APPENDIX 3 Quality Performance Incentive and Supplemental Payments RY24.docx

COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

MASSHEALTH PROGRAM CDR HOSPITAL CONTRACT

APPENDIX 3:

QUALITY PERFORMANCE INCENTIVE AND SUPPLEMENTAL PAYMENTS

The Contractor may qualify to receive quality performance incentive payments or supplemental payments under this Contract as specified below:

A. RY2024 Quality Performance Incentive Payments to CDR Hospitals other than Pediatric CDR Hospitals Subject to legislative authorization, compliance with all applicable federal statutes, regulations, state plan provisions, the availability of funds, and full federal financial participation, in RY2024 EOHHS will make a total aggregate amount of $3 Million available for Quality Performance Incentive Payments to qualifying CDR Hospitals, as described below.

1. Qualification In order to qualify for a Quality Performance Incentive Payment for RY2024, a CDR hospital must meet the following criteria:

a. Be a CDR Hospital other than a Pediatric CDR Hospital located in Massachusetts that serves MassHealth members; and

b. Have recorded performance, on the following Centers for Medicare and Medicaid Services (CMS) 2021 Inpatient Rehabilitation Facility Compare and Long Term Care Hospital Compare measure, as reported by CMS and updated as of June 21, 2023:

i. Quality Measure: Catheter-Associated Urinary Tract Infections (CAUTI) from LTCH/IRF (Measure Period: 07/01/2021-06/30/2022; Improvement Base Period:07/01/2020-06/30/2021);

ii. Quality Measure: Rate of potentially preventable hospital readmissions 30 days after discharge from an LTCH/IRF (Measure Period for both IRF and LTCH: 07/01/2019-12/31/2019 and 07/01/2020-06/30/2021);

iii. Improvement Base Period for IRF and LTCH: 10/01/2017-09/30/2019; and

iv. Quality Measure: Percentage of patients with pressure ulcers/pressure injuries that are new or worsened (Measure Period for both IRF and LTCH 10/01/2021-09/30/2022. Improvement Base Period for IRF and LTCH 10/01/2020-09/30/2021

2. Quality Performance Measurement System A CDR Hospital’s performance on the selected quality measure will be calculated using a quality point system. A CDR Hospital may earn points based on where the CDR Hospital’s Measure Rate falls, relative to the Attainment and Benchmark thresholds for the applicable Measure Period and may earn points for improvement from the applicable Improvement Base Period for each Quality Measure.

The Benchmark Threshold is the mean of the 10th percentile scores for all the hospitals in the national database, during the Measure Period as applicable to each Quality Measure. The Attainment Threshold is the national median score during the Measure Period as applicable to each Quality Measure.

a. Attainment Point Scale. CDR Hospitals will be awarded Attainment Points as follows:

i. 10 points if the Hospital’s recorded performance is above the Benchmark Threshold;

ii. 0.5-9.5 points if the Hospital’s recorded performance is above the Attainment Threshold, but at or below the Benchmark Threshold; and

iii. Zero (0) points if performance is at or below the Attainment Threshold.

b. Attainment Point Calculation. The number of Attainment Points a CDR hospital receives is determined by the ratio of the difference between the CDR hospital’s Measure Rate and the Attainment Threshold divided by the difference between the Benchmark Threshold and the Attainment Threshold. That ratio is then multiplied by 9 and increased by 0.5.

c. Improvement Point Scale. CDR Hospitals will be awarded Improvement Points based on how much the CDR hospital’s recorded performance on each Quality Measure has improved from the applicable Improvement Base Period. A CDR hospital will be awarded between 0 and 10 points if performance improves over the previous year.

d. Improvement Point Calculation. The number of improvement points a CDR Hospital receives is determined by the ratio of the difference between the CDR Hospital’s recorded performance and the previous year’s recorded performance, as applicable to each Quality Measure, divided by the difference between the Benchmark Threshold and the previous year’s recorded performance. This ratio is multiplied by 10 and decreased by 0.5.

3. Calculation of the Quality Performance Incentive Payment EOHHS will calculate the amount of each qualifying CDR Hospital’s Quality Performance Incentive Payment as follows:

a. For each CDR Hospital and each measure, the Hospital’s point total is the sum of 75% of the Hospital’s Attainment Point Score and 25% of the Hospital’s Improvement Point Score.

b. For each CDR Hospital and each measure, an adjusted point total is calculated by multiplying the point total by the hospital’s Medicaid days excluding MCO.

c. For each eligible CDR Hospital, the CDR Hospital’s Quality Incentive Supplemental payment equals the ratio of the hospital’s adjusted point total divided by the statewide sum of the adjusted point total for all eligible hospitals, times $3 million.

4. Payment EOHHS will issue the RY2024 Quality Performance Incentive Payment to qualifying CDR Hospitals in one installment during RY2024 as follows: April 2024.

B. Discharge Planning Centered Quality Performance Incentive Payments to CDR Hospitals other than Pediatric CDR Hospitals.

EOHHS will make Discharge Planning Centered (DPC) Quality Performance Incentive Payments to qualifying CDR hospitals as described below. The criteria for receiving a DPC Quality Performance Incentive Payment are as follows:

1. Qualification: In order to qualify for a DPC Quality Performance Incentive Payment in RY2023, a CDR hospital must meet the following criteria:

a. Be a CDR Hospital other than: a Pediatric CDR Hospital or nonacute chronic hospital with no fewer than 500 licensed beds as of June 30, 2005, with no fewer than 150,000 Medicaid patient days in the state fiscal year ended June 30, 2006, and with an established geriatric teaching program for physicians, medical students, and other health professionals;

b. Be a CDR Hospital located in Massachusetts and serving MassHealth members;

c. Demonstrate to EOHHS that the CDR hospital made appropriate efforts to discharge MassHealth member(s) in accordance with criteria as designated by EOHHS; and

d. Bill for unpaid administrative days using appropriate billing codes as designated by EOHHS.

2. Payment Subject to legislative authorization, compliance with all applicable federal statutes, regulations, state plan provisions, the availability of funds, and full federal financial participation EOHHS will make available $700 to each qualifying CDR Hospital for each patient day on which a MassHealth member for whom the hospital meets the criteria designated pursuant to Section 1 of this Appendix 3, above, is in the 45-day nonpayment period. Payment will be issued as described below:

EOHHS will issue the RY2024 DPC Quality Performance Incentive Payments to qualifying CDR Hospitals on or before the last day of the month following the month that the discharge planning form was submitted to EOHHS.

C. Reserved D. Supplemental payments for High-Complexity Pediatric Care provided by Pediatric CDR Hospitals Subject to compliance with all applicable federal statutes, regulations, state plan provisions, the availability of funds, and full federal financial participation, in RY 2024 EOHHS will make a total aggregate amount of $3 million available for Supplemental Payments for High-Complexity Pediatric Care provided by Pediatric CDR Hospitals to qualifying Pediatric CDR Hospitals.

1. Qualifications In order to qualify for a Supplemental payment for High-Complexity Pediatric Care provided by a Pediatric CDR Hospital, a Pediatric CDR Hospital must be a chronic disease and rehabilitation hospital that serves solely children and adolescents with complex acute rehabilitation and chronic needs that is located in Massachusetts, that serves MassHealth members, and that operates DMH licensed beds.

2. Payment EOHHS will issue the Supplemental payment for High-Complexity Pediatric Care in April 2024, apportioned equally across the Pediatric CDR Hospitals that qualify.

Amendment 1 – Appendix 3 - RY24 - October 1, 2023