As in effect on June 1, 2008
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.
This rule establishes the process for the collection of HMO enrollee satisfaction data from Utah licensed health maintenance organizations. The data are needed to promote consumer choice in health plan selection and measure the quality of care provided by Utah licensed health maintenance organizations.
These definitions apply to rule R428-12:
(1) "Office" as defined in R428-2-3A.
(2) "Health Maintenance Organization"(HMO) means any person licensed under Title 31A, Chapter 8.
(3) "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) "Eligible Enrollee" means an enrollee who meets the following criteria:
(a) enrolled in the HMO as of January 1, of the year when the survey is conducted;
(b) continuously enrolled in the HMO for at least twelve months for commercial HMOs and six months for Medicaid HMOs prior to January 1 of the survey year, allowing one break in coverage for up to 45 days;
(c) not employed by the HMO, except that HMOs can choose to survey their employees, in which case a flag needs to be included in the sample frame so that they can be identified;
(d) has Utah zip code, except that HMOs can choose to survey their enrollees residing outside of Utah, in which case a flag needs to be included in the sample frame so that they can be identified; and
(e) Medicare is not the enrollee's primary payer.
(5) "Employee" means any person employed by a health plan or HMO.
(6) "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.
(7) "Sampling Frame" means the HMO enrollment file as described in HEDIS 2002, Volume 3, Specifications for Survey Measures published by NCQA, which is incorporated by reference, for all eligible enrollees of the HMO. The sampling frame includes only records that meet the eligibility criteria in R428-12-3(4).
(8) "Sample file" means the data file containing records of selected eligible enrollees drawn by the survey agency from the HMO's sampling frame.
(9) "Aggregate statistics" means the total number of enrollees in the particular HMO by age and sex.
(10) "Survey agency" means an independent contractor on contract with the Office of Health Care Statistics.
(1) The sources for enrollment data are HMOs licensed in Utah. Each HMO shall include in the sampling frame all eligible enrollees. The HMO may not exclude any record except those that do not meet eligibility criteria as specified in R428-12-3(4).
(2) Each HMO shall create the sampling frame according to the format specified by HEDIS 2002, Volume 3, Specifications for Survey Measures published by NCQA.
(3) The sampling frame and procedures used by the reporting HMO are subject to audit by the Office of Health Care Statistics and by an NCQA certified auditor against aggregate statistics for the reporting HMO.
(1) The HMO shall copy the sampling frame onto an electronic medium acceptable to the survey agencyand send it to the survey agency. If the HMO submits the sampling frame electronically, the HMO must encrypt and password protect the file.
(2) The HMO shall fill out the "Sample Description" sheet to be provided by the survey agency and send it with the diskette or other electronic file. Each HMO shall submit to the survey agency the sampling frame for its HMO products no later than the due date assigned by the survey agency.
The HMO shall submit to the Office of Health Care Statistics aggregate statistics from its total enrollment population, before screening to identify eligible enrollees, in the following format:
TABLE 2
For adult surveys:
Age Male Female
18-24 xxxxx xxxxx
25-36 xxxxx xxxxx
37-44 xxxxx xxxxx
45-54 xxxxx xxxxx
55-64 xxxxx xxxxx
65-up xxxxx xxxxx
For child surveys:
<1 xxxxx xxxxx
1-3 xxxxx xxxxx
4-7 xxxxx xxxxx
8-12 xxxxx xxxxx
13-17 xxxxx xxxxx
Each year, the Utah Department of Health, in consultation with health plans, will determine the target survey population and the scope of the survey.
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.
health maintenance organization, performance measurement, health care quality
August 14, 2002
April 3, 2007
26-33a-104; 26-33a-108
Rule converted into HTML by the Division of Administrative Rules.
For questions regarding the content or application of rules under Title R428, please contact the promulgating agency (Health, Center for Health Data, Health Care Statistics). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html.
For questions about the rulemaking process, please contact the Division of Administrative (801-538-3764). Please Note: The Division of Administrative Rules is not able to answer questions about the content or application of these rules.
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