Reporting and Data Collection

States and the Federal Government collect a variety of data on Medicaid services delivery to children and adolescents. These data are used for program evaluation, managing relationships with Medicaid managed care organizations (MCOs) that serve children, and measuring and improving the quality of services available to children. This section describes data collection initiatives in states, reporting by MCOs, and quality measurement using the CMS’s core set of children’s health care quality measures for CHIPRA Medicaid/CHIP (Child Core Set).


Alabama No information at this time.
As part of Tri-State Child Health Improvement Consortium (T-CHIC), Alaska is requiring successful medical home pilots to address the following areas:
  • Developing, adopting and implementing quality measurement tools;
  • Developing, adopting and/or improving Health Information Technology, Electronic Health Records (EHR), and participation in Health Information Exchanges (HIE); and
  • Developing, adopting and/or improving medical home approaches
The participating medical homes also must comply with the CHIPRA Core Measures for voluntary use by Medicaid and CHIP programs.
The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, provides EPSDT Tracking Forms that must be used by providers to document all age-specific, required information related to EPSDT screenings and visits. Providers may choose to use an electronic EPSDT Tracking Form generated through AHCCCS or the provider’s electronic health record system if the electronic form includes components on the AHCCCS EPSDT Tracking form, such as:
  • Documentation of comprehensive physical exam
  • Age-appropriate screenings
  • Developmental surveillance
  • Anticipatory guidance
  • Social-emotional health surveillance
  • Age-appropriate lab and immunizations, and
  • Medically necessary referrals including those to the member’s dental home starting at 1 year of age, or sooner as needed, for routine biannual examinations.
The Arkansas Foundation for Medical Care (AFMC) staffs Quality Improvement specialists that work with providers on a number of projects. A number of these quality improvement projects have focused on issues affecting children including: Adolescent Health, Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders, Pediatric Overweight, Breastfeeding Promotion, Pregnancy and Tobacco Use, Well Child Screening, and EPSDT.

For many of these quality improvement projects data and metrics are an important aspect of the initiative. For example, for the Well Child Screening initiative the QI teams are tracking indicators related to the number of well visits in the first 15 months of life, administration and documentation of immunizations in accordance with national recommendations, and completion of an EPSDT medical screening components according to age-specific schedule.  

California The Medicaid program offers Managed Care Performance Dashboards that offer quarterly insights on plan performance, including on consumer satisfaction for children’s families. Performance measure reports on HEDIS scores include data for:

  • Childhood Immunization Status
  • Children and Adolescents’ Access to Primary Care Practitioners
  • Well-child visits in the Third, Fourth, Fifth, and Sixth Years of Life
Colorado In 2013, Colorado added a well child visit “key performance indicator” to its Accountable Care Collaborative program. Providers and the entities administering the program will be able to earn incentive payments based on performance on this indicator.
Utilization data: Under the administrative services organization structure, services are provided on a fee-for-service basis and all claims go through the state’s Medicaid Management Information System.
Reporting: Connecticut Voices for Children conducts independent performance monitoring of care delivered to Medicaid children under a contract between the Department of Social Services and the Hartford Foundation for Public Giving. Voices for Children analyzes that data collected by DSS and issues reports on a range of topics, including utilization of well-child, emergency room, and dental care.
Connecticut’s External Quality Review Organization, Mercer Government Human Services, collects measures for well-child visits (3, 4, 5, and 6 years of life) and developmental screening (9, 18, and 24 month).
Delaware No information at this time.
District of Columbia The District requires its managed care organizations (MCOs) to compile and submit quarterly reports for HealthCheck utilization and outreach efforts. These reports are generated by MCOs using encounter data, and supplemented by other data sources.
Managed care organizations are required to report on a set of performance measures that include HEDIS measure for:
  • Adolescent Well Care Visits
  • Childhood Immunization Status
  • Follow-up for Children Prescribed ADHD Medication
  • Immunizations for Adolescents
  • Lead Screening in Children
  • Well-child Visits in the First 15 Months of Life
  • Well-child Visits in the Third, Fourth, Fifth, and Sixth Years of Life
  • Children and Adolescents’ Access to Primary Care
The measure set also includes measures defined by the state Medicaid agency, including measures of transportation timeliness and availability.
Managed care organizations (MCOs) must select certain care elements to monitor in physician profiles; one possible element is preventive care, which includes Medicaid well-child visits.MCO contracts also require the MCO to submit an EPSDT report that, at a minimum, lists:
  • Number of live births,
  • Number of initial newborn visits within 24 hours of birth, and
  • Number of members that received an initial health visit and screening within 90 calendar days of enrollment

