HEDIS® Reporting Requirements

30.1 - HEDIS® Reporting Requirements (Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) HEDIS® is a trademark product of NCQA. All Medicare Advantage plans must submit audited summary-level HEDIS® data to NCQA, and this includes cost contracts with closed enrollment. Patient-level data must be reported to the CMS designated patient- level data contractor. Information about HEDIS® reporting requirements is posted in HPMS. During the contract year, if an HPMS contract status is listed as a consolidation, a merger, or a novation, the surviving contract must report HEDIS® data for all members of the contracts involved. If a contract status is listed as a conversion in the data year, the contract must report if the new organization type is required to report. CMS collects audited data from all benefit packages designated as SNPs and contracts with ESRD Demonstration Plans that had 30 or more members enrolled as reported in the SNP Comprehensive Report (which can be found at http://www.cms.hhs.gov/MCRAdvPartDEnrolData/SNP/list.asp#TopOfPage). The data collection methodologies for HEDIS® are either the administrative or hybrid types. The administrative method is from transactional data for the eligible populations and the hybrid method is from medical record or electronic medical record and transactional data for the sample. MAOs new to HEDIS® must become familiar with the requirements for data submissions to NCQA, and make the necessary arrangements as soon as possible. The organization should work with an NCQA Licensed Organization (www.ncqa.org/audit.aspx), to arrange for a HEDIS® Audit and is responsible for determining fees and entering into contracts. HEDIS® Compliance Audits result in audited rates or calculations at the measure level and indicate if the HEDIS® measures can be publicly reported. All HEDIS® measures selected for public reporting must have a final, audited result. The auditor approves the rate or report status of each HEDIS® measure and survey included in the audit. For HEDIS® measures, the auditor approves the rate of report status of each measure and survey included in the audit as follows: • A rate or numeric result. The organization followed the specifications and produced a reportable rate or result for the measure. • Small Denominator (NA). The organization followed the specifications but the denominator was too small (<30) to report a valid rate. • Benefit Not Offered (NB). The organization did not offer the health benefit required by the measure (e.g., mental health, chemical dependency). • Not Reportable (NR). The organization calculated the measure but the rate was materially biased, or the organization chose not to report the measure or was not required to report the measure. Following are requirements for MAOs with special circumstances: 1. MAOs with Multiple Contract Types - An MAO cannot combine small contracts of different types, e.g., risk and cost, into a larger reporting unit. 2. MAOs with contract conversions: For HEDIS® measures with a continuous enrollment requirement and for enrollees who converted from one type of contract to another (within the same organization), enrollment time under the prior contract will not be counted. 3. MAOs with New Members “Aging-in” from their Commercial Product Line – These MAOs must consider “aging in” members eligible for performance measure calculations assuming that they meet any continuous enrollment requirements. That is, plan members who switch from an MAO’s commercial product line to the MAO’s Medicare product line are considered continuously enrolled. Please read the General Guidelines of HEDIS® Volume 2: Technical Specifications for a discussion of “age-ins” (see “Members who switch product lines”) and continuous enrollment requirements. 4. MAOs with Changes in Service Areas - MAOs that received approval for a service area expansion during the previous year and those that will be reducing their service area effective January 1 of the next contract and reporting year must include information regarding those beneficiaries in the expanded or reduced areas based on the continuous enrollment requirement and Utilization of the particular measure being reported. 5. HMOs with Home and Host Plans - The home plan must report the data related to services received by its members when out of the plan’s service area. As part of the Visitor Program/Affiliate Option (portability), the host plan is treated as another health care provider under the home plan’s contract with CMS. The home plan is responsible for assuring that the host plan fulfills the home plan’s obligations. Plan members that alternate between an MAO’s visitor plan and the home plan are considered continuously enrolled in the plan. 6. New Contracts - MAOs whose effective date is January 1st of the measurement year will not report HEDIS® performance measures for the corresponding reporting year. 7. Non-renewing/Terminating MAOs - Entities that meet the HEDIS® reporting requirements but which have terminated contracts effective January 1st of the reporting year will not be required to submit a HEDIS® report or participate in the Medicare CAHPS® or Medicare HOS surveys. 8. MAOs with Continuing Section 1876 Cost Contracts - For cost contracts, CMS has modified the list of HEDIS® measures to be reported. Cost contractors will not report the inpatient Utilization measures. The measures to be reported are listed on Exhibit I.A. CMS does not require cost contractors to report inpatient (e.g., hospitals, skilled nursing facilities (SNFs)) measures because MAOs with cost-based contracts are not always responsible for coverage of the inpatient stays of their members. Cost members can choose to obtain care outside of the plan without authorization from the MAO. Thus, CMS and the public would not know to what degree the data for these measures are complete. 