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Employees
Health
Benefits
Program
2019 FEHB
Plan Performance Assessment
Procedure Manual
Date: October 25, 2018
Table of Contents
INTRODUCTION ..................................................................................................................................................... 1
SECTION 1: REPORTING HEDIS AND CAHPS DATA .................................................................................................. 1
S
UBSECTION A: OPM GENERAL REQUIREMENTS FOR HEDIS COLLECTION AND REPORTING .........................................................1
HEDIS Cost to FEHB Health Plans ..........................................................................................................................2
HEDIS Timeline .....................................................................................................................................................2
S
UBSECTION B: OPM GENERAL REQUIREMENTS FOR CAHPS COLLECTION AND REPORTING ........................................................3
CAHPS Surveys and OMB Clearance......................................................................................................................5
CAHPS Processing Fee ...........................................................................................................................................5
CAHPS Timeline ....................................................................................................................................................6
S
UBSECTION C: REPORTING HEDIS AND CAHPS RESULTS TO NCQA ......................................................................................6
S
UBSECTION D: SUMMARY OF CHANGES TO CLINICAL QUALITY, CUSTOMER SERVICE AND RESOURCE USE (QCR) MEASURE SET AND
FARM TEAM IN 2019 .....................................................................................................................................................8
Measures Being Added to QCR Score in 2019.......................................................................................................8
Measure Retired in 2019.......................................................................................................................................8
Farm Team Update for 2019.................................................................................................................................8
SECTION 2: QCR SCORING AND CALCULATION PROCEDURES................................................................................. 8
S
UBSECTION A: PRODUCT REPORTING TYPES.......................................................................................................................8
S
UBSECTION B: QCR SCORING .......................................................................................................................................10
S
UBSECTION C: HEDIS AUDITOR CODES AND QCR SCORING ...............................................................................................10
S
UBSECTION D: CONTRACT ROLL-UP................................................................................................................................11
S
UBSECTION E: QCR DATA PREVIEW PERIOD ....................................................................................................................11
S
UBSECTION F: DATA CORRECTION PROCEDURE.................................................................................................................11
S
UBSECTION G: CORRECTIVE ACTION PLANS......................................................................................................................13
SECTION 3: CONTRACT OVERSIGHT PROCEDURES................................................................................................ 13
SECTION 4: NEW FEHB CARRIERS (CONTRACTS)................................................................................................... 14
S
UBSECTION A: FIRST YEAR IN THE FEHB .........................................................................................................................15
S
UBSECTION B: SECOND YEAR IN THE FEHB......................................................................................................................15
S
UBSECTION C: THIRD YEAR IN THE FEHB.........................................................................................................................15
SECTION 5: REFERENCES & RESOURCES ............................................................................................................... 16
S
UBSECTION A: CAHPS SURVEY PARTICIPATION FORM AND SAMPLE CROSSWALK ...................................................................16
S
UBSECTION B: 2019 CLINICAL QUALITY, CUSTOMER SERVICE AND RESOURCE USE MEASURE SET AND FARM TEAM MEASURE SET .19
S
UBSECTION C: QUALITY IMPROVEMENT CORRECTIVE ACTION PLAN TEMPLATE FOR 2019 ........................................................20
S
UBSECTION D: TIMELINE ..............................................................................................................................................23
Introduction
The 2019 Procedure Manual provides guidance for FEHB Carriers to report Clinical Quality, Customer
Service and Resource Use (QCR) measures, Farm Team measures, and Contract Oversight information
under the FEHB Plan Performance Assessment in fulfillment of their FEHB contractual obligations. The
manual also outlines specific reporting instructions for the Healthcare Effectiveness Data and
Information Set (HEDIS®)
1
and Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
2
measures.
In this manual, OPM refers to FEHB Carriers and the health plan options offered by FEHB Carriers under
their FEHB contract. In some instances, FEHB Carriers and their health plan options are synonymous. In
other cases, the FEHB contract that FEHB Carriers have entered into with the Office of Personnel
Management (OPM) contain multiple health plan options in different geographic areas. In this annual
procedure manual, OPM will refer to FEHB Carriers or their health plan options depending on the intent
of the section. If an FEHB Carrier has multiple health plan options under a FEHB contract, the term
“FEHB Carrier” or “Carrier” in this procedure manual refers to their respective data reporting
requirements under each health plan option.
If there are questions related to the material within this manual, please contact your Health Insurance
Specialist and/or email FEHBPerformance@opm.gov
.
Section 1: Reporting HEDIS and CAHPS Data
Subsection A: OPM General Requirements for HEDIS Collection and Reporting
• The National Committee for Quality Assurance (NCQA) compiles the HEDIS data on OPM’s
behalf; therefore, FEHB Carriers must follow NCQA’s data submission process when submitting
data for their health plan options. Additional information is outlined below and can also be
found at: www.ncqa.org/hedis-quality-measurement/hedis-data-submission
.
• FEHB Carriers are expected to report on the book(s) of business in which FEHB members are
enrolled. For many FEHB Carriers this will be the commercial book of business. If there are FEHB
members enrolled in multiple health plan product types under one FEHB contract, OPM will use
the plan product type with the highest FEHB enrollment to score all reports.
• FEHB Carriers that are in their first year of offering benefits under a new FEHB contract must
report HEDIS and CAHPS in the second full year of participation in the FEHB. Reports submitted
before this time are not eligible for inclusion in the Plan Performance Assessment. Additional
details on requirements for new FEHB Carriers, including the definition of what constitutes a
new health plan option are defined for this purpose, appear in Section 4.
1
HEDIS
®
, IDSS and Quality Compass® are registered trademarks of the National Committee for Quality Assurance (NCQA).
2
CAHPS
®
is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
1
• Existing FEHB Carriers with new enrollment codes or health plan options are expected to report
HEDIS and CAHPS data that includes the new code or option. For example, if Acme Insurance
Company had a Standard Health Plan enrollment code option in the 2018 FEHB Program and
added a Basic Option Enrollment Code in the 2019 FEHB Program under the same contract, they
would be expected to report on both the Basic and Standard Option data for the 2019 Plan
Performance Cycle.