MCOs must establish internal tracking systems registering compliance with the state’s Health Check requirements. These systems must track:

  • Initial newborn Health Check visit occurring in the hospital;
  • Periodic and preventive/well child screens and visits as prescribed by the periodicity schedule;
  • Diagnostic and treatment services, including Referrals;
  • Immunizations, lead, tuberculosis and dental services; and
  • A reminder/notification system.
External Quality Review reports track several performance measures related to Health Check Services, including children’s access to primary care providers, well-child visits, and others.
Managed care plans are required to submit encounter data at least once per month.
Electronic Data Reporting
Hawaii Medicaid is in the process of implementing an online EPSDT  reporting system that allows providers to submit data electronically. The system will capture information on vaccines, screenings, and referrals, and would provide prompts and alerts for services that are due.
Idaho Medicaid has reporting requirements for two of its initiatives: the Idaho Medical Home Collaborative multi-payer pilot and its ACA Section 2703 State Plan Amendment. Practices participating in the Medical Home Collaborative must achieve National Committee for Quality Assurance (NCQA) PCMH recognition and report on measures in three categories: clinical measures, including chronic disease outcome measures and preventive measures; practice transformation; and patient and provider/staff satisfaction.
Idaho Medicaid is using claims and chart-based process and outcome measures as endorsed by the National Quality Forum to track progress on six goals for the state’s health home program. Two of these are specific to children:
  • Improve care for asthma among adults and children.
  • Increase preventive care for children.
Illinois collects data on several Healthcare Effective Data and Information Set measures pertaining to children, including measures of well-child visits, developmental screenings, and immunizations. The state’s Medicaid agency also collects and reports data on a number of the CHIPRA children’s health quality measures (see the table on page 19 of the state’s annual report on Medicaid for FY10-12).
The majority of CMS-416 data collected in Illinois comes from claims data. The state processes the data through its Medicaid Management Information System (MMIS) and then sends it to a Enterprise Data Warehouse, an analysis tool within Illinois’ MMIS. Illinois uses the CMS-416 data to track and show participant rates, and publishes the data online for others to use.
Oral Health
The state’s Medicaid dental contractor, DentaQuest, processes all dental claims and sends the Department of Healthcare and Family Services a weekly file of all services that were adjudicated during the week. The state then puts this information through its MMIS system for re-adjudication of the data to ensure that all edits are met.
Managed care organizations (MCOs) are required to collect quality measurement data on areas that include: EPSDT services, immunization rates, and blood lead testing.
MCOs also offer performance bonuses to providers based on HEDIS measures as part of the Indiana 2014 Performance Bonus Program for Hoosier Healthwatch. Among the measures determining performance bonuses are:
  • Annual well-child visits: 3-6 years of age
  • Annual well-adolescent visits: 12-21 years
Iowa uses its fee-for-service claims payment system to keep track of services for mandatory reporting to CMS. The state also analyzes its CMS Form-416 data at a county-by-county level and uses this data to pinpoint where in the state Medicaid-enrolled children face issues in accessing dental and physical health services.
Primary Care Case Management
As outlined in the procedural guide for the primary care case management (PCCM) program, known as the Medicaid Patient Access to Services System (MediPASS), Iowa Medicaid provides participating providers with information on the utilization of enrolled families and children on a quarterly basis. Providers may also receive a Quarterly Member Utilization Exception Report.  Quality Assurance/Utilization Reviews are performed by Medicaid on a quarterly basis to collect and analyze provider information on 24-hour access, appointment access for urgent and routine care, and proper use of referral numbers.
Child and Adolescent Reporting System
The Title V child health agencies that deliver many services under the Medicaid benefit all use a Child and Adolescent Reporting system electronic health record to record the provision of services. The system provides a clinical record for all children receiving services at one of the agencies, not only children enrolled in Medicaid.
Behavioral Health
Currently, Medicaid pays for general developmental screens, social-emotional developmental screens, and autism screens all under the 96110 CPT code. Iowa uses claims data to, among other things, produce the CHIPRA core measure on developmental screening.
Contract language for the Iowa Plan for Behavioral Health requires the behavioral health organization (BHO), Magellan Health Services, to submit monthly or quarterly reports (depending on the specific indicator) to the Department of Public Health and the Department of Health Services on child-specific measures, including 7-, 30-, and 90-day mental health readmission, integrated services and supports, involuntary hospitalizations, and improvement in the psychosocial domain of Medicaid children and adolescents who are receiving services.
KanCare, as part of its Section 1115 Waiver, has a significant quality measurement component. Additionally, each of the three KanCare health plans and their subcontractors are required to obtain accreditation by the National Committee for Quality Assurance.
In terms of Evaluation Design of its 1115 Waiver, Kansas incorporates different measures from the KanCare contracts related directly to the goals of the KanCare program. This includes quantitative measure such as: Healthcare Effectiveness Data and Information Set (HEDIS); mental health measures including Serious Emotional Disturbance (SED) Waiver reports and National Outcome Measures; Substance Use Disorder measures; and Case Record reviews. Kansas also includes a number of qualitative reports such as: Consumer Assessment of Health Plans Survey (CAHPS), Substance Abuse Disorder consumer surveys, Provider Surveys, and other reports/surveys.
KanCare also has a pay for performance (P4P) program that ties payment to six performance measures related to operations for the first year, and fifteen performance measures related to quality for the later years. Among the fifteen quality measures that Kansas will be tying to payment are: well-child visits in the first 15 months of life and preterm births.
Kentucky Kentucky Medicaid managed care contract language requires contractors to submit encounter data for each of their members who receive EPSDT services, as well as quarterly and annual reports on EPSDT services for CMS reporting.
Louisiana contracts with IPRO to serve as an External Quality Review Organization (EQRO) to monitor the different managed care plans. The results form IPRO’s analysis are available on the Louisiana Department of Health and Hospitals Bayou Health page. IPRO tracked plan compliance with contract requirements including those related to care coordination, screening and referral services for EPSDT beneficiaries, and the integration of behavioral health and referral services as defined by the EPSDT benefit. Additionally, each CCN operating under the managed care plans are required to report on different performance measure sets including AHRQ and CHIPRA measures.
Improving Health Outcomes for Children (IHOC)
The Improving Health Outcomes for Children (IHOC) grant works to:
  • Collect and report on the use of evidence-based child health quality measures;
  • Expand Health Information Technology to improve the flow of child health data; and
  • Promote a collaborative child health learning environment.

