Monitoring Health Maintenance Organizations Definitions

PURPOSE: This rule establishes the procedures for health maintenance organizations to collect and submit data to the Department of Health pursuant to section 192.068, RSMo. (1) The following definitions shall be used in the interpretation and enforcement of this rule: (A) Department means Missouri Department of Health and Senior Services; (B) Director means the director of the Missouri Department of Health and Senior Services; (C) Health care plan means any separately licensed entity subject to the provisions of sections 354.400 to 354.636, RSMo which had enrollees in the plan for at least six (6) months of the year for which data are to be reported and for at least six (6) months of the following year; (D) NCQA means the National Committee on Quality Assurance; and (E) HEDIS® means the current Health Plan Employer Data and Information Set. (2) Starting in 1998, health care plans shall submit annually to the department, member satisfaction survey data— (A) The member satisfaction survey shall be conducted according to HEDIS® technical specifications, including survey instrument, sample size, sampling method, collection protocols and CAHPS® component of the HEDIS® compliance audit; (B) The commercial and Medicaid member satisfaction data shall be submitted to the department in electronic form, through a certified survey vendor, and meet the specifications of Table A. Table A is included herein. (C) In 1998 the data shall be submitted by September 1. In subsequent years a final member-level data file and a CAHPS® component audit verification letter shall be submitted by June 15 or the date required by NCQA if other than June 15. If the required submission date falls on a weekend or a federally recognized holiday, the due date will be the first working day following the weekend or federal holiday. The data year (reporting period) for the CAPHS® submission shall be the calendar year (CY) immediately preceding the JUne 15 submission date; and (D) Medicare health care plans shall participate in a member satisfaction survey conducted by the Centers for Medicare and Medicaid Services. The department will obtain the data from the Centers for Medicare and Medicaid Services. (3) Starting in 1998, health care plans shall provide annually to the department, audited quality indicator data— (A) Quality indicator data shall be in accordance to all HEDIS® specifications; (B) All health care plans shall submit to the department documentation from a NCQA licensed organization that the quality indicator data submitted to the department have been audited through a partial or complete compliance audit according to HEDIS® specifications; (C) Each licensed health care plan shall submit separate quality indicator data files for their commercial, Medicaid and Medicare enrollees. Health care plans that contract with the Division of Medical Services to provide coverage in more than one Medicaid region, shall submit separate quality indicator data for the enrollees in each region. The quality indicator data shall be submitted to the department in electronic form and conform to the specifications listed in Table B. Table B is included herein. (D) In 1998 the data shall be submitted by September 1. In subsequent years a final data file shall be submitted by June 15 or the date file required by NCQA if other than June 15. If the required submission date falls on a weekend or a federally recognized holiday, the due date will be the first working day following the weekend or federal holiday. The data year (reporting period) for the HEDIS® (Table B) submission shall be the calendar year (CY) immediately preceding the June 15 submission date. (4) In 1998 access to care data shall be submitted by September 1. In subsequent years the data shall be submitted by June 15. If the required submission date falls on a weekend or a federally recognized holiday, the due date will be the first working day following the weekend or federal holiday. The data year (reporting period) for Table D (access to care) submission shall be the calendar year (CY) immediately preceding the June 15 submission date. Access to care data shall include the data elements and conform to the specifications listed in Table D. Table D is included herein. (5) A health care plan demonstrates continual or substantial failure to comply with the provisions of this rule when the health care plan has been notified by the department that it fails to comply with the provisions of section 192.068, RSMo and this rule and the health care plan— (A) Fails to provide required data; (B) Fails to submit data that meet the data standards detailed in this rule; or (C) Fails to submit data within the time frames established in this rule. Table A Member Satisfaction Survey Data File Specifications File Content Commercial: Member satisfaction survey data for commercial plans shall be based on the version of the NCQA-required Consumer Assessment of Health Plans Study (CAHPS) Questionnaire, applicable for the reporting year. The data