Product Lines:
Priority Partners.

Eligible Population:
Adults enrolled in a disabled coverage group (SSI) aged 21-64 years old as of December 31 of the measurement. This includes Value Based Purchasing (VBP) for Priority Partners.

Definition:
Adults enrolled in a disabled coverage group (SSI) aged 21-64 years as of December 31 of the measurement year who meet all of the following criteria during the calendar year:

• Enrolled in a disabled coverage group for 320 or more days.
• Enrolled in a single HealthChoice MCO for 320 or more days.
• Enrolled in the HealthChoice MCO as of December 31 of the measurement year.
• Had no more than one gap in enrollment of up to 45 days during the measurement year.
• Enrolled in a disabled coverage group on December 31 of the measurement year. 

The disabled coverage groups include the following eligibility categories:

• S01: Public Assistance to Adults
• S02: SSI Recipients
• S98: ABD – Medically Needy
• H01: HCBS Waiver and PACE participants
• A04: Disabled adults, no Medicare, up to 77% FPL

Best Practice and Measure Tips

This measure excludes

• Inpatient admissions and emergency department services.
• Members in hospice or using hospice services any time during the measurement year.

This measure includes

• Ambulatory care visits with a behavioral health diagnosis code (mental or chemical dependency), if those visits were covered by the MCO.
• At least one ambulatory care visit in an office, or a virtual visit, or any PCP outpatient visit. Preventative well visits preferred.

Documentation via claims

• This is a Maryland Department of Health (MDH) custom measure and reporting is captured by billing and encounter codes only.

Measure Codes

• Urgent care center visit 
  • HCPCS: S9083, S9088
• Telephone Visits Value Set: CPT 98966-98968, 99441-99443.
• Telephone Visits Modifiers: GT, 95
  • GT: Via interactive audio and video telecommunication system.
  • 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System.
• Telehealth Place of Service (POS): 02, 10 
  • 02: Telehealth Provided Other than in Patient’s Home
  • 10: Telehealth Provided in Patient’s Home
• E-visit or Virtual Check-in (Online Assessments Value Set):
  • CPT: 98970-98972, 99421-99423, 99444, 99457, 99458 
    • Note: Effective January 1, 2020, CPT code 98969 was deleted from the AMA CPT Code list. 
  • HCPCS: G0071, G2010, G2012, G2061-G2063, G2250- G2252
• Ambulatory Outpatient Visit:
  • CPT: 92002, 92004, 92012, 92014, 99202*-99205, 99211-99215, 99241-99245, 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99461, 99483 
    • NOTE: *Effective January 1, 2020, CPT code 99201 was deleted from the AMA CPT Code list. However, CPT code 99201 will be used for claim data reporting prior to code deletion
  • HCPCS: G0463, T1015**   
    • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC)
  • UBREV: 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0524, 0525, 0526, 0527, 0528, 0529, 0982, 0983