Under the grant, Maine developed a Master List of Pediatric Measures that builds upon the CHIPRA Initial Core Set of Children’s Health Care Quality Measures. This list includes measures on topics such as well child visits, general development and autism screening, oral health, and behavioral health.


Primary Care Provider Incentive Payment (PCPIP) Program
Maine’s Primary Care Provider Incentive Payment (PCPIP) program includes child-specific quality and access measures on which participating providers are measured, including:

  • Percentage of members 0-20 years of age who had one or more EPSDT procedure(s) during the reporting period;
  • Well-child visits in the first 15 months of life;
  • Follow-up care for children prescribed attention-deficit/hyperactivity disorder medication;
  • Adolescent well care visits; and
  • Children aged 1-3 who had a developmental screening during the measurement year.
The state issues report cards on Medicaid managed care organizations (MCOs) that compare MCOs on several metrics, including “Keeping Kids Healthy.” This domain includes measures of:

  • Immunizations
  • Well-child visits to physicians and dentists
  • Lead testing
No information at this time.
The Michigan Department of Community Health publishes Statewide Aggregate Reports of Medicaid health plan performance on HEDIS measures. These measures include metrics in a child and adolescent care domain, including:
  • Childhood Immunization Status
  • Immunizations for Adolescents
  • Well-Child Visits in the First 15 Months of Life (Six or More Visits)
  • Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life
  • Adolescent Well-Care Visits
  • Lead Screening in Children
  • Appropriate Treatment for Children With Upper Respiratory Infection
  • Appropriate Testing for Children With Pharyngitis
  • Follow-Up Care for Children Prescribed ADHD Medication

The department also collects high-level data into a Health Plans Quality Checkup document for consumers. Medicaid health plans are given “below average,” “average,” or “above average” ratings on five key indicators. A Keeping Kids Healthy indicator measures how well “children in the plan get regular checkups and important shots that help protect them against serious illness.”