10. Section 1876 Cost Contracts: Cost contracts will provide patient-level data for all the HEDIS® Effectiveness of Care and the Utilization measures for which they submit summary level data. 11. Mergers and Acquisitions – An entity that acquires and is novating an existing Medicare contract must file a HEDIS® report since the membership; benefits and medical delivery system are essentially unchanged. Therefore, during negotiations for the acquisition it is essential that parties agree on a method of data exchange that will permit the acquiring organization to file a HEDIS® report covering the measurement year in which the transaction occurred. If the Health Plan Management System (HPMS) contract status is listed as a consolidation, a merger, or a novation during the measurement year, the surviving contract must report HEDIS® data for all members of the contracts involved. If a contract status is listed as a conversion in the measurement year, the contract must report if their new organization type is required to report. CMS annually provides guidance in the month of August for the upcoming reporting year. This information is in an annually-issued HPMS memorandum from CMS, entitled “Updated Requirements for Reporting of HEDIS®, HOS, and CAHPS® Measures.” All MA contracts by their specific organization type, are listed, that are required to report HEDIS®. There is no minimum enrollment requirement for submitting MA HEDIS®. The HPMS Memorandum provides information about required HEDIS® measures for reporting, changes in the data specifications, data submission schedule and deadlines, and instructions about data submission. All MA contracts shall use the annual guidance in the CMS HPMS Memorandum issued annually in August regarding the HEDIS® requirements for the upcoming reporting year. Refer to the annual HEDIS®, Volume 2: Technical Specifications for Health Plans for measure specifications and general guidelines for calculations and sampling. Medicare Advantage contracts that are required to report HEDIS® summary-level data must also provide the patient-level data used to calculate the summary-level data for each MA contract. Submission of the patient-level HEDIS® data is not required for the SNP- specific HEDIS® measures. Reporting HEDIS® for Medicare All members covered under the contracts listed below are included in Medicare HEDIS® reporting. CMS communicates directly with all contracted organizations and benefit plans on HEDIS® reporting requirements (e.g., plan type, enrollment criteria). HEDIS® reporting is required for: • Medicare Advantage (MA contracts); • Section 1876 cost contracts with active enrollment; • Medical Savings Account (MSA) contracts; • Private Fee-for-Service (PFFS) contracts; • Employer/Union Only Direct Contract PFFS contracts; • Special Need Plans (SNPs) offered by MA contracts; • Certain demonstration projects. Exclusions: The Medicare Hospice benefit is considered a gap in enrollment, and contracts shall exclude MA members electing the hospice benefit through Traditional Medicare or FFS Medicare, and choose to remain enrolled in the MA plan, beginning on the date when the hospice benefits begin. CMS collects patient-level data with patient-level identifiers for the numerator and the denominator of each required HEDIS® measure because this allows CMS to match HEDIS® data to other patient-level data for special projects of national interest and research, such as an assessment of whether certain groups (e.g., ethnic, racial, gender, geographic) are receiving fewer or more services than others. CMS is committed to assuring the validity of the summary data collected before it is released to the public, and to making the data available in a timely manner for beneficiary information. MAOs and §1876 cost contracts must submit summary measures, after completing the NCQA HEDIS® Compliance Audit required by Medicare, by mid-June of each reporting year. MAOs, including PPO, PFFS, and §1876 cost contracts must submit HEDIS® patient-level data at the same time. CMS requires the submission of the following patient-level data on the same date as summary data to ensure that the patient- level data match the summary data. Auditors will review patient-level data for the numerator and denominator of audited measures when checking for algorithmic compliance during the HEDIS® audit. The summary data are sent to NCQA and the patient-level data are sent only through the designated CMS secure data submission system to the CMS contractor. 1. Summary Data a. Required Measures - MAOs that held Medicare contracts in the measurement year and meet the criteria in the previous section of this chapter must report summary data for all required HEDIS® measures except for the HOS measures. The HEDIS® measures Flu Vaccination for Adults 65 and older, Pneumococcal Vaccination Status for Older Adults, and Medical Assistance with Smoking and Tobacco Use Cessation are collected through the CAHPS® survey instrument. MAOs must attempt to produce every Medicare required measure, and report a numerator and denominator even if the numbers are small, i.e., the denominator is less than 30. b. Data Submission - NCQA will annually post Health Organization Questionnaires (HOQ) on the NCQA Web site in late January. MAOs must accurately complete the HOQ in order to receive the appropriate Interactive Data Submission System (IDSS). MAOs must submit HEDIS® results for the measurement year using this web-based tool. 2. Patient-Level Data - Analysis of data with patient-level identifiers for the numerator and denominator of each measure allows CMS to match HEDIS® data to other patient-level data for special projects of national interest and research, such as an assessment of whether certain groups (e.g., ethnic, racial, gender, geographic) are receiving fewer or more services than others. a. Required Measures – MAOs must provide patient-level data identifying the contribution of each beneficiary to the denominator and numerator of every required summary measure. b. Data Submission – Patient-level HEDIS® data are submitted via the CMS Enterprise FTP client system that contracts use to submit other beneficiary specific information to CMS. Contracts use their existing system that connects to the designated CMS secure data transmission system to upload patient-level data files. The CMS contractor accesses the patient-level data through the same secure system to perform data validations. Contracts must retain the data used for reporting for six years. As specified in 42 CFR §422.504 and §423.505, all MA contracts are required to maintain the privacy and security of protected health information and other personally identifiable information of Medicare enrollees. There have been questions expressed about the provision of behavioral health measures in the patient-level data files. Contracts are accountable for providing patient-level data, unless prohibited by State laws. In such cases, contracts must notify CMS with appropriate documentation of the legal prohibition for consideration.