DAR File No. 40174

Health, Center for Health Data, Health Care Statistics

Rule R428-13

Health Data Authority. Audit and Reporting of Health Plan Performance Measures

Notice of Proposed Rule

(Amendment)

DAR File No.: 40174
Filed: 01/29/2016 12:51:06 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment is in response to a review of Rule R428-13 that identified inconsistencies in the writing of the rule.

Summary of the rule or change:

The changes are as follows: 1) clarify terms and requirements used in the rule; 2) make technical and conforming amendments; 3) delete Section R428-13-4, "Release of Performance Measures", because similar reference is contained in Rule R428-2; and 4) edit numbering of sections where needed.

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 enactment of the amended version will not create any cost or savings impact to the state budget or UDOH's budget since the change 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 since all potentially impacted businesses have 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:

Technical changes 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:

There is no fiscal impact on business because technical changes do not add compliance costs to affected businesses.

Joseph Miner, MD, 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 [email protected]
• Stephanie Saperstein at the above address, by phone at 801-538-6430, by FAX at , or by Internet E-mail at [email protected]

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:

03/16/2016

This rule may become effective on:

03/23/2016

Authorized by:

Joseph Miner, Executive Director

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 the process for the collection of [performance measurement]HEDIS data from Utah carriers that are needed to promote informed consumer choice in plan selection and measure the quality of care provided to enrollees of Utah carriers.

 

R428-13-3. Submission of Performance Measures.

(1) Each carrier shall compile and submit HEDIS data for the preceding calendar year to the Office [according to this rule]by July 1 of each year.

(2) By January 1 of each year, each carrier shall submit to the Office 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.]

( 3[4]) Each carrier shall contract with an independent audit agency certified by the NCQA to verify the HEDIS data using NCQA HEDIS specifications prior to submitting [it]data to the Office.

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

( 5[6]) If a carrier 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 the NCQA HEDIS Specifications.

(8) Each 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.]

( 6[9]) Each 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 carrier's comments.

 

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

(1) The Health Data Committee shall follow the requirements in the NCQA HEDIS 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 carriers 35 days to review any report using data received under this Section which identifies it by name. The identified carrier may submit comments and alternative interpretations to the Office.]

 

R428-13- 4 [5]. Exemptions.

(1) Notwithstanding the requirements in Subsection R428-2-11(2), a carrier that cannot comply with the requirements of this rule must request an exemption by January 1 of the relevant submission year.

(2) A carrier may request an exemption from this rule if the 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 carrier's control.

[(3) The Office may request additional information from the carrier relevant to the exemption request.]

 

KEY: health, health planning, health policy

Date of Enactment or Last Substantive Amendment: [August 5, 2014]2016

Notice of Continuation: November 14, 2012

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