• Each FEHB Plan must submit audited HEDIS results regardless of enrollment size.
• Questions: FEHBPerformance@opm.gov
HEDIS Cost to FEHB Health Plans
As stated in the FEHB contract, “costs incurred by the Carrier for collecting or contracting with a vendor
to collect quality measures/data shall be the Carrier’s responsibility.” For all measures where NCQA
allows collection of a HEDIS metric by either hybrid
3
or administrative
4
methodology, OPM will also
accept either method. In offering this choice, OPM aligns with national commercial benchmarks which
contain a mix of hybrid and administrative data, while remaining mindful of the cost that may be
associated with hybrid collection. Experience-Rated Carriers should note that OPM will not cover the
additional cost of hybrid collection if NCQA allows administrative reporting. For metrics that are
collected via hybrid methodology exclusively, Experience-Rated Carriers may submit a justification of
expenses associated with collecting this measure that exceed their administrative services cost
breakdown.
HEDIS Timeline
• December 2018:
o NCQA sends the HEDIS Data Submission Kick-off to Primary and Secondary contacts.
NCQA posts the XML Templates, Validations and Data Dictionaries for Interactive Data
Submission System© (IDSS) to the data submission webpage.
• January 2019:
o NCQA releases the 2019 Online Healthcare Organization Questionnaire (HOQ) for health
plans to request and update submissions.
3
Organizations look for numerator compliance in both administrative and medical record data. The denominator consists of a
systematic sample of members drawn from the measure’s eligible population. Organizations should review administrative data
to determine if members in the systematic sample received the service and review medical record data for members who do
not meet the numerator criteria through administrative data. The reported rate is based on members in the sample who are
found to have received the service required for the numerator. (HEDIS Technical Specifications, Volume 2, page 26.)
4
Transaction data or other administrative databases are used to identify the eligible population and numerator. The reported
rate is based on all members who meet the eligible population criteria (after optional exclusions, if applicable) and who are
found through administrative data to have received the service required for the numerator.
2
• February 2019:
o Carriers finalize their HOQ requests to obtain access to the IDSS and submission IDs for
HEDIS and CAHPS.
• April 2019:
o NCQA releases the 2019 IDSS for data loading and validation.
o NCQA distributes Submission IDs for survey measures to NCQA certified survey vendors.
• May 2019:
o NCQA sends the Conditions for Public Reporting letter to Primary and Secondary HEDIS
contacts. This letter includes the rules used for displaying data in NCQA’s public
reporting program (i.e., Health Plan Ratings).
o Carriers verify their Health Plan Ratings. Carriers verify the information that will
determine how their organization is displayed in the ratings (e.g., states and
accreditation statuses).
• June 2019:
o IDSS Plan-lock must be applied for all audited submissions to ensure Auditors have
sufficient time to review plan results.
o Carriers submit FINAL HEDIS (non-survey data) results via the IDSS.
o All HEDIS Attestations must be submitted to NCQA via electronic signature.
o NCQA’s implements the “Health Plan Ratings Data Freeze.” The ratings are based on
HEDIS and CAHPS data and accreditation standards scores as of this date.
• July 2019:
o NCQA releases the 2019 Quality Compass® commercial edition.
• August 2019:
o NCQA releases “Projected Health Plan Ratings” via the Health Plan Ratings website.
Carriers are required to confirm their rating and accreditation information (if
applicable).
• For specific dates and additional information, please visit the NCQA HEDIS timeline:
www.ncqa.org/hedis-quality-measurement/hedis-data-submission/hedis-data-submission-
timeline
Subsection B: OPM General Requirements for CAHPS Collection and Reporting
• All FEHB contracts must administer the CAHPS Health Plan Survey 5.0H Adult Commercial
Version following the NCQA requirements set forth in HEDIS Volume 3: Specifications for Survey
Measures.
3
• The survey must be administered by an NCQA-certified CAHPS vendor.
• The sample frame must be approved by an NCQA-certified HEDIS compliance auditor.
• Members who have Medicare as their primary coverage must not be included in the sample.
• FEHB Carriers with new contracts entering the FEHB program must report HEDIS and CAHPS in
the second full year of participation in the FEHB. Reports submitted before this time are not
eligible for inclusion in the Plan Performance Assessment. Additional details on requirements for
FEHB Carriers entering into new FEHB contracts, including how a new contract is defined for this
purpose, appear in Section 4.
• Existing FEHB Carriers with new enrollment codes or health plan options are expected to report
HEDIS and CAHPS data that includes the new code or option. For example, if Acme Insurance
Company had a Standard Health Plan enrollment code option in the 2018 FEHB program and
added a Basic Health Plan enrollment code option in the 2019 FEHB Program under the same
contract, they would be expected to report data on both their Basic and Standard health plan
options for the 2019 Plan Performance Cycle.
• Each FEHB Carrier reporting CAHPS survey data to OPM must also report the CAHPS
Effectiveness of Care measure related to Flu Vaccinations for Adults Ages 18–64.
• CAHPS survey results must be submitted to NCQA. Files generated by NCQA, after the
submission has been processed, will be provided to OPM.
• CAHPS reporting guidelines are listed below:
o FEHB Carriers submitting samples to NCQA from commercial products that include FEHB
contract holders may submit those samples to OPM.
o FEHB Plans not submitting commercial samples to NCQA must:
Submit a separate CAHPS sample for any FEHB health plan option in a state in
which that health plan option has more than 5,000 FEHB contract holders
5
.
Enrollees in FEHB health plan options that have fewer than 5,000 FEHB contract
holders
5
per state may be included in a health plan option specific CAHPS
sample labelled as “Other.” An example is outlined below:
• An FEHB Carrier has 12,000 FEHB contract holders in New York with
3,000 in the High option and 9,000 in the Standard option. The FEHB
Carrier must conduct one FEHB specific CAHPS sample on the Standard
option in New York. The FEHB Carrier is required to then combine the
3,000 FEHB enrollees in the High option with all other states with fewer
5
Members who have Medicare as their primary coverage must not be included in the sample. Given the typical mix
of annuitant and non-annuitant enrollees in FEHB, this population threshold (5,000 FEHB contract holders) should
ensure a sufficient number of survey respondents.