Child and Teen Checkups (C&TC) Reporting
The state uses specialized software to track C&TC-enrolled children and to assist C&TC Coordinators and outreach staff in conducting and documenting outreach and follow-up activities. The software generates and tracks standard mailings to the children and families about the program as well as information on how to access services. Once a month, updated information on enrolled children and families is collected from the state’s Medicaid Management Information System (MMIS) and MAXIS, a computer system used in Minnesota to determine eligibility for public programs. Encounter data is also collected on a monthly basis from health plans. This information is then compiled and distributed to users of the software, who can update beneficiary information such as name, address, and language.
Mississippi Billing

Only enrolled Mississippi Cool Kids providers are permitted to bill for EPSDT screens, and these providers must use an EPSDT modifier when billing.
Reporting Requirements
Mississippi’s coordinated care program, MississippiCAN, includes EPSDT-specific contract language for participating coordinated care organizations (CCOs)—capitated health plans with specified care management responsibilities—on data and reporting. The state Medicaid agency evaluates EPSDT claims data and sample medical records to determine CCO compliance with EPSDT service provision requirements. CCOs are required to achieve a screening rate of 85% and an immunization rate of 90%; those who do not meet these rates are required to refund Mississippi Medicaid $10 per enrollee for all enrollees under age 12 months. Medicaid publishes the screening rates of CCOs that achieve rates of 85% or greater for the Medicaid population and the medical community in applicable service areas. CCOs are also required to make these screening rates known to potential enrollees in educational and marketing presentations.

MississippiCan CCOs also supply the Department of Medicaid with encounter data that includes claims payment for EPSDT services. In addition to the encounter data, the CCOs must submit quarterly 416 reports that indicate whether the CCOs have met the screening and immunization standards described above.

