No. 38567 (Amendment): Rule R428-13. Health Data Authority. Audit and Reporting of Health Plan Performance Measures

(Amendment)

DAR File No.: 38567
Filed: 06/02/2014 10:06:08 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment is in response to a review of Title R428 that identified inconsistencies in the writing of the rule.

Summary of the rule or change:

This amendment removes definitions of terms, exemption and extension procedures, and penalties contained in Rule R428-2. It also makes technical and conforming amendments.

State statutory or constitutional authorization for this rule:

• Title 26, Chapter 33a

Anticipated cost or savings to:

the state budget:

This amendment makes technical changes that improve consistency and clarity of Rule R428-13. The Utah Department of Health (UDOH) determines that these changes 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:

Minor technical changes in Rule R428-13 will not create any cost or savings to businesses, individuals, local governments or persons that are not small businesses.

Compliance costs for affected persons:

There are no compliance costs for persons affected by these changes to Rule R428-13. Although there are several modifications within this amendment, they will not impact affected persons.

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

No effect on business because it makes no material change in current practices.

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]
• Rex Olsen at the above address, by phone at 801-538-9498, by FAX at 801-536-0940, or by Internet E-mail at [e-mail]
• Norman Thurston at the above address, by phone at 801-538-7052, by FAX at 801-237-0787, 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:

07/15/2014

This rule may become effective on:

07/22/2014

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 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]the process for the collection of performance measurement data [collection and reporting system for health plans licensed in the State of]from Utah [and certain health plans. The data]carriers that are needed to promote informed consumer choice in [health ]plan selection and measure the quality of care provided [by]to enrollees of Utah [health plans]carriers.

 

[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)" 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) "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.

(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.

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

(6) "HEDIS" means the Healthcare Effectiveness Data and Information Set, a set of standardized performance measures developed by the NCQA.

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

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

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

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

(11) "Submission year" means the year immediately following the covered period.

 

]R428-13-[4]3. Submission of Performance Measures.

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

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

(3) By July 1 of each year, each carrier shall submit to the Office HEDIS data for the preceding calendar year.

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

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

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

([6]7) The auditor shall follow the guidelines and procedures contained in [2012: Volume 5:]the NCQA HEDIS [Compliance Audit: Standards, Policies, and Procedures published by NCQA]Specifications.

([7]8) Each [health plan]carrier 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.

([8]9) Each [health plan]carrier 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 [health plan's]carrier's comments.

 

R428-13-[5]4. Release of Performance Measures.

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

(2) The Office shall give [health plans]carriers 35 days to review any report using data received under this Section which identifies it by name. The identified [health plan]carrier may submit comments and alternative interpretations to the Office.

 

R428-13-[6]5. Exemptions.

(1) [A health plan]Notwithstanding the requirements in Subsection R428-2-11(2), a carrier that cannot [meet]comply with the [reporting ]requirements of this rule may]must request an exemption by January 1 of [each]the relevant submission year[ by submitting to the Office a written request for an exemption, accompanied by all documentation necessary to establish the health plan's inability to report].

(2)  A [health plan]carrier may request an exemption from this rule if the [HMO or health plan]carrier 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 [health plan's]carrier's control.

([2]3) The Office may request additional information from the [HMO and health plan]carrier relevant to the exemption [or extension ]request.[  If the committee denies the exemption, the 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: [July 2, 2012]2014

Notice of Continuation: November 14, 2012

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

 

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