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DAR File No. 32651

This filing was published in the 06/01/2009, issue, Vol. 2009, No. 11, of the Utah State Bulletin.

Health, Center for Health Data, Health Care Statistics

R428-12

Health Data Authority Survey of Enrollees in Health Maintenance Organizations

NOTICE OF PROPOSED RULE

DAR File No.: 32651
Filed: 05/05/2009, 10:08
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This proposed amendment simplifies the language present in the rule.

Summary of the rule or change:

Changes have been made to the language in the enrollment criteria in the definitions section. The sample methodology sections have been simplified as well.

State statutory or constitutional authorization for this rule:

Title 26, Chapter 33a

Anticipated cost or savings to:

the state budget:

The language changes have no effect on the budget. This is due to the fact the language changes simplify how to obtain the sample that is to be used in the survey, not the actual survey procedures. While the language has been altered slightly, the procedures are still in place from previous iterations of the rule.

local governments:

The language changes have no effect on the budget. This is due to the fact the language changes simplify how to obtain the sample that is to be used in the survey, not the actual survey procedures. While the language has been altered slightly, the procedures are still in place from previous iterations of the rule.

small businesses and persons other than businesses:

The language changes have no effect on small business. This is due to the fact the language changes simplify how to obtain the sample that is to be used in the survey, not the actual survey procedures. While the language has been altered slightly, the procedures are still in place from previous iterations of the rule.

Compliance costs for affected persons:

It costs anywhere from $1,000 to $10,000 to administer the survey depending upon how many covered lives the insurance company has in Utah. This cost is the responsibility of the health plan, and not the state or other business entities.

Comments by the department head on the fiscal impact the rule may have on businesses:

There is no fiscal impact. David N. Sundwall, 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:

Sam Vanous at the above address, by phone at 801-538-7074, by FAX at 801-538-9916, or by Internet E-mail at svanous@utah.gov

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:

07/01/2009

This rule may become effective on:

07/08/2009

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R428. Health, Center for Health Data, Health Care Statistics.

R428-12. Health Data Authority Survey of Enrollees in Health Maintenance Organizations.

R428-12-3. Definitions.

These definitions apply to rule R428-12:

(1) "Office" as defined in R428-2-3A.

(2) "Carrier" means:

(a) "Health Maintenance Organization"(HMO) means any person licensed under Title 31A, Chapter 8.

(b) a governmental plan as defined in Section 414 (d), Internal Revenue Code.

(c) a non-electing church plan as described in Section 410 (d), Internal Revenue Code.

(d) "Preferred Provider Organization (PPO)" means all commercial insurance companies engaged in the business of health care insurance in the state of Utah (as defined in 31A-1-301(75)(a) and (b)), and offers a insurance product where an insured member has the choice of using either an in network provider at a discounted rate, also called preferred providers, or any out of network provider at a higher rate, also called non-preferred provider. Payments to preferred and non-preferred providers are paid according the preferred provider contract provisions as described in 31A-22-617(2)(a)(b).

(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:]criteria outlined by HEDIS 2009, Volume 3, Specifications for Survey Measures published by NCQA.

[(a) enrolled with the carrier as of May 1, 2008;

(b) continuously enrolled with the carrier for at least twelve months prior to May 1 of the current year, allowing one break in coverage for up to 45 days;

(c) not employed by the carrier;

(d) age 18 or older;

(e) not enrolled in Medicaid or Medicare; and

(f) has Utah zip code.

]([7]5) "Sampling Frame" means the carrier enrollment file as described criteria outlined by HEDIS 2009, Volume 3, Specifications for Survey Measures published by NCQA.[in Table 1 for all eligible enrollees of the carrier]. The sampling frame includes only records that meet the eligibility criteria in R428-12-3(4).

([8]6) "Sample file" means the data file containing records of selected eligible enrollees drawn by the survey agency from the carrier's sampling frame.

([9]7) "Aggregate statistics" means the total number of enrollees with the particular carrier by age and sex.

([10]8) "Survey agency" means an independent contractor on contract with the Office of Health Data Analysis.

 

R428-12-4. Creating the Sampling Frame.

(1) The sources for enrollment data are health plan carriers licensed in Utah. Each carrier shall include in the sampling frame all eligible enrollees. The carrier may not exclude any record except those that do not meet eligibility criteria as specified in R428-12-3(4).

(2) Each carrier shall create the sampling frame according to the criteria outlined by HEDIS 2009, Volume 3, Specifications for Survey Measures published by NCQA.[the format in the Table 1 or 2.