reported to the Department shall include the member level and a CAHPS component audit verification letter from the commercial adult core set of questions, plus any NCQA-mandated or -recommended items for the adult segment of the questionnaire. The data shall also include any HEDIS measures specified in Table B, for a given product line and reporting year, that are collected via the CAHPS survey tool. Medicaid: Member satisfaction survey data for MC+ plans shall be based on the version of the NCQA-required Consumer Assessment of Health Plans Study (CAHPS) Questionnaire, applicable for the reporting year. The data reported to the Department shall include the member level and a CAHPS component audit verification letter from the child core survey (Medicaid version) plus any additional questions required by the Division of Medical Services for the reporting year. The data shall also include any HEDIS measures specified in Table B, for a given product line and reporting year, that are collected via the CAHPS survey tool. File format and media The member level and a CAHPS component audit verification letter and their respective record layouts shall be submitted electronically, using the data submission tools (DST) specified by the Department. Other file specifications shall conform to those required by NCQA for submission of the CAHPS Questionnaire results by the certified vendors. File consistency Plans that elect to submit separate files for sub-groups of their enrollment population must consistently do so for all data submission categories required by this rule. of Data to Monitor Health Maintenance Organizations Table B Quality Indicator Data Specifications Data reported for each of the indicators listed below shall conform to the NCQA HEDIS Data Submission Tool and all other HEDIS technical specifications for indicator descriptions and calculations. An “X” in the table below indicates data are to be reported for this quality indicator if the health care plan offers this product line to Missouri residents. NCQA rotates certain measures every year. Rotated measurers shall be reported in accordance with current HEDIS® technical specifications for reporting rotated measures. Measures followed by an asterisk (*) shall be reported every year regardless of NCQA’s rotation strategy. Applicable to: Indicator Commercial Medicaid Medicare Childhood Immunization Status* X X Adolescent Immunization Status* X X Adolescent Well-Care Visits X X Use of Appropriate Medications for People with Asthma X X Chlamydia Screening for Women X X Breast Cancer Screening X X Cervical Cancer Screening X X Beta Blocker Treatment After Heart Attack X X Controlling High Blood Pressure X X Cholesterol Management After Acute Cardiovascular Event X X Comprehensive Diabetes Care X X Antidepressant Medication Management X X Flu Shots for Older Adults (CAHPS®) X Advising Smokers to Quit (CAHPS) X X Annual Dental Visit X ______________________________________________________________________________________ File Content As applicable for each of the quality indicators listed above, except for those collected via the CAHPS questionnaire, the plans shall report the following elements from the NCQA HEDIS Data Submission Tool: 1. Data collection methodology (Administrative or Hybrid). 2. Eligible member population (i.e., members who meet all denominator criteria). 3. Minimum required sample size (MRSS) or other sample size. 4. Number of original sample records excluded because of valid data errors. 5. Number of records excluded because of contraindications identified through administrative data. 6. Number of records excluded because of contraindications identified through medical record review. 7. Additional records added from the auxiliary list. 8. Denominator. 9. Numerator events by administrative data. 10. Numerator events by medical record. 11. Reported rate. 12. Lower 95% confidence interval. 13. Upper 95% confidence interval. All data elements above shall conform to the HEDIS technical specifications, as outlined in the NCQApublished technical manuals. Table D Managed Health Care Services File Specifications Responses to the survey items in Table D must be submitted electronically, in a data file format specified by the Department. Table D must be completed for each managed care product line (Commercial, Medicaid, or Medicare) offered by each licensed health care plan. Responses should be based on activity or status during the reporting period, within each product line (payer). Survey questions in Table D shall apply, except where otherwise noted, only to fully insured (ERISA exempt) enrollments. Table B Quality Indicator Data Specifications (continued) File format and media The quality indicator data shall be submitted electronically, in a data file format to be specified by the Department. All other data specifications shall conform to those required by NCQA for submission of the audited quality indicator data. File Consistency Plans that elect to submit separate files for sub-groups of their enrollment population must consistently do so for all data submission categories required by this rule. Health care plans that contract with the Division of Medical Services to provide coverage in more than one Medicaid region, shall submit separate quality indicator data for the enrollees in each region. of Data to Monitor Health Maintenance Organizations Table D Managed Health Care Services I. HEALTH PLAN INFORMATION Instructions: Submit one set of Table D information, Parts I and II, for each product line (i.e. type of payor) offered by your organization. 