No. 32118 (Amendment): R428-12. Health Data Authority Survey of Enrollees in Health Maintenance Organizations and Preferred Provider Organizations

DAR File No.: 32118
Filed: 11/04/2008, 03:40
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to broaden the criteria for health plans to be included in the enrollee's Consumer Assessment of Health Care Providers and Systems survey (CAHPS "Consumer Assessment of Health Plans").

Summary of the rule or change:

In addition to the current health plans being surveyed, HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations), governmental, and non-electing church plans were added as well.

State statutory or constitutional authorization for this rule:

Title 26, Chapter 33a

Anticipated cost or savings to:

the state budget:

The cost of the survey is billed to the state, but then the health plans are billed for their portion, leaving the state with no additional expense.

local governments:

The cost to local governments is $0.00 because they are not involved with the data collection process.

small businesses and persons other than businesses:

The cost to small businesses is $0.00 because the health plans that are required to submit data all have more than 50 employees.

Compliance costs for affected persons:

It costs anywhere from $1,000 to $10,000 to administer the survey depending upon how many covered lives the insurance company has in Utah. This cost is the responsibility of the health plan, and not the state or other business entities.

Comments by the department head on the fiscal impact the rule may have on businesses:

No fiscal impact. David Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Center for Health Data, Health Care Statistics
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Sam Vanous at the above address, by phone at 801-538-7074, by FAX at 801-538-9916, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

12/31/2008

This rule may become effective on:

01/07/2009

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R428. Health, Center for Health Data, Health Care Statistics.

R428-12. Health Data Authority Survey of Enrollees in Health Maintenance Organizations.

R428-12-2. Purpose.

This rule establishes the process for the collection of [HMO]Health Insurance Carrier enrollee satisfaction data from Utah licensed health insurance carriers[health maintenance organizations]. The data are needed to promote consumer choice in health plan selection and measure the quality of care provided by Utah licensed health maintenance organizations.

 

R428-12-3. Definitions.

These definitions apply to rule R428-12:

(1) "Office" as defined in R428-2-3A.

(2) "Carrier" means:

(a) "Health Maintenance Organization"(HMO) means any person licensed under Title 31A, Chapter 8.

(b) a governmental plan as defined in Section 414 (d), Internal Revenue Code.

(c) a non-electing church plan as described in Section 410 (d), Internal Revenue Code.

(d) "Preferred Provider Organization (PPO)" means all commercial insurance companies engaged in the business of health care insurance in the state of Utah (as defined in 31A-1-301(75)(a) and (b)), and offers a insurance product where an insured member has the choice of using either an in network provider at a discounted rate, also called preferred providers, or any out of network provider at a higher rate, also called non-preferred provider. Payments to preferred and non-preferred providers are paid according the preferred provider contract provisions as described in 31A-22-617(2)(a)(b).

(3) "Enrollee" means any individual who has entered into a contract with a health maintenance organization for health care or on whose behalf such an arrangement has been made.

(4) "Eligible Enrollee" means an enrollee who meets the following criteria:

(a) enrolled with [in ]the carrier [HMO ]as of [January]May 1, [of the year when the survey is conducted]2008;

(b) continuously enrolled with[in] the carrier[HMO] for at least twelve months [for commercial HMOs and six months for Medicaid HMOs ]prior to [January]May 1 of the [survey]current year, allowing one break in coverage for up to 45 days;

(c) not employed by the carrier[HMO, except that HMOs can choose to survey their employees, in which case a flag needs to be included in the sample frame so that they can be identified];

(d) [has Utah zip code, except that HMOs can choose to survey their enrollees residing outside of Utah, in which case a flag needs to be included in the sample frame so that they can be identified; and]age 18 or older;

(e) [Medicare is ]not [the enrollee's primary payer.]enrolled in Medicaid or Medicare; and

(f) has Utah zip code.

[ (5) "Employee" means any person employed by a health plan or HMO.

(6) "NCQA" means the National Committee for Quality Assurance, a not-for-profit organization committed to evaluating and reporting on the quality of managed care plans.

] (7) "Sampling Frame" means the carrier[HMO] enrollment file as described in [HEDIS 2002, Volume 3, Specifications for Survey Measures published by NCQA, which is incorporated by reference,]Table 1 for all eligible enrollees of the carrier[ HMO]. The sampling frame includes only records that meet the eligibility criteria in R428-12-3(4).

(8) "Sample file" means the data file containing records of selected eligible enrollees drawn by the survey agency from the carrier's[HMO's] sampling frame.

(9) "Aggregate statistics" means the total number of enrollees with[in] the particular carrier[HMO] by age and sex.

(10) "Survey agency" means an independent contractor on contract with the Office of Health [Care Statistics]Data Analysis.

 

R428-12-4. Creating the Sampling Frame.

(1) The sources for enrollment data are health plan carriers[HMOs] licensed in Utah. Each carrier[HMO] shall include in the sampling frame all eligible enrollees. The carrier[HMO] may not exclude any record except those that do not meet eligibility criteria as specified in R428-12-3(4).

(2) Each carrier[HMO] shall create the sampling frame according to the format [specified by HEDIS 2002, Volume 3, Specifications for Survey Measures published by NCQA]in the Table 1 or 2.

(3) The layout described in Table 1 and 2 shall be followed exactly. Column starts or widths of fields shall not be changed. The sample file must be in ASCII format, one member record per line, all records the same length. Records shall not contain quotes, hyphens in phone numbers, dashes, or any other punctuation.