(3) The layout described in Table 1 and 2 shall be followed exactly. Column starts or widths of fields shall not be changed. The sample file must be in ASCII format, one member record per line, all records the same length. Records shall not contain quotes, hyphens in phone numbers, dashes, or any other punctuation.

 

TABLE 1
SAMPLING FRAME LAYOUT (Adult Survey)


Required Data Element Field Positions Value Labels
Length Start End
Health care
organization name 60 1 60
Product line 1 61 61 1 = Commercial
2 = Medicaid
Product 1 62 62 1 = HMO
2 = POS
Subscriber or familyID number 16 63 78
Member-unique ID 16 79 94 This ID
differentiates
between individuals
when family members
share the subscriber ID
Member first name 25 95 119
Member middle initial 1 120 120
Member last name 25 121 145
Member gender 1 146 146 1 = Male
2 = Female
Member date of birth 8 147 154 MMDDYYYY
Member mailing address 1 50 155 204 Street address or post
office box
Member mailing address 2 50 205 254 Mailing address 2nd
line (if needed)
Member city 30 255 284
Member state 2 285 286 2-character state
abbreviation
Member Zip code 5 287 291 5-digit number
Member telephone number 10 292 301 3-digit area code
plus 7-digit phone
number; no separators
or delimiters
Flu Shots for Adults Ages 50-64
Eligibility Flag 1 302 302 1 = Eligible
2 = Ineligible
9 = Member is in
a product
or product
line for
which the
measure is
not being
reported

 

 

TABLE 2
SAMPLING FRAME LAYOUT (Child Survey)


Required Data Elements Field Positions Value Labels
Length Start End
Health care
organization name 60 1 60
Product line 1 61 61 1 = Commercial
2 = Medicaid
Product 1 62 62 1 = HMO
2 = POS
Subscriber or family
ID number 16 63 78
Member-unique ID 16 79 94 This ID
differentiates
between individuals
when family members
share the subscriber
ID
Member first name 25 95 119
Member middle initial 1 120 120
Member last name 25 121 145
Member gender 1 146 146 1 = Male
2 = Female
Member date of birth 8 147 154 MMDDYYYY
Mailing address 1 50 155 204 Street address or post office box
Mailing address 2 50 205 254 Mailing address
2nd line (if needed)
City 30 255 284
State 2 285 286 2-character state
abbreviation
Zip code 5 287 291 5-digit number
Telephone number 10 292 301 3-digit area code
plus 7-digit phone
number; no
separators or
delimiters
Parent/caretaker
first name 25 302 326 Required only if
mailing materials
are to be addressed
to the parent or
caretaker
Parent/caretaker
middleinitial 1 327 327 Required only if
mailing materials
are to be addressed
to the parent or
caretaker
Parent/caretaker last
name 25 328 352 Required only if
mailing materials
are to be addressed
to the parent or
caretaker
Prescreen status code 1 353 353 1 = No claims or
encounters that meet
criteria
2 = Claims or
encounters that meet
criteria
9 = Member is in a
product or product
line for which
the CCC measure is
not being reported

]

([4]3) The sampling frame and procedures used by the reporting carrier are subject to audit by the Office of Health Data Analysis against aggregate statistics for the submitting carrier.

 

R428-12-5. Sampling Frame Submission.

(1) The carrier shall create the sampling frame according to the eligibility criteria in R428-12-3(4). The carrier shall copy the sampling frame (formatted as described [in "Sampling Frame Layout" in Table 1]by HEDIS 2009, Volume 3, Specifications for Survey Measures published by NCQA) [onto an IBM PC 3.5 inch high density diskette]using a electronic medium acceptable to the survey agency and send to the survey agency.

(2) The carrier shall fill out the "Sample Description" sheet to be provided by the survey agency and send it [with the diskette]with the electronic sample file. Each carrier shall submit to the survey agency the sampling frame for each of its carrier products no later than four weeks after the receipt of the sampling memo from the survey agency.

 

KEY: health maintenance organization, performance measurement, health care quality, preferred provider organization

Date of Enactment or Last Substantive Amendment: [January 8], 2009

Notice of Continuation: April 3, 2007

Authorizing, and Implemented or Interpreted Law: 26-33a-104; 26-33a-108

 

 

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Sam Vanous at the above address, by phone at 801-538-7074, by FAX at 801-538-9916, or by Internet E-mail at svanous@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.

Last modified:  07/14/2009 10:28 PM