No. 36111 (Amendment): Rule R428-13. Health Data Authority:Audit and Reporting of HMO Performance Measures

(Amendment)

DAR File No.: 36111
Filed: 04/30/2012 09:31:37 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; strikes references to HMO(s) throughout document where applicable; updates "Definitions" section to be uniform with definitions in Rule R428-12; renumbers sections as necessary; deletes unnecessary language "incorporated by reference". (DAR NOTE: The proposed amendment to Rule R428-12 is under DAR No. 36110 in this issue, May 15, 2012, of the Bulletin.)

Summary of the rule or change:

The title of the rule is updated to reflect inclusion of health plans, not just HMOs. Also, minor technical edits are made.

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 that health plans (not just HMOs) are affected by the rule 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:

None--Small businesses are not impacted by this rule change, with all potentially impacted having more than 50 employees. As a result, the rule will have no effect on small business budgets for costs or savings.

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

Cost to the health plan industry, specifically to Preferred Provider Organizations now required to report HEDIS data to the state, will total approximately $500,000 (4 PPOs x $125,000). See more information under "Compliance costs for affected persons".

Compliance costs for affected persons:

This rule amendment included the addition of PPOs to the HEDIS data collection process. PPOs that are not currently collecting this data will have to implement changes to both personnel and data systems. This will increase the PPOs budget and workload, depending on how the PPOs are going to collect the data. It is estimated to cost approximately $125,000 to collect HEDIS data per health plan, which does not include any necessary staff.

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:

• Mike Martin at the above address, by phone at 801-538-9205, by FAX at 801-538-9916, or by Internet E-mail at [e-mail]
• 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.

R428-13. Health Data Authority. Audit and Reporting of Health Plan[MO] Performance Measures.

R428-13-1. Legal Authority.

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

 

R428-13-2. Purpose.

This rule establishes a performance measurement data collection and reporting system for health [maintenance organizations (HMOs)]plans licensed in the State of Utah and certain health plans. The data are needed to promote informed consumer choice in health plan selection and measure the quality of care provided by Utah health plans.

 

R428-13-3. Definitions.

These definitions apply to rule R428-13:

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

(2) "Health plan" means:

(a) 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 "Health Maintenance Organization (HMO)" [means]is defined as any person or entity operating in Utah which is licensed under Title 31A, Chapter 8, Utah Code . ;

(c) a governmental plan as defined in Section 414(d), Internal Revenue Code;

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

(e) a "Preferred Provider Organization (PPO)" 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 an 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) "Health plan" means 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.

] ([4]3) "Utah Health Care Performance Measurement Plan" means the plan for data collection and public reporting of health-related measures, adopted by the Utah Health Data Committee to establish a statewide health performance reporting system.

([5]4) "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.

([6]5) "Performance Measure" means the quantitative, numerical measure of an aspect of the [HMO or] health plan, or its membership in part or in its entirety, or qualitative, descriptive information on the [HMO]health plan in its entirety as described in HEDIS.

([7]6) "HEDIS" means the Health care [Plan Employer]Effectiveness Data and Information Set, a set of standardized performance measures developed by the NCQA.

([8]7) "HEDIS data" means the complete set of HEDIS measures calculated by [HMOs and]the health plans according to NCQA specifications, including a set of required measures and voluntary measures defined by the department, in consultation with [HMOs or]the health plans.

([9]8) "Audited HEDIS data" means HEDIS data verified by an NCQA certified audit agency.

([10]9) "Committee" means Utah Health Data Committee established under the Utah Health Data Authority Act, Title 26, Chapter 33a, Utah Code.

(1[1]0) "Covered period" means the calendar year on which the data used for calculation of HEDIS measures is based.

(1[2]1) "Submission year" means the year immediately following the covered period.

 

R428-13-4. Submission of Performance Measures.

(1) Each [HMO and] health plan shall compile and submit HEDIS data to the Office according to this rule.

(2) By July 1 of each year, all [HMOs and] health plans shall submit to the Office audited HEDIS data for the preceding calendar year.

(3) Each [HMO and] health plan shall contract with an independent audit agency certified by the NCQA to verify the HEDIS data prior to the [HMO's or] health plan's submitting it to the Office.

[ (4)

] ([5]4) Each [HMO and] health plan may employ the rotation strategy for HEDIS measures developed and updated by NCQA.

([6]5) If a[n] [HMO or] health plan presents "Not Reported (NR)" for required measures, it must document why it did not report the required measure.

([7]6) The auditor shall follow the guidelines and procedures contained in 20[08]12: Volume 5: HEDIS Compliance Audit: Standards, Policies, and Procedures published by NCQA[, which is incorporated by reference].

([8]7) Each [HMO and] health plan shall cause its contracted audit agency to submit a copy of the audit agency's report by July 1 of the submission year to the Office.

([9]8) Each [HMO and] health plan shall cause its contracted audit agency to submit a copy of the audit agency's final report by August 15 of the submission year to the Office. The final report shall incorporate the [HMO's or] health plan's comments.

 

R428-13-5. Release of Performance Measures.

(1) The Health Data Committee shall follow NCQA's "HEDIS Compliance Audit: Standards, Policies, and Procedures" to determine the HEDIS Data Set that the Office may include in reports for public release for public use.

(2) The Office shall give [HMOs and] health plans 35 days to review any report which identifies it by name. The identified [HMO or] health plan may submit comments and alternative interpretations to the Office.

 

R428-13-6. Exemptions.

(1) A[n HMO or] health plan that cannot meet the reporting requirements of this rule may request an exemption by January 1 of each submission year by submitting to the Office a written request for an exemption, accompanied by all documentation necessary to establish the [HMO's or] health plan's inability to report.[ The exemption request shall be signed by the chief executive officer of the HMO or health plan who shall certify that all information contained in the request is true and correct.] A[n HMO or] health plan may request an exemption if the HMO or health plan did not operate in Utah for the reporting year, if the number of covered lives is too low for HEDIS standards, or for other similarly prohibitive circumstances beyond the [HMO's or] health plan's control.

(2) The Office may request additional information from the HMO and health plan relevant to the exemption or extension request. If the committee denies the exemption, the [HMO or] health plan may resubmit the request to the Office if it has additional information or analysis bearing on the request.

 

R428-13-7. 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, health planning, health policy

Date of Enactment or Last Substantive Amendment: [May 16, 2008]2012

Notice of Continuation: April 21, 2008

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

 

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