State BlueCare Prime Plus POS

BlueCare Prime Network Criteria

High Performing Provider Criteria

Cost index

  • A cost index is calculated by dividing the actual risk-adjusted allowed PMPM for all members associated with that provider by an expected risk-adjusted market allowed PMPM comparison.
  • The market allowed comparison is based on members with the same mix of members by market (Medicare fee locality, typically county divisions), member age group, product swim lane (e.g. PPO, HMO), and product drug coverage
  • A lower cost index is favorable
  • Providers are ranked by cost index, forming percentiles, and the 50th percentile (median) value is determined.

Quality index

  • A provider quality index is constructed by comparing a provider group’s compliance rate to a market compliance rate.
  • A market quality comparison of the line of business, provider state, and mix of quality measures for all participating providers is used.
  • The quality index is the average of all of the compliance rates on the various metrics compared to the market value, it is not a weighted average based on membership
  • An individual measure must have a denominator of 5 in order to be scored. A provider must have 2 scoreable measures and a combined denominator of 30 to receive a quality score.
  • Not all providers have all quality metrics.
  • Providers have an average of 33 quality metrics (range 2 – 109)
  • A higher quality index is favorable


  • Baseline threshold values of cost and quality indices were established using claims 4/1/2018-3/31/2019, paid through 6/30/2019
  • A provider with a cost and quality index that meets the thresholds aforementioned is considered a high performing provider


  • All Anthem commercial members in CT
  • For primary care, Only members with affinity to primary care provider are measured for participation
  • Cooperative Care providers are considered high performing
  • No special adjustments were made for downside risk contracts


  • Claims over $250K excluded from calculation of the cost index
  • Members with affinity to specialists
  • Unidentified providers
  • Providers missing quality data

Sample Quality Measures

  • HEDIS Well Child Visit Age 12-21yo AWC19
  • HEDIS Cervical Cancer Screen CCS19
  • HEDIS BrCA Screen BCS19
  • HEDIS Well Child Visit Age 3-6yo W34(2019)
  • HEDIS Chlamydia Screen modif CHL19 PQP
  • Statin adherence PQP
  • ACE ARB adherence PQP
  • HEDIS PersistACE ARB MPM19
  • HEDIS DM Eye Exam CDC19
  • HEDIS DM HbA1c CDC19
  • HEDIS DM proteinuria CDC19
  • HTN Rx Adherence PQP
  • Rotavirus vaccine babies 6-18 months PQP
  • HEDIS HPV Vaccine Adolescents IMA19 PQP
  • HEDIS Meningococcal Vaccine Adolescents IMA19 PQP
  • HEDIS Tdap Vaccine Adolescents IMA19 PQP
  • HEDIS DTaP vaccination CIS19 PQP
  • HEDIS HiB vaccination CIS19 PQP
  • HEDIS IPV vaccination CIS19 PQP
  • HEDIS MMR vaccination CIS19
  • HEDIS Pneumococcal vaccination CIS19 PQP
  • HEDIS VZV Vaccination CIS19
  • DM HbA1C<8 NQF0729 PQP
  • HEDIS Well Child Visit Age 0-15 mo W15(2019)
  • RHI Barium Swallow Inapp Use AMA PQP

Specialist High Performing Criteria

  • Anthem participating specialist and within two percentile of quality and affordability
  • In good standing with Anthem provider participation agreement
  • Participants in the State of CT Episodes of Care Program

Primary Care Physician Participation Criteria

  • Anthem HPP or within two percentile of quality and affordability benchmarks
  • In good standing with Anthem provider participation agreement
  • Utilization of a referral management program
  • Commitment to the tenets of value-based care and a patient centered practice model consistent with the shared principles of high performing primary care
  • Adoption of e-consult platform
  • Participation in at least two education meetings each year and good citizenship
  • Open panel with same day appointment slots; evening and weekend appointments or equivalent coverage