A calendar year during which Provider is eligible to participate in MA-HIP described
in these Terms and Conditions (for example, January 1, 2014 through December 31, 2014).
PCOR: The Patient Care Opportunity Report generated by CIP on a monthly basis that summarizes
performance data about various HEDIS measures, including the MA-HIP Measures, using CIP claims
data available at the time the report is generated, for MA-HIP Customers enrolled in Medicare
Advantage Benefit Plans whom CIP attributes to a Provider Physician for purposes of this report.
Performance Criteria: The MA-HIP eligibility condition(s) described in Paragraph 2.B.
Provider: Either (i) a physician, medical group, clinic, IPA, or PHO that is a party to an Agreement
and has met the requirements set forth in the opening paragraph of these Terms and Conditions, or
(ii) a medical group or clinic that is not a party to an Agreement, but employs or contracts with
Provider Physicians, and has met the requirements set forth in the opening paragraph of these Terms
and Conditions.
Provider Physician: A physician who is a doctor of medicine or osteopathy, duly licensed and
qualified under the laws of the jurisdiction in which he/she provides health services to Customers, and
who meets one of the following: (i) the physician is a Provider who is a party to an Agreement, (ii) the
physician practices as a shareholder, partner, employee, or subcontractor of a Provider that is a party to
an Agreement, or (iii) where the Provider is not a party to an Agreement, the physician is a party to a
CIP participation agreement or provider contract under which he/she participates in CIP’s network for
Medicare Advantage Benefit Plans and is a practicing shareholder, partner, employee, or subcontractor
of that Provider. Each Provider Physician is assigned to a specific Provider based on the criteria above.
Review Period: The period for assessing Provider’s performance on a MA-HIP Measure which is the
HEDIS review period ending at the end of the MA-HIP Term, using the HEDIS look-back period
applicable to the measure.
Threshold Criteria: The MA-HIP eligibility condition(s) described in Paragraph 2.A.
Total Eligible Patients: The total number of MA-HIP Customers identified in Provider’s PCOR Report,
on the “Member Adherence Report” tab, as having an “Annual Care Visit” with a date of service during
the current MA-HIP Term.
CIP: Care Improvement Plus and/or the Care Improvement Plus affiliate(s) named in the Agreement.
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2015 Medicare Advantage HEDIS Improvement Program Effective January 1, 2015
Care Improvement Plus (CIP)
Confidential and Proprietary
Revised 1/1/2015