No information at this time.
Montana No information at this time.
Managed care contracts specify that “improvement in child/adolescent care” are an objective of the Nebraska Health Connection managed care program and:
“Data for the measures used in this approach are derived from HEDIS and HEDIS-like measures of data collection for performance measures, encounter data, quarterly and annually data reporting required of the contractors, and client satisfaction surveys. Other sources of data may include findings from the External Quality Review (EQR) Technical Report, evaluation results of improvement initiatives, and results from on-site visits.”
Nevada is modifying its Medicaid Management Information System (MMIS).  As part of a long-range effort, EPSDT staff have developed an electronic version of an EPSDT screening form.  Eventually, the form will be completed online and the information will be fed directly into the MMIS system.
Managed care organizations (MCOs) in Nevada are required to report on child-specific performance measures. They can receive incentive payments (see page 11) based on performance on Health Effectiveness Data and Information Set (HEDIS) measures for well-child visits and childhood immunization status. They must also report on a non-incentive measure for children and adolescents’ access to primary care practitioners.
New Hampshire
Managed care organizations in New Hampshire are required to report on measures sets that include:
  • CHIPRA Child Quality Measures
  • NCQA Medicaid Accreditation and HEDIS/CAHPS Measures
  • CAHPS measures that include for children with chronic conditions
In the first year of operation of the managed care program, the Adolescent Well Care Visits HEDIS measure is a performance incentive measure for managed care organizations.
New Jersey has in place a performance-based incentive program for managed care organizations (MCOs). MCOs earn back an amount withheld from their capitation payment based on performance on maternity care and prevention screening measures; the latter category includes a measure of the percentage of Medicaid enrollees aged 3-17 who have evidence of a body mass index percentile documentation.
MCOs must also report annually on a set of HEDIS performance measures that include:
  • Childhood Immunization Status (requires Member Level Data)
  • Immunizations for Adolescents
  • Well-Child Visits in First 15 Months of Life
  • Well-Child Visits in the 3rd , 4th , 5th and 6th Years of Life
  • Appropriate Testing for Children with Pharyngitis
  • Adolescent Well-Care Visits
  • Follow-Up Care for Children Prescribed ADHD Medication
  • Child and Adolescent Access to Primary Care Practitioners
  • Lead Screening in Children
The New Mexico Human Services Department (HSD) completes the CMS Form-416, using encounter data submitted by managed care organizations (MCOs) and the state’s fee-for-service third party administrator. Managed care organizations in the state transmit encounter data to the HSD electronically on a weekly basis. Data and system requirements for Medicaid managed care organizations are laid out in a MCO/CSP Systems Manual. The state’s Medicaid Management Information Systems edits the incoming data: the system verifies the validity of the recipient, as well as the validity of the diagnosis and the procedure. Data from fee-for-service claims and from managed care encounter data is housed together in the same database. However, each claim is marked as fee-for-service or managed care inside the data warehouse and tagged with information identifying the specific managed care organization that submitted it.
New managed care contracts under Centennial Care require that MCOs use the most recent version of the CAHPS Adult and Child Survey Instruments, including the Children with Chronic Conditions to assess member satisfaction as part of Health Effectiveness Data and Information Set (HEDIS) reporting requirements and report on them to the Human Services Department. The contracts also include performance measures that pertain to Medicaid services for children, such as a measure of the percentage of members ages 5-11 and 12-18 who are identified as having persistent asthma and who were appropriately prescribed medication during the measurement year.
Reporting on quality of services for children
Medicaid officials in New York rely on a combination of National Committee for Quality Assurance (NCQA) Health Effectiveness Data and Information Set (HEDIS) measures and additional measures developed by the state—together known in New York as the Quality Assurance Reporting Requirements (QARR)—to monitor the quality of care provided by Medicaid MCOs. Several child-specific HEDIS measures are included in required reporting under New York’s QARR, including measures for well-child visits in the first 15 months of life, well-child visits in the 3rd, 4th, 5th, and 6th year, and adolescent well-care visits. This data is used to issue MCO-specific performance reports. The MCOs submit person-specific data on an annual basis that the Medicaid agency can use to analyze the results by race and ethnicity, location, and Medicaid coverage group. The Medicaid agency offers a managed care reference guide on encounter data submissions to provide MCOs with additional information on the process.
Collecting data for the Form CMS-416
New York requires MCOs to submit encounter data on physical health, mental health, and (where applicable) oral health to the Medicaid agency. Data elements included in encounter data include procedure codes and are listed in the “MEDS II Data Element Dictionary.” Each month Medicaid-contracted MCOs submit electronic encounter data. This data, along with claims submitted through the fee-for-service Medicaid system, is used to populate the Form CMS-416. Claims data for dental services or services provided to children who are not enrolled in managed care is submitted to eMedNY, the Medicaid program’s claims processing system. Managed care encounter data is also used to calculate risk-adjusted capitation rates, giving managed care plans a financial incentive not to underreport data.
Oral Health
Medicaid uses fee-for-service claims data and encounter data from MCOs to determine the number of sealants placed.
Community Care of North Carolina (CCNC) maintains an Informatics Center in connection with the Division of Medical Assistance (DMA), the Office of Rural Health and Community Care (ORHCC), and the Centers for Medicare & Medicaid Services (CMS). The Informatics Center contains health care claims data provided by Medicaid and includes a Case Management Information System that is used by the CCNC care managers to help coordinate the care of Medicaid recipients, including children (for more information see Care Coordination).

North Carolina, via the DMA and ORHCC, was awarded $9.2 million dollars to work on three of the five categories of the CHIPRA Quality Demonstration Grant. North Carolina’s CHIPRA grant will experiment with new and existing quality measures for children, promote health information technology as a tool for the delivery of care to children, and create and evaluate models that will improve the delivery of care while demonstrating impact on health, quality, and cost.