 

TABLE 1
SAMPLING FRAME LAYOUT (Adult Survey)

 Required Data Element     Field Positions        Value Labels

 Length  Start  End

 Health care

 organization name         60    1      60

 Product line              1     61     61        1 = Commercial

 2 = Medicaid

 Product                   1     62     62        1 = HMO

 2 = POS

 Subscriber or family

 ID number                 16    63     78

 Member-unique ID          16    79     94   This ID

 differentiates

 between individuals

 when family members

 share the subscriber ID

 Member first name         25    95     119

 Member middle initial     1    120     120

 Member last name          25   121     145

 Member gender             1    146     146       1 = Male

 2 = Female

 Member date of birth      8    147     154   MMDDYYYY

 Member mailing address 1  50   155     204   Street address or post

 office box

 Member mailing address 2  50    205    254   Mailing address 2nd

 line (if needed)

 Member city               30    255    284

 Member state              2     285    286   2-character state

 abbreviation

 Member Zip code           5     287    291   5-digit number

 Member telephone number   10    292    301   3-digit area code

 plus 7-digit phone

 number; no separators

 or delimiters

 Flu Shots for Adults Ages 50-64

 Eligibility Flag        1     302     302       1 = Eligible

 2 = Ineligible

 9 = Member is in

 a product

 or product

 line for

 which the

 measure is

 not being

 reported

 

TABLE 2
SAMPLING FRAME LAYOUT (Child Survey)

 Required Data Elements     Field Positions       Value Labels

 Length  Start  End

 Health care

 organization name         60     1     60

 Product line              1     61     61        1 = Commercial

 2 = Medicaid

 Product                   1     62     62        1 = HMO

 2 = POS

 Subscriber or family

 ID number                 16    63     78

 Member-unique ID          16    79     94  This ID

 differentiates

 between individuals

 when family members

 share the subscriber

 ID

 Member first name         25     95    119

 Member middle initial     1     120    120

 Member last name          25    121    145

  Member gender            1     146    146       1 = Male

 2 = Female

 Member date of birth      8     147    154  MMDDYYYY

 Mailing address 1         50    155    204  Street address or post
office box

 Mailing address 2         50    205    254  Mailing address 2nd line (if
needed)

 City                      30    255    284

 State                     2     285    286  2-character state
abbreviation

 Zip code                  5     287    291  5-digit number

 Telephone number          10    292    301  3-digit area code

 plus 7-digit phone

 number; no

 separators or

 delimiters

 Parent/caretaker

 first name                25    302    326  Required only if

 mailing materials

 are to be addressed

 to the parent or

 caretaker

 Parent/caretaker middle

 initial                   1     327    327  Required only if

 mailing materials

 are to be addressed

 to the parent or

 caretaker

 Parent/caretaker last

 name                      25    328    352  Required only if

 mailing materials

 are to be addressed

 to the parent or

 caretaker

 Prescreen status code    1      353    353       1 = No claims or

 encounters that meet

 criteria

 2 = Claims or

 encounters that meet

 criteria

 9 = Member is in a

 product or product

 line for which

 the CCC measure is

 not being reported

 

(4) The sampling frame and procedures used by the reporting carrier[HMO] are subject to audit by the Office of Health [Care Statistics and by an NCQA certified auditor]Data Analysis against aggregate statistics for the [reporting]submitting carrier[HMO].

 

R428-12-5. Sampling Frame Submission.

(1) The carrier[HMO] shall create the sampling frame according to the eligibility criteria in R428-12-3(4). The carrier shall copy the sampling frame (formatted as described in "Sampling Frame Layout" in Table 1) onto an [electronic medium acceptable to the survey agencyand]IBM PC 3.5 inch high density diskette and send [it ]to the survey agency.[ If the HMO submits the sampling frame electronically, the HMO must encrypt and password protect the file.]

(2) The carrier[HMO] shall fill out the "Sample Description" sheet to be provided by the survey agency and send it with the diskette[ or other electronic file]. Each carrier[HMO] shall submit to the survey agency the sampling frame for each of its carrier[HMO] products no later than four weeks after the [due date assigned by]receipt of the sampling memo from the survey agency.

 

[R428-12-6. Submission of Aggregate Statistics.

The HMO shall submit to the Office of Health Care Statistics aggregate statistics from its total enrollment population, before screening to identify eligible enrollees, in the following format:

 

TABLE 2

For adult surveys:

 Age       Male     Female

 18-24     xxxxx     xxxxx

 25-36     xxxxx     xxxxx

 37-44     xxxxx     xxxxx

 45-54     xxxxx     xxxxx

 55-64     xxxxx     xxxxx

 65-up     xxxxx     xxxxx

 

 For child surveys:

 <1        xxxxx     xxxxx

 1-3       xxxxx     xxxxx

 4-7       xxxxx     xxxxx

 8-12      xxxxx     xxxxx

 13-17     xxxxx     xxxxx

 

]

R428-12-[8]6. Penalties.

Pursuant to Section 26-23-6, any person that violates any provision of this rule may be assessed an administrative civil money penalty not to exceed $3,000 upon an administrative finding of a first violation and up to $5,000 for a subsequent similar violation within two years. A person may also be subject to penalties imposed by a civil or criminal court, which may not exceed $5,000 or a class B misdemeanor for the first violation and a class A misdemeanor for any subsequent similar violation within two years.

 

KEY: health maintenance organization, performance measurement, health care quality, preferred provider organization

Date of Enactment or Last Substantive Amendment: [August 14, 2002]2009

Notice of Continuation: April 3, 2007

Authorizing, and Implemented or Interpreted Law: 26-33a-104; 26-33a-108