4
than 5,000 FEHB contact holders to create a CAHPS sample labelled,
“High option – other.”
o FEHB Carriers reporting differently for accreditation purposes, seeking to submit a larger
number of samples, or with other unique circumstances should submit a written
explanation and request to their Health Insurance Specialist and copy
FEHBPerformance@opm.gov
.
o Questions: FEHBPerformance@opm.gov.
CAHPS Surveys and OMB Clearance
All the following statements must be included on mailed surveys:
In the upper right corner of each questionnaire: “Form approved: OMB No. 3206-0236.”
The following language must also be included within the questionnaire: “This information collection has
been approved by the U.S. Office of Management and Budget (Control Number 3206-0236) and is in
compliance with the Paperwork Reduction Act of 1995. We estimate that it will take an average of 20
minutes to complete, including the time to read instructions and to gather necessary information. You
may send comments about our estimate or any suggestions for minimizing respondent burden, reducing
completion time or any other aspect of this information collection to the U.S. Office of Personnel
Management (OPM), Reports and Forms Officer (OMB Number 3206-0236), Washington, DC 20415-
7900. Your participation in this information collection is voluntary. The OMB Number, 3206-0236, is
currently valid. OPM may not collect this information, and you are not required to respond, unless this
number is displayed.”
The questionnaire must also include the standard NCQA instructions which state: “Personally
identifiable information will not be made public and will only be released in accordance with Federal
laws and regulations. You may choose to answer this survey or not. If you choose not to, this will not
affect the benefits you get. You may notice a number on the cover of this survey. This number is ONLY
used to let us know if you returned your survey, so we don't have to send you reminders. If you want to
know more about this study, please call (survey vendor number here).”
CAHPS Processing Fee
Each FEHB Carrier that reports survey data to OPM is responsible for a pro-rata share of the cost of
compiling, processing and reporting the survey results. As in previous years, a processing fee will apply
to each unique NCQA Submission ID for which data is submitted on an FEHB Carrier’s behalf to
OPM.
6
OPM’s CAHPS data collection contractor, Office Remedies, Inc. (ORI), will invoice you directly.
6
Plans will be charged for each NCQA data file submitted. Any plan that withdraws from the FEHB Program after submitting
data in accordance with these requirements is liable for the processing fee.
5
CAHPS Timeline
• February 1, 2019: All FEHB Carriers must complete and submit the CAHPS Survey Participation
Form (see Section 5; Subsection A) to FEHBPerformance@opm.gov. If you conduct multiple
surveys, please list the name and FEHB Subcode for each survey.
• May 1, 2019: All FEHB Carriers must submit a CAHPS crosswalk file (see Section 5; Subsection A)
that maps your NCQA Submission ID (s) to your FEHB Plan name and Carrier Subcode no later
than two weeks after NCQA issues submission IDs. This crosswalk must also accompany each
submission of CAHPS survey results to OPM though its contractor ORI. The crosswalk includes
each:
o NCQA Member-level File Name
o NCQA Submission ID
o NCQA Plan Name
o FEHB Plan Subcode
o FEHB Plan Name
• Please direct questions regarding the crosswalk to ORI at OPM2019@oriresults.com
.
June 15, 2019:
• NCQA-generated Member level data file and NCQA-generated summary reports are due. ORI
accepts your files after they have been processed by NCQA and you have provided NCQA with a
signed Attestation of Accuracy. Your survey vendor may submit data via e-mail or other
electronic or digital format to OPM’s contractor, ORI, at the following address:
OPM2019@oriresults.com
.
• To comply with HIPAA privacy rules, survey vendors should use appropriate encryption
technology.
Subsection C: Reporting HEDIS and CAHPS Results to NCQA
All FEHB Carriers must follow NCQA’s procedures for HEDIS reporting, including the HEDIS Compliance
Audit™
7
for which a summary can be found at www.ncqa.org/hedis-quality-measurement/data-
reporting-services/hedis-compliance-audit-program/hedis-compliance-audit-program. To fully
understand and comply with HEDIS technical specifications and to obtain the appropriate measure
specifications you will need HEDIS 2019 Volume 2: Technical Specifications for Health Plans and Volume
5: The HEDIS Compliance Audit: Standards, Policies and Procedures and Technical Specifications for
Health Plans, which can be purchased at NCQA’s website:
store.ncqa.org/index.php/performance-
measurement/hedis-publications-outline.html.
7
NCQA HEDIS Compliance Audit
TM
is a trademark of the National Committee for Quality Assurance (NCQA).
6
All surveys must be conducted according to NCQA protocols described in HEDIS Volume 3: Specifications
for Survey Measures, and administered by a vendor that is NCQA-certified for this purpose.
8
This
document can be purchased at NCQA’s website: store.ncqa.org/index.php/performance-
measurement.html.
All FEHB Carriers must generate the sample frame according to NCQA specifications
9
. NCQA requires a
minimum sample size of 1,100 members. Over-sampling is allowed, as outlined in HEDIS Volume 3:
Specifications for Survey Measures. You may use an enhanced protocol or add supplemental questions
with prior NCQA approval.
To report HEDIS and CAHPS results to NCQA, FEHB Carriers must complete NCQA's annual Healthcare
Organization Questionnaire (HOQ) online through NCQA’s website at my.ncqa.org
using a password.
When filling out the HOQ, please list the appropriate NCQA Organization ID Code, Submission ID, and
FEHB Carrier Codes and Carrier Subcodes associated with your Submission ID(s). If your Submission ID
has multiple FEHB codes associated with it, please include all the FEHB codes in the HOQ.
The FEHB Carrier’s designated HEDIS contact will receive an email notification from
NCQADataCollections@ncqa.org with information on how to access the 2019 HOQ on-line. If the FEHB
Carrier does not currently have a designated Primary HEDIS contact, you must contact NCQA’s Data
Collection Operations team at my.ncqa.org.