North Dakota Providers are encouraged to use the MCH/Health Tracks Pediatric Assessment Form to meet documentation requirements. These requirements can also be met using an internal form as long as the information contains all of the components listed in the Health Tracks Service Requirements. Documentation requirements include each component of a well-child screen under the EPSDT benefit.
Ohio Appendix M of Ohio’s managed care contracts specify minimum performance standards on select quality measures. Several child-specific measures specified in the contracts are NCQA Healthcare Effectiveness Data and Information Set (HEDIS) metrics, including measures of child and adolescent access to primary care and number of child and adolescent well-care visits. The contracts also gauge performance based on children’s rating of a health plan (in a CAHPS survey) and use a CHIPRA core set measure of asthma-related emergency room visits.
No information at this time.
The Oregon Health Authority is required to regularly report to the Oregon Health Policy Board, the Governor, and the legislative Assembly on its progress in implementing Coordinated Care Organizations (CCOs). Oregon has also released a set of Year 1 CCO Accountability Metrics for reporting purposes in the first year, which include measures of developmental screening by 36 months and mental health assessments for children in Department of Human Services custody. Additionally the Oregon Health Authority (OHA) will collect CMS CHIPRA Core Measures, including:

  • Childhood & adolescent immunizations
  • Well child visits
  • Appropriate treatment for children with pharyngitis and otitis media
  • Annual HbA1C testing
  • Utilization of dental, emergency department care (including emergency department visits for asthma)
  • Pediatric Central Line-Associated Bloodstream Infections
  • Follow up for children prescribed ADHD medications

The Oregon Health Authority is also tracking 17 CCO incentive metrics. The incentive metrics include several that are specific to children:

  • Adolescent well-care visits
  • Developmental screening in the first 36 months of life
  • Elective delivery
  • Follow-up care for children prescribed Attention Deficit Hyperactivity Disorder (ADHD) medication.
  • Mental and physical health assessment within 60 days for children in DHS custody
No information at this time.
No information at this time.
South Carolina South Carolina’s Quality Through Technology and Innovation in Pediatrics (QTIP) initiative (funded through a CHIPRA quality grant) is supporting work to collect CHIPRA quality indicator data from 18 pediatric practices,
South Dakota
South Dakota’s Medicaid program relies on fee-for-service claims submissions to gather data on the EPDST benefit. Dental claims are processed by Delta Dental, which transfers claims data back to the Department of Social Services
The Department of Social Services offers providers a list of well-child billing codes on its website that crosswalks each screening code to the state’s EPSDT periodicity schedule.
The state collects effectiveness of care measures to monitor PCCM providers on a number of clinical standards including immunization status, asthma control, and follow-up after hospitalization for mental illness.  The state also utilizes the complaint resolution process, recipient surveys, twenty-four hour access surveys, and caseload monitoring to identify quality and (or) access issues among providers.
Tennessee Tennessee is one of only 12 states that require MCOs to be accredited by the National Committee for Quality Assurance (NCQA). This includes the reporting of Health Care Effectiveness Data and Information Set (HEDIS) data, from which several measures in the CHIPRA core set of measures for children are drawn, including adolescent well-care visits and well child visits in the first 15 months of life.
The Texas Health and Human Services Commission requires managed care organizations to report on the number of check-ups provided to children under Texas Health Steps.
No information at this time.
No information at this time.
Virginia Virginia is one of only 12 states that require MCOs to be accredited by the National Committee for Quality Assurance (NCQA). This includes the reporting of Health Care Effectiveness Data and Information Set (HEDIS) data, from which several measures in the CHIPRA core set of measures for children are drawn including, adolescent well-care visits and well child visits in the first 15 months of life.
Washington collects a variety of NCQA HEDIS measures from Medicaid managed care plans, including measures pertaining to children. This includes measures of childhood and adolescent immunization status, well-child visits, and child access to primary care providers.
Managed care organizations in Washington are required to implement a performance improvement plan if NCQA HEDIS measures of well care visits for children and adolescents fall below set benchmarks.
Medicaid managed care organizations in West Virginia are required to report to the state quarterly on:
  • EPSDT screening and referral rates,
  • Well-child visit rates
  • Dental visits, and
  • Immunization rates.
Wisconsin Managed care contracts in Wisconsin require that enrolled children receive at least 80% of the expected number of HealthCheck screens; managed care organizations that fail to meet this metric face recoupment of some of their capitation payments.
Wyoming No information at this time.



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