(a) The commission shall develop quality-based outcome and process measures that:
(1) promote the provision of efficient, quality health care; and
(2) can be used in the child health plan program and Medicaid to implement quality-based payments for acute care services and long-term services and supports across all delivery models and payment systems, including fee-for-service and managed care payment systems.
(b) The commission, in coordination with the Department of State Health Services, shall develop and implement a quality-based outcome measure for the child health plan program and Medicaid to annually measure the percentage of enrollees or recipients with HIV infection, regardless of age, whose most recent viral load test indicates a viral load of less than 200 copies per milliliter of blood.

(c) To the extent feasible, the commission shall develop outcome and process measures:
(1) consistently across all child health plan program and Medicaid delivery models and payment systems;
(2) in a manner that takes into account appropriate patient risk factors, including the burden of chronic illness on a patient and the severity of a patient’s illness;
(3) that will have the greatest effect on improving quality of care and the efficient use of services, including acute care services and long-term services and supports;
(4) that are similar to outcome and process measures used in the private sector, as appropriate;
(5) that reflect effective coordination of acute care services and long-term services and supports;
(6) that can be tied to expenditures; and
(7) that reduce preventable health care utilization and costs.
(d) In developing the outcome and process measures, the commission must include measures that are based on potentially preventable events and advance quality improvement and innovation. The outcome measures based on potentially preventable events must:
(1) allow for a rate-based determination of health care provider performance compared to statewide norms; and
(2) be risk-adjusted to account for the severity of the illnesses of patients a provider serves.
(e) The commission may modify the outcome and process measures to:
(1) promote continuous system reform, improved quality, and reduced costs; and
(2) account for managed care organizations added to a service area.
(f) To the extent feasible, the commission shall align the outcome and process measures with measures required or recommended under reporting guidelines established by:
(1) the Centers for Medicare and Medicaid Services;
(2) the Agency for Healthcare Research and Quality; or
(3) another federal agency.
(g) The executive commissioner by rule may require physicians, other health care providers, and managed care organizations participating in the child health plan program and Medicaid to report information necessary to develop the outcome and process measures to the commission in a format the executive commissioner specifies.
(h) If the commission increases physician and other health care provider reimbursement rates under the child health plan program or Medicaid as a result of an increase in the amounts appropriated for those programs for a state fiscal biennium as compared to the preceding state fiscal biennium, the commission shall, to the extent permitted under federal law and to the extent otherwise possible considering other relevant factors, correlate the increased reimbursement rates with the quality-based outcome and process measures.

Text of section effective on April 01, 2025