My.ncqa.org is a web-based Q&A system where FEHB Carriers can track questions and answers. If you
are already registered in an NCQA system (other than ISS, the Interactive Survey System), you can use
existing NCQA credentials to sign into my.ncqa.org. New accounts can also be created at my.ncqa.org.
Refer to the NCQA website, www.ncqa.org, or submit a request to my.ncqa.org for general questions
regarding HEDIS and CAHPS or HEDIS technical specifications. Questions about the data submission
process should be addressed to the FEHB Carrier’s assigned NCQA HEDIS Data Submission Account
Manager.
Access www.ncqa.org/hedis-quality-measurement/hedis-data-submission to find the data submission
timeline which includes the following:
• The date HOQ opens to plans via the NCQA website
• The deadline for plans to complete NCQA's on-line HOQ
• The date NCQA provides health plans with access to use the Interactive Data Submission System
(IDSS)
8
A list of certified survey vendors is available at http://www.ncqa.org/hedis-quality-measurement/data-reporting-
services/cahps-5-0-survey
9
Plans must use the standardized layout and format for the sample frame data file described in Volume 3 and must include all
required data elements in Table S-1.
7
• The date plan-lock must be applied to the submission to ensure HEDIS Compliance Auditors have
sufficient time to review, approve and audit-lock the submission
• The deadline for plans to submit HEDIS results to NCQA and e-sign attestations
Subsection D: Summary of Changes to Clinical Quality, Customer Service and Resource
Use (QCR) Measure Set and Farm Team in 2019
The following changes apply to data collected and reported in 2019. A complete list of the QCR Measure
Set and Farm Team is contained in Section 5; Subsection B of this manual. FEHB Carriers were notified of
these changes in Carrier Letter 2017-11, titled “2019 Clinical Quality, Customer Service, and Resource
Use Measures.”
Measures Being Added to QCR Score in 2019:
• Emergency Department Utilization (Priority Level 2; Measure Weight 1.25)
• Statin Therapy for Patients with Cardiovascular Disease – Adherence Rate (Priority Level 2;
Measure Weight 1.25)
Measure Retired in 2019:
• Medication Management for People with Asthma will be retired in 2019
Farm Team Update for 2019:
• No new measures will be added to the 2019 Farm Team
For FEHB Carriers requiring clarification regarding any measure, please send inquiries to
FEHBPerformance@opm.gov.
Section 2: QCR Scoring and Calculation Procedures
Subsection A: Product Reporting Types
In order to compare FEHB contracts to the most appropriate benchmark, OPM aligns the health plan
options data reported to NCQA with NCQA Quality Compass Benchmark Level Breakouts illustrated in
Table 1, below. OPM will normally compare measure results to the Level 3 benchmark that corresponds
to the reporting product selected by the contract when submitting data to NCQA. In the event that
NCQA does not issue a complete set of Level 3 benchmarks, OPM will use the Level 2 benchmarks. For
example, if NCQA does not have a Point of Service (POS) benchmark for each QCR measure, a contract
with a POS Reporting Product would be scored against the All LOBs (Excluding PPO and EPO) benchmark.
In the event that NCQA does not issue a complete set of Level 2 benchmarks, OPM will use the Level 1
benchmarks. This situation could occur if NCQA determines that not enough health plans submitted data
for particular reporting products to generate valid benchmarks at Level 3 or Level 2. Additional
8
information can be found in Carrier Letter 2018-02 and at https://www.opm.gov/healthcare-
insurance/healthcare/carriers/2018/2018-02.pdf.
9
TABLE 1:
Reporting Product
Quality
Compass
Benchmark
Level 3
Quality Compass
Benchmark Level 2
Quality Compass
Benchmark Level 1
HMO
HMO
All LOBs (Excluding PPO
and EPO)
All LOBs
HMO/PPO Combined
HMO/EPO Combined
HMO/PPO/EPO Combined
HMO/POS Combined
HMO/POS
HMO/POS/PPO Combined
HMO/POS/EPO Combined
HMO/PPO/POS/EPO Combined
POS
POS
POS/PPO Combined
PPO/POS/EPO Combined
POS/EPO Combined
PPO
PPO and EPO PPO and EPO
PPO/EPO Combined
EPO
Subsection B: QCR Scoring
The FEHB Plan Performance Assessment – Consolidated Methodology Carrier Letter (2017-15) provides
a comprehensive explanation of the QCR Scoring Process and Methodology. For more information on
methodology, upcoming measures, or other guidance, please visit the Plan Performance Assessment
website at www.opm.gov/healthcare-insurance/healthcare/carriers/#url=Performance-Assessment
.
Subsection C: HEDIS Auditor Codes and QCR Scoring
HEDIS auditors make determinations about the usability of the data and code it accordingly. OPM
incorporates three of these codes into the QCR calculations. The codes are NA, NR, and BR.
• If an FEHB Carrier receives an NA (Small Denominator) designation, that measure result will not
have the score or weights included in the QCR calculation.
• For NR (Not Reported) or BR (Biased Rate) measure codes, OPM will score that measure as a
zero and the measure weight will be included in the denominator of the QCR score.
10
Subsection D: Contract Roll-up
In some instances, an FEHB contract may be associated with multiple QCR measure reports. When this is
the case, OPM aggregates QCR measures to obtain a contract level enrollment-adjusted result. For
example, a contract may include more than one Carrier Code and report QCR measures on each Carrier
Code to OPM. Where there are multiple reports under one contract, OPM aggregates to the contract
level in proportion to the overall FEHB enrollment associated with each report, as detailed in Carrier
Letter 2017-15.
Subsection E: QCR Data Preview Period
FEHB Carriers will have an opportunity to preview their QCR calculations and score prior to the Final
QCR Score during the QCR Data Preview Period. FEHB Carriers will receive their QCR Data Preview report
annually in the fall. Carriers will then have ten calendar days to review both their QCR Score and
Improvement Increment. For 2019, FEHB Carriers must actively respond during the QCR Data Preview
Period. Carriers can concur with their score or provide feedback to point out factual errors, omissions or
miscalculations during this timeframe. The QCR Data Preview Period is the dedicated opportunity for
Carriers to review and concur, or ask specific questions regarding the calculation of the Initial QCR Score
and Improvement Increment. All queries must be accompanied by detailed questions or a description of
variances detected.
