No. 36110 (Amendment): Rule R428-12. Health Data Authority Survey of Enrollees in Health Maintenance Organizations

(Amendment)

DAR File No.: 36110
Filed: 04/30/2012 09:30:45 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The amendment changes the title of rule to reflect health plans, not just health maintenance organizations; changes references from "carrier" to "health plan" throughout document; updated "Definitions" section to be uniform with definitions in Rule R428-13; updates the volume year (2009 to 2012) where applicable for HEDIS Specifications book; changes the name of Office of Health Data Analysis to Office of Health Care Statistics; and renumbers sections as necessary. (DAR NOTE: The proposed amendment to Rule R428-13 is under DAR No. 36111 in this issue, May 15, 2012, of the Bulletin.)

Summary of the rule or change:

The rule is updated to reflect current policy that mandates reporting from Preferred Provider Organizations. Also technical edits are made including correct office name, year of publication, and appropriate definitions.

State statutory or constitutional authorization for this rule:

• Title 26, Chapter 33a

Anticipated cost or savings to:

the state budget:

This rule amendment does not change the process currently in place by rule, it only clarifies the reporting requirement of Preferred Provider Organizations as well as makes technical changes for consistency; therefore, the Utah Department of Health (UDOH) determines that these amendments will not create any cost or savings impact to the state budget or UDOH's budget, since the changes will not increase workload and can be carried out with existing budget.

local governments:

This filing does not create any direct cost or savings impact to local governments since they are not directly affected by the rule; nor are local governments indirectly impacted because the rule does not create a situation requiring services from local governments.

small businesses:

Minor technical changes to Rule R428-12 will not result in costs or savings to small businesses.

persons other than small businesses, businesses, or local governmental entities:

Minor technical changes to Rule R428-12 will not result in costs or savings to persons other than small businesses, businesses, or local government entities.

Compliance costs for affected persons:

There are no compliance costs for affected persons. The changes clarify definitions and update publication dates which do not result in compliance costs.

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

Regulated entities should all be aware of this proposed rule amendment. Fiscal impact should be minimal as this reporting is already required in most instances. Public comment will be carefully evaluated.

David Patton, PhD, 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:

• Keely Cofrin Allen at the above address, by phone at 801-538-6551, 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:

06/14/2012

This rule may become effective on:

06/21/2012

Authorized by:

David Patton, 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]Plans.

R428-12-1. Legal Authority.

This rule is promulgated under authority granted by Title 26, Chapter 33a (Utah Code Annotated) and in accordance with the Utah Health Plan Performance Measurement Plan.

 

R428-12-2. Purpose.

This rule establishes the process for the collection of Health [Insurance Carrier]Plan enrollee satisfaction data from Utah licensed health [insurance carriers]plans. The data are needed to promote informed 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]Health plan" means:

(a) "[Health Maintenance Organization"(HMO) means any person licensed under Title 31A, Chapter 8]any insurer under a contract with the Utah Department of Health to serve clients under Title XIX or Title XXI of the Social Security Act[.];

(b) a [governmental plan as defined in Section 414 (d), Internal Revenue Code]"Health Maintenance Organization (HMO)" defined as any person or entity operating in Utah which is licensed under Title 31A, Chapter 8, Utah Code[.];

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

(d) a "Preferred Provider Organization (PPO)" [means]is defined as 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 n 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) "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.

([3]4) "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]5) "Eligible Enrollee" means an enrollee who meets the criteria outlined by HEDIS 20[09]12, Volume 3, Specifications for Survey Measures published by NCQA.

([5]6) "Sampling Frame" means the [carrier]health plan enrollment file as described criteria outlined by HEDIS 20[09]12, Volume 3, Specifications for Survey Measures published by NCQA. The sampling frame includes only records that meet the eligibility criteria in R428-12-3(4).

([6]7) "Sample file" means the data file containing records of selected eligible enrollees drawn by the survey agency from the [carrier]health plan's sampling frame.

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

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

 

R428-12-4. Creating the Sampling Frame.

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

(2) Each [carrier]health plan shall create the sampling frame according to the criteria outlined by HEDIS 20[09]12, Volume 3, Specifications for Survey Measures published by NCQA.

(3) The sampling frame and procedures used by the reporting [carrier]health plan are subject to audit by the Office of Health [Data Analysis]Care Statistics against aggregate statistics for the submitting [carrier]health plan.

 

R428-12-5. Sampling Frame Submission.

(1) The [carrier]health plan shall create the sampling frame according to the eligibility criteria in R428-12-3(4). The [carrier]health plan shall copy the sampling frame (formatted as described by HEDIS 20[09]12, Volume 3, Specifications for Survey Measures published by NCQA) using a n electronic medium acceptable to the survey agency and then send to the survey agency.

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

 

R428-12-6. 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.

 

R428-12-7. Administration of Survey.

Each year, the Utah Department of Health, in consultation with health plans, will determine the target survey population and the scope of the survey.

 

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

Date of Enactment or Last Substantive Amendment: [August 6, 2009]2012

Notice of Continuation: November 30, 2011

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

 

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