In MY 2011, health plans may submit results for the Medicare product line and for the commercial product line. Because the Medicare product line is now reported by health plans, the Health Plan Clinical and Testing Measure file layouts have three tabs for the possible reporting scenarios (commercial HMO/POS and Medicare, commercial HMO/POS only, Medicare only).
Scenario 1: The health plan has both commercial HMO/POS and Medicare product lines
Clinical Measure File Layout: Plans that report for both the commercial HMO/POS and Medicare populations must have 66 clinical measure IDs per DMHC ID/Sub Unit, even if an individual PO has only commercial or Medicare enrollment.
Testing Measure File Layout: Plans that report for both the commercial HMO/POS and Medicare populations must have 31 clinical measure IDs per DMHC ID/Sub Unit, even if an individual PO has only commercial or Medicare enrollment.
Refer to Tab (5) Sample HP FileBoth Commercial and Medicare
Examples 1_3: The plan has commercial and Medicare product lines; Pos 11111-00, 22222-03, 22222-05 and 33333-05 also have commercial and Medicare members: the plan submits commercial and Medicare data for these Pos.
Example 4: The plan has commercial and Medicare product lines; PO 44444-01 has only Medicare members: the plan submits Medicare data for PO 44444-01 and populates commercial rows for PO 44444-01 with zero enrollment, zero denominator, zero numerator and rate NB.
Scenario 2: The health plan has commercial HMO/POS product line only
Refer to Tab (6) Sample HP FileCommercial Only: Plans that have the commercial product line only submit data for the commercial product. There are no rows for the Medicare product.
Clinical Measure File Layout: The plan reports 59 clinical measure IDs per DMHC ID/Sub Unit for the commercial product.
Testing Measure File Layout: The plan reports 10 testing measure IDs per DMHC ID/Sub Unit for the commercial product.
Scenario 3: The health plan has Medicare product line only
Refer to Tab (7) Sample HP FileMedicare Only: Plans that have the Medicare product line only submit data for the Medicare product. There are no rows for the commercial HMO/POS product.
Clinical Measure File Layout: The plan reports 7 clinical measure IDs per DMHC ID/Sub Unit for the Medicare product.
Testing Measure File Layout: The plan reports 21 clinical measure IDs per DMHC ID/Sub Unit for the Medicare product.