Instructions on concurrence or feedback procedures for 2019 will be included with the QCR Preview
Report. Concurring responses, as well as questions or feedback, must be provided within the ten day
review period. Carriers must include documentation or materials pertinent to their response that point
out factual errors, omissions or miscalculations. All FEHB Carriers responses are limited to the specifics
of their data preview. OPM has thirty days in which to consider any responses related to questions or
feedback and render a final determination.
Subsection F: Data Correction Procedure
OPM’s Plan Performance Assessment requires that all FEHB Carriers report accurate data (e.g., HEDIS,
CAHPS) according to the procedures outlined in OPM communications. Data accuracy and sample
compliance impact results.
In the event that OPM staff/contractors detect anomalous data or are otherwise notified of data quality
issues, the procedures and timeline below apply. Only written communication fulfills the requirements
of these procedures. The data correction options available in any specific situation will be determined by
the type of error. OPM will leave all relevant information blank on OPM health insurance webpages
intended for current and prospective enrollees until remediation is complete.
Upon discovery that potentially anomalous data has been received, OPM will prepare a Performance
Measure Carrier Deficiency Notice (DN). The notice will describe the nature of the anomaly and provide
any available supporting documentation. Within 14 calendar days of receiving the DN from OPM, the
11
FEHB Carrier must elect and fulfill one of the following options (in writing, via email, or OPM designated
portal as applicable):
Option 1: Provide verification that the original data is both correct and compliant
• Requires supporting documentation from the contract’s HEDIS/CAHPS certified vendor/data
auditor, including verifiable information from NCQA when applicable
Option 2: Accept NR or BR for the measures in question
• If an FEHB Carrier does not respond within the required timeframe, it will be considered
acceptance of an NR or BR
Option 3: Propose remediation of the anomaly for OPM approval
• Requires supporting documentation from the Carrier’s HEDIS/CAHPS certified vendor/data
auditor, including verifiable information from NCQA, when applicable
• OPM will approve/disapprove the remediation within 14 calendar days
o If OPM fails to respond within 14 calendar days the proposed remediation is approved
• Remediation must be completed within 21 calendar days of OPM’s written approval
• If OPM disapproves, the Carrier has 7 calendar days to revise the remediation or accept an NR or
BR
• OPM approval/disapproval of the revised remediation is a final action
• OPM will review the remediation data submission, and, if approved, data will be updated. If
OPM rejects the remediation data submission, then the Carrier will receive an NR or BR for the
measure(s) in question
Under Option 3, when the Carrier proposes and OPM approves remediation, the procedure is:
1. The FEHB Carrier must provide a letter to the Contracting Officer and Health Insurance Specialist
from their third-party, certified vendor/data auditor:
• Certifying that:
o The resubmitted sample has been corrected based on the approved
remediation
o The sample is now in compliance with OPM requirements
o The sample is in compliance with all NCQA specifications
• Include the survey instrument, if CAHPS, and any other appropriate information the
vendor/data auditor or OPM deems necessary
2. OPM will verify that the new data corrects the anomaly and can be used to calculate an updated
score. If OPM determines it is not corrected or an updated score cannot be calculated:
• Carrier receives an NR or BR for the measure(s) for that year
• Additional data validation will be conducted at OPM’s discretion
o Based on this additional data validation, OPM may assign an NA rather than an
NR or BR
12
Failure to follow these procedures will result in OPM assigning an NR or BR for the measure(s) in
question. An NR or BR designation will result in a score of zero for that measure and the measure weight
will be included in the denominator of the QCR score. This will result in a lower QCR score and
potentially has implications for the calculation of the Improvement Increment. Improvement Increment
eligibility is described in greater detail in Carrier Letter 2017-15
.
Subsection G: Corrective Action Plans
In 2019, FEHB Carriers that score below the 25
th
percentile on any QCR measure are required to submit
a Corrective Action Plan (CAP) designed to raise their result. All CAPs must be submitted using the
Quality Improvement Corrective Action Template to your Health Insurance Specialist within 30 days of
receiving the 2019 Overall Performance report. A copy of the Quality Improvement Corrective Action
Template is located in Section 5, Subsection C.
FEHB Carriers may be asked for greater clarity on remediation methods. Specifically, Carriers submitting
the third or subsequent CAP on the same measure will be subject to additional OPM reviews and
discussions to ensure that the listed actions can be expected to produce improvement.
Section 3: Contract Oversight Procedures
Contract Oversight is the area of Plan Performance Assessment that allows OPM to assess other
dimensions of performance critical to meeting FEHB program objectives and contractual obligations. As
indicated in Carrier Letter 2017-15 (https://www.opm.gov/healthcare-
insurance/healthcare/carriers/2017/2017-15.pdf), the Contract Oversight performance from July 1,
2018 through June 30, 2019 will be assessed against four domains: Contract Performance;
Responsiveness to OPM; Contract Compliance, and Technology Management and Data Security.
OPM will notify FEHB Carriers regarding the timeframe for submitting input for Contract Oversight
scoring. Input should include any/all pertinent information for the Contracting Officer to consider in
assessing performance in the domains and components listed in Carrier Letter 2017-15. Complete
responses must include all items in Table 9 of Carrier Letter 2017-15, or an explanation of why any
omitted item is not applicable.
Input may also include other matters as discussed with the Contracting Officer or designated Health
Insurance Specialist during the performance period. In addition to providing evidence of contract
fulfillment, Carrier may submit descriptions of problems that occurred and how these were addressed.
Examples include significant events, accreditation deficiencies, audit findings, and/or member
disruption. Performance issues may be scored in one or multiple Oversight domains, or within multiple
components of a domain, according to the Contracting Officer’s assessment of severity and impact.
13
For 2019, Contract Oversight scoring will account for 35% of the Overall Performance Score (OPS). The
OPS forms the basis of each Carrier’s Performance Adjustment or the Service Charge.