1.) Product Line (CHECK ONE): ( ) Commercial ( ) Medicare ( ) Medicaid 2.) Missouri Department of Insurance Licensed Plan Name: ___________________________________ Dba (if applicable): ______________________ 3.) Extended NAIC Identification Number (7-digit): __ __ __ __ __ __ __ 4.) Name as marketed to your members (for Consumer’s Guide display purposes): ____________________________________________________________________________ 5.) List the following for each of your products within this product line: Marketed ------------Phone Numbers------------- a.) Product Name b.) HMO/POS c.) Customer Service d.) RN Hotline ___________________ _________ ______________ ___________ ___________________ _________ ______________ ___________ 6.) Through what organization was your managed care organization accredited as of the last day of the reporting period? Accrediting organization: ( ) NCQA ( ) URAC ( ) JCAHO ( ) None Level of Accreditation: _________ _________ _________ 7.) Managed Care Organization Contact Person for Table D Information: a.) Name: _______________________________ b.) Title: __________________________ c.) Phone: _______________ d.) Fax: ________________ e.) E-mail: __________________ Table D Managed Health Care Services II. HEALTH PLAN SERVICES 1.) Please indicate for each of the following high risk conditions/diseases, if your managed care plan (A) has screening mechanisms, (B) distributes educational material for all plan enrollees, (C) provides specific educational materials to persons-at-risk, (D) provides case management, and (E) provides disease management. (CHECK ALL THAT APPLY. SEE NOTE BELOW.) (A) (B) (C) (D) (E) High Risk Screening Education for Education for Case Disease Conditions/Diseases Mechanisms All Plan Enrollees Persons-at-Risk Management Management Asthma ( NA ) ( ) ( NA ) ( ) ( ) Stroke/Cardiovascular Disease ( NA ) ( ) ( NA ) ( ) ( ) Breast Cancer ( ) ( ) ( ) ( ) ( ) Cervical Cancer ( ) ( ) ( ) ( ) ( ) Ovarian Cancer ( NA ) ( ) ( NA ) ( ) ( ) Colorectal Cancer ( NA ) ( ) ( NA ) ( ) ( ) Sickle Cell Disorders ( NA ) ( ) ( NA ) ( ) ( ) Congestive Heart Failure (CHF) ( NA ) ( ) ( NA ) ( ) ( ) Chronic Obstructive Pulmonary Disease (COPD) ( NA ) ( ) ( NA ) ( ) ( ) Diabetes ( NA ) ( ) ( NA ) ( ) ( ) Depression ( NA ) ( ) ( NA ) ( ) ( ) HIV ( NA ) ( ) ( NA ) ( ) ( ) High Risk Pregnancy ( NA ) ( ) ( NA ) ( ) ( ) Obesity ( NA ) ( ) ( NA ) ( ) ( ) Lead Poisoning ( NA ) ( ) ( NA ) ( ) ( ) Chlamydia: Females ( NA ) ( ) ( NA ) ( ) ( ) High Blood Pressure ( NA ) ( ) ( NA ) ( ) ( ) Alcohol/Substance Abuse: Adolescents ( NA ) ( ) ( NA ) ( ) ( ) Pregnant Women ( NA ) ( ) ( NA ) ( ) ( ) Tobacco Use ( NA ) ( ) ( NA ) ( ) ( ) Other__________________ (PLEASE SPECIFY) ( ) ( ) ( ) ( ) ( ) Note: Screening Mechanisms is a protocol by which the Managed Care Organization identifies through administrative data, members at risk for certain diseases or conditions, utilizing clinical guidelines, and then formally conveys to the network PCPs or personal physician to proactively screen these at-risk patients in their daily practice. Education strategies for plan enrollees may include but are not limited to newsletters, periodicals, direct mailings and similar types of media campaigns. Case management is a protocol where case managers work with providers and physicians to coordinate the medical care that patients with complex or chronic illnesses need to receive. Case managers help members obtain services and medical equipment as ordered by their physicians. Disease management is a strategy where nurses and other health professionals help members learn to self-manage their chronic condition effectively through disease-specific education, general health promotion and reinforcement of the treatment plan designed by each member’s physician. of Data to Monitor Health Maintenance Organizations of Data to Monitor Health Maintenance Organizations of Data to Monitor Health Maintenance Organizations of Data to Monitor Health Maintenance Organizations AUTHORITY: section 192.068, RSMo 2000.* Emergency rule filed Jan. 16, 1998, effective Jan. 26, 1998, terminated April 15, 1998. Original rule filed Jan. 16, 1998, effective Aug. 30, 1998. Amended: Filed Oct. 30, 1998, effective May 30, 1999. Amended: Filed Dec. 20, 1999, effective May 30, 2000. Amended: Filed Sept. 15, 2000, effective April 30, 2001. Amended: Filed Oct. 2, 2001, effective March 30, 2002. Amended: Filed Oct. 2, 2002, effective April 30, 2003. Amended: Filed Sept. 12, 2003, effective March 30, 2004. *Original authority: 192.068, RSMo 1997.