As in effect on August 1, 2008
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.
This rule establishes a performance measurement data collection and reporting system for health maintenance organizations (HMOs) licensed in the State of Utah and certain health plans.
These definitions apply to rule R428-13:
(1) "Office" as defined in R428-2-3A.
(2) "Health Maintenance Organization (HMO)" means any person or entity operating in Utah which is licensed under Title 31A, Chapter 8, Utah Code.
(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) "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) "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) "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 in its entirety as described in HEDIS.
(7) "HEDIS" means the Health Plan Employer Data and Information Set, a set of standardized performance measures developed by the NCQA.
(8) "HEDIS data" means the complete set of HEDIS measures calculated by HMOs and health plans according to NCQA specifications, including a set of required measures and voluntary measures defined by the department, in consultation with HMOs or health plans.
(9) "Audited HEDIS data" means HEDIS data verified by an NCQA certified audit agency.
(10) "Committee" means Utah Health Data Committee established under the Utah Health Data Authority Act, Title 26, Chapter 33a, Utah Code.
(11) "Covered period" means the calendar year on which the data used for calculation of HEDIS measures is based.
(12) "Submission year" means the year immediately following the covered period.
(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) Each HMO and health plan may employ the rotation strategy for HEDIS measures developed and updated by NCQA.
(6) If an HMO or health plan presents "Not Reported (NR)" for required measures, it must document why it did not report the required measure.
(7) The auditor shall follow the guidelines and procedures contained in 2008: Volume 5: HEDIS Compliance Audit: Standards, Policies, and Procedures published by NCQA, which is incorporated by reference.
(8) 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) 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.
(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.
(1) An 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. An 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.
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, health planning, health policy
May 16, 2008
April 21, 2008
26-33a
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