Section 4: New FEHB Carriers (Contracts)
An FEHB contract is considered to be in its first year if any of the following conditions are met:
1. The Carrier did not offer FEHB plans for the 2018 contract year.
2. The Carrier adds a separate and distinct service area under a separate contract
3. The Carrier adds a new plan option under a separate contract
4. The Carrier is offering plans classified under one paragraph of Section 8903 of Title 5 in 2018 but
has entered into a new contract to offer plans under a different paragraph of Section 8903 in
2019.
A new health plan option offered under a Carrier’s existing contract or administrative renumbering or
realignment of an ongoing contractual relationship is not an FEHB contract in its first year. Carriers with
unique circumstances not defined in this section are strongly encouraged to obtain written confirmation
regarding “first year” status from the Contracting Officer.
At the end of each contract year, OPM determines the Performance Adjustment or Service Charge based
on the Carrier’s Overall Performance Score. Performance Adjustment or Service Charge Payments are
made in the following year. Any plan payments during the course of the initial year in the FEHB, if
applicable, will be described in appendix B of the new Carrier’s contract. For an Experience-Rated
Carrier, sufficient funds must exist from the premiums after drawdown for claims and administrative
expenses to pay a Service Charge, which may be drawn down in 12 monthly installments from the Letter
of Credit Account (LOC).
For all Carriers, the calculation of the Service Charge or Performance Adjustment will follow the
methodology described in Carrier Letter 2017-15 for Community-Rated and Experience-Rated Carriers.
In addition, Carrier Letter 2017-15 addresses the unlikely event that a very low Overall Performance
Score results in a very low Service Charge, or a very High Performance Adjustment. When this is the
case, the Contracting Officer will base the threshold amount on the Contract Group Size Element
minimum value range shown in Carrier Letter 2017-15.
FEHB Carriers with new FEHB contracts do not receive a QCR score their first year. For Community-
Rated Carriers, the Community-Rated Adjustment does not apply to the first year of a new contract.
Carriers with new contracts are not eligible for the Improvement Increment until their third year in the
FEHB. Year by year details of Overall Performance Score determination for Carriers with new FEHB
contracts are described in the following paragraphs. More information on the Community-Rated
Adjustment may be found in Carrier Letter 2017-02 at
https://www.opm.gov/healthcare-
insurance/healthcare/carriers/2017/2017-02.pdf.
14
Subsection A: First Year in the FEHB
At the end of the first year in the program, the Overall Performance Score will be based on the Contract
Oversight score as determined by the Contracting Officer. The period of performance runs from the
acceptance of the contract by OPM through June 30. Community-Rated Carriers may receive up to their
full net-to-carrier premium and Experience-Rated Carriers may receive up to the full service charge
amount.
Subsection B: Second Year in the FEHB
At the end of the second year in the program, the Overall Performance Score will be determined based
on the QCR and Contract Oversight scores. The QCR score will not include the Improvement Increment.
Community-Rated Carriers may also receive the Community-Rated Adjustment.
Subsection C: Third Year in the FEHB
At the end of the third year in the program, the Overall Performance Score will be based on the QCR,
Contract Oversight, plus any earned Improvement Increment. Community-Rated Carriers may also
receive the Community-Rated Adjustment.
Table 2 below summarizes Overall Performance Scoring for a contract’s first 3 years in the FEHB.
TABLE 2:
Contract Year
Report HEDIS
and CAHPS
Eligible For Improvement
Increment
Overall Performance Score Basis
End of YR 1
Not Required
No
Contract Oversight
End of YR 2
Yes
No
Contract Oversight + QCR
End of YR 3
Yes
Yes
Contract Oversight + QCR +
Improvement Increment
15
•
•
Section 5: References & Resources
Subsection A: CAHPS Survey Participation Form and Sample Crosswalk
2019 CAHPS Survey Participation Form
(Please submit one form per Plan and indicate each FEHB Subcode that is sharing data)
Plan Name: Click here to enter text.
FEHB Subcode(s): Click here to enter text.
Indicate which subcodes share data: Click here to enter text.
Please check the appropriate box(es) below:
Health plan will conduct the CAHPS® 5.0H Adult Commercial Survey
Health plan is new to FEHB Program for 2019 and is not required to conduct CAHPS® Surveys in 2019
Name of NCQA Certified Survey Vendor that will be conducting the survey (s):
Click here to enter text.
Survey Vendor Contact Information:
Name: Click here to enter text.
Address: Click here to enter text.
Email: Click here to enter text.
Telephone Number: Click here to enter text.
Health Plan Contact for CAHPS:
Name: Click here to enter text.
Address: Click here to enter text.
Email: Click here to enter text.
Telephone Number: Click here to enter text.
Plan Contact & Address for Invoice (if different from above):
Name: Click here to enter text.
Address: Click here to enter text.
Email: Click here to enter text.
Telephone Number: Click here to enter text.
Please e-mail the completed form by February 1, 2019 to: FEHBPerformance@opm.gov
CAHPS Survey Participation Form (Page 1 of 3)
16
CAHPS Sample Crosswalk
Every data submission that your CAHPS
®
5.0H Survey vendors send to OPM must be accompanied by a
“crosswalk” that will allow OPM to map your plan’s data to the appropriate FEHB Subcode. This is the
only way that OPM will be able to identify submissions and allocate data correctly. The crosswalk must
include the following information:
• Member-level file name
• NCQA Submission ID
• NCQA Plan Name
• FEHB Subcode
• FEHB Plan Name
Information Submission Explanation (Data Dictionary)
Category
Explanation
Member-level file name
• Name of the NCQA IDSS Submission
NCQA Submission ID
• Use previous NCQA Submission ID
NCQA Plan Name
• The Plan Name associated with the NCQA submission
FEHB Subcode
The FEHB Subcode is broken out as follows
• Two digit Carrier Code (dash)
• Three digit Plan Filing Type (dash)
• Two digit area code (dash)
• Three digit Plan Level Category
FEHB Plan Name
• The FEHB Plan name that corresponds with the FEHB contract
Please note that the Member-level filenames must follow the NCQA naming conventions. Any variation
will not be accepted.
