J.1(d)_QIN-QIO_Community_Selection_Criterion.docx

Attachment J.1(d)- QIN-QIO Community Selection Criteria

HHSM-500-2014-RFP-QIN-QIO

Community Selection Criterion Identify geographic areas of Medicare Beneficiaries as specified by Resident ZIP Code. The following guidelines are intended to assist QIOs in determining relative size of communities recruited and convened.

· An average number of Medicare Beneficiaries per community may be approximately 80,000. (Range of 35,000-140,000) with a Medicare population that has at least 1000 admissions per year and a population of Medicare beneficiaries that is expected to be reasonably stable for at least three years.

· Identify “target providers” who are primarily responsible for the health care delivered to the target Medicare Beneficiaries.

· The target providers should have a reasonable overlap with health care provider claims to the resident zip codes of the Target Medicare Beneficiaries. An average overlap is approximately 60%. For communities with a larger number of ZIP codes and hospitals, CMS recommends a higher percentage overlap for optimal success.

· It is recommended that 2-6 acute care hospitals are included in the target providers (while 1-hospital communities may occur in isolated areas.

· Communities should not overlap more than 10% with another community, already in the program, or have more than 10% lie within another state