CAHPS Survey Participation Form (Page 2 of 3)
17
The table below shows an example of a crosswalk for a vendor submission.
Sample
Row
Member-Level File
NCQA
Submission
ID
NCQA Plan
Name
FEHB
Subcode
FEHB Plan
Name
1
AdultCom1234.txt
1234
XYZ Health
Plan Inc.
AA-HMO-UT-000
XYZ Health
Plan
2
AdultCom2345.txt
2345
QRS
Healthcare
BB-HMO-IN-000
QRS
Healthcare
3
AdultCom2345.txt
2345
QRS
Healthcare
BB-HMO-IL-000
QRS
Healthcare
• Sample row 1 shows the most straightforward example where it is a one-to-one mapping
between the NCQA Sub ID and FEHB Subcode.
• Sample rows 2 and 3 show how the crosswalk should appear when one set of NCQA data is
mapped to two FEHB Subcodes. In this case, only one member-level file should be submitted to
OPM.
CAHPS Survey Participation Form (Page 3 of 3)
END
18
Subsection B: 2019 Clinical Quality, Customer Service and Resource Use Measure Set and Farm Team Measure Set
Performance Area
Measure Title
Measure
Source
Measure
Priority
Measure
Weight
Clinical Quality
Controlling High Blood Pressure
HEDIS
1
2.50
Prenatal Care (Timeliness)
HEDIS
1
2.50
Breast Cancer Screening
HEDIS
2
1.25
Well-Child Visits First 15-Months of Life (6 visits)
HEDIS
2
1.25
Flu Vaccinations for Adults (18-64)
CAHPS
2
1.25
Cervical Cancer Screening
HEDIS
2
1.25
Comprehensive Diabetes Care HbA1C <8%
HEDIS
2
1.25
Asthma Medication Ratio
HEDIS
2
1.25
Avoidance of Antibiotics in Adults with Acute Bronchitis
HEDIS
2
1.25
Follow-up after Hospitalization for Mental Illness (7-day and 30-day)
HEDIS
2
1.25
Statin Therapy for Patients with Cardiovascular Disease (Adherence)
HEDIS
2
1.25
Customer Service
Plan Information on Costs
CAHPS
3
1.00
Getting Care Quickly
CAHPS
3
1.00
Getting Needed Care
CAHPS
3
1.00
Claims Processing
CAHPS
3
1.00
Overall Health Plan Rating
CAHPS
3
1.00
Coordination of Care
CAHPS
3
1.00
Overall Personal Doctor Rating
CAHPS
3
1.00
Customer Service
CAHPS
3
1.00
Resource Use
Plan All-Cause Readmissions
HEDIS
1
2.50
Emergency Department Utilization
HEDIS
2
1.25
Use of Imaging Studies for Low Back Pain
HEDIS
2
1.25
Farm Team (Measures Reported but not Scored)
• Acute Hospital Utilization (Collection as of 2018)
• Follow-up after Discharge from the Emergency Department for Mental Illness (30 day rate) (Collection as of 2017)
• Follow-up after Discharge from the Emergency Department for Alcohol or Other Drug Dependence (30 day rate) (Collection as of 2017)
• Use of Opioids From Multiple Providers (Collection as of 2018)
• Colorectal Cancer Screening (Collection as of 2018)
19
Subsection C: Quality Improvement Corrective Action Plan Template for 2019
Carriers must submit a Corrective Action Plan (CAP) for each QCR measure below the 25
th
percentile.
Measures set to retire or transition to the Farm Team in 2020 do not require a CAP. The table below
reflects the list of measures for CAPs in 2019. For more information on 2020 QCR measures, please see
Carrier Letter 2018-07.
All CAPs must be submitted using this Quality Improvement Corrective Action Template to your Health
Insurance Specialist within 30 days of receiving the 2019 Overall Performance report. Within the CAP,
please specify the Quality Improvement implementation plan to improve the care associated with the
identified measure.
Please note that FEHB Carriers submitting a third or subsequent CAP on the same measure will be
subject to additional OPM reviews and discussions to ensure that the listed actions can be expected to
produce improvement.
In the table below, please indicate the measure(s) that require a CAP.
Measures
CAP Submission
(check all that apply)
Breast Cancer Screening
☐
Prenatal Care (Timeliness)
☐
Well-Child Visits First 15-Months of Life (6 visits)
☐
Flu Vaccinations for Adults (18-64)
☐
Controlling High Blood Pressure
☐
Cervical Cancer Screening
☐
Comprehensive Diabetes Care - HbA1c <8%
☐
Asthma Medication Ratio
☐
Avoidance of Antibiotics in Adults with Acute Bronchitis
☐
Statin Therapy for Patients with Cardiovascular Disease (Adherence)
☐
Plan Information Costs
☐
Getting Care Quickly
☐
Getting Needed Care
☐
Claims Processing
☐
Overall Health Plan Rating
☐
Coordination of Care
☐
Overall Personal Doctor Rating
☐
Emergency Department Utilization
☐
Use of Imaging Studies for Low Back Pain
☐
2019 Corrective Action Plan Submission (Page 1 of 3)
20
For each CAP, provide the following information in 750 words or less.
1. Measure: _________________________________________
2. Plan Analysis
• Analysis: Strengths and weaknesses of current quality practices related to this measure.
• Barriers: Identify potential barriers to improvement in results. If a CAP for this measure has
been submitted previously, include an evaluation of why you have not achieved expected
results to date.
• Outreach: Estimate the number of members that need to be engaged to increase the score
to at least the 25
th
percentile.
3. Action Steps
• Action Outline: List in-depth steps in your Corrective Action Plan to raise the score to at least
the minimum threshold. If your score has fallen below the threshold for 2 or more years,
discuss new or different actions this year to improve performance to the minimum
threshold.
• Classification: OPM strongly encourages Carriers with performance below the 10
th
percentile
benchmark to develop novel
10
actions, rather than reinforcement
11
actions, to increase
quality performance.
• Action Timeline: Identify the start date, and if applicable, end date of each action step.
• Progress Projection: Identify the projected improvement results including a timeline of
when improvement can be expected.
Corrective Action Plan Template Submission
Each Carrier submitting one or more CAPs needs to complete the below information one time.
CAP Point of Contact: ____________________________
2019 Corrective Action Plan Submission (Page 2 of 3)
10
Introduction of a new practice.
11
Modification of an existing practice.
21
•
•
•
Certification
The undersigned have read the attached Corrective Action Plan(s) and agree to the terms.
FEHB Carrier Quality Improvement POC:
Printed Name Signature Date
The undersigned have read the attached Corrective Action Plan(s) and agree to the terms.
The undersigned have read the attached Corrective Action Plan(s) and do not agree to the
terms. Further clarification may be required; the Health Insurance Specialist will schedule a
meeting to discuss the resolution of issues.
OPM Health Insurance Specialist:
Printed Name
OPM Health Insurance Chief:
Signature Date
Printed Name Signature Date
2019 Corrective Action Plan Submission (Page 3 of 3)
END
22
Subsection D: Timeline
Below is a compilation of the HEDIS and CAHPS Timelines previously provided in Section 1 of this
document. In addition, the timeline includes Plan Performance Assessment related reports that OPM
provides to the Carriers.
Label/Color codes:
HEDIS (Blue): To report HEDIS metric results, FEHB Carriers must complete NCQA's annual Healthcare
Organization Questionnaire (HOQ) online. Major timeline dates are listed below, with a blue HEDIS at
the beginning of the bullet to indicate that this is a HEDIS action item. For specific dates and additional
information, please visit the NCQA HEDIS timeline:
www.ncqa.org/hedis-quality-measurement/hedis-
data-submission/hedis-data-submission-timeline
CAHPS (Orange): Action items related to CAHPS are highlighted with an orange CAHPS at the beginning
of each bullet. For these dates, Carriers are expected to submit information either to OPM or ORI/CSS.
OPM to Carriers (Green): As part of the Plan Performance Assessment Process, OPM provides reports to
Carriers that include the QCR Preview Report, Procedure Manual, Performance Assessment Scores, and
a Detailed QCR Performance Summary Report.
• December 2018:
o HEDIS: NCQA sends the HEDIS Data Submission Kick-off to Primary and Secondary
contacts.
o HEDIS: NCQA posts the XML Templates, Validations and Data Dictionaries for Interactive
Data Submission System© (IDSS) to the data submission webpage.
• January 2019:
o HEDIS: NCQA releases the 2019 Healthcare Organization Questionnaire (HOQ) for health
plans to request and update submissions.
• February 2019:
o HEDIS and CAHPS: Health plans finalize HOQ requests to obtain access to the IDSS and
submission IDs for HEDIS and CAHPS.
o CAHPS: All FEHB Carriers must complete and submit the CAHPS Survey Participation
Form (see Section 5; Subsection A) to FEHBPerformance@opm.gov. If you conduct
multiple surveys, please list the name and FEHB Subcode for each survey.
23
• April 2019:
o HEDIS: NCQA releases the 2019 IDSS for data loading and validation.
o HEDIS: NCQA distributes Submission IDs for survey measures to NCQA certified survey
vendors.
• May 2019:
o HEDIS: NCQA sends the Conditions for Public Reporting letter to Primary and Secondary
HEDIS contacts. This letter includes the rules used for displaying data in NCQA’s public
reporting program (i.e. Health Plan Ratings).
o HEDIS: Carriers verify their ratings in NCQA’s “Health Plan Ratings.” Carriers verify the
information that will determine how their organization is displayed in the ratings (e.g.,
states and accreditation statuses).
o CAHPS: NCQA certified survey vendors begin submission of CAHPS 5.0H member-level
data files to NCQA on behalf of FEHB Carriers.
o CAHPS: All FEHB Carriers must submit a CAHPS crosswalk file (see Section 5; Subsection
A) that maps your submission ID(s) to your FEHB Plan name and Carrier Subcode no
later than two weeks after NCQA issues submission IDs. This crosswalk must accompany
each submission of CAHPS survey results to OPM though their contractor ORI. Please
direct questions regarding the crosswalk to ORI at OPM2019@oriresults.com
. The
crosswalk includes each:
NCQA Member-level File Name
NCQA Submission ID
NCQA Plan Name
FEHB Subcode
FEHB Plan Name
• June 2019:
o HEDIS: IDSS Plan-lock must be applied for audited submission to ensure Auditors have
sufficient time to review plan results.
o HEDIS: Health plans submit FINAL HEDIS (non-survey data) results via the IDSS.
o HEDIS: All HEDIS Attestations must be submitted to NCQA via electronic signature.
o HEDIS: Health Plan Ratings Data Freeze. The ratings are based on HEDIS and CAHPS data
and accreditation standards scores as of this date.
o CAHPS: NCQA-generated Member level data file and NCQA-generated summary reports
are due. ORI accepts your files after they have been processed by NCQA and you have
provided NCQA with a signed Attestation of Accuracy. Your survey vendor may submit
24
data via e-mail or other electronic or digital format to OPM’s contractor, ORI, at the
following address: OPM2019@oriresults.com. To comply with HIPAA privacy rules,
survey vendors should use appropriate encryption technology.
• July 2019:
o HEDIS: NCQA Releases the 2019 Quality Compass® commercial edition.
• August 2019:
o HEDIS: NCQA releases “Projected Health Plan Ratings” via the Health Plan Ratings
website. Carriers are required to confirm their rating and accreditation information (if
applicable).
• Fall 2019:
o OPM to Carriers: FEHB Carriers review the QCR Preview Report.
o OPM to Carriers: OPM releases updated FEHB Plan Performance Assessment Procedure
Manual.
o OPM to Carriers: OPM communicates the Overall Performance Assessment scores to
FEHB Carriers.
• Winter 2019:
o OPM to Carriers: OPM provides Carriers with the Detailed QCR Performance Summary
Report, which includes graphs showing where FEHB Carrier’s scores are located in
relation to other FEHB Carriers for each QCR measure and the Final QCR score.
25
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