DAR File No. 38566
This rule was published in the June 15, 2014, issue (Vol. 2014, No. 12) of the Utah State Bulletin.
Health, Center for Health Data, Health Care Statistics
Health Data Authority Survey of Enrollees in Health Plans
Notice of Proposed Rule
DAR File No.: 38566
Filed: 06/02/2014 10:00:15 AM
Purpose of the rule or reason for the change:
This amendment is in response to a review of Title R428 that identified inconsistencies in the writing of the rule.
Summary of the rule or change:
This amendment removes definitions of terms, exemption and extension procedures, and penalties contained in Rule R428-2. It also makes technical and conforming amendments.
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 R428-12. The Utah Department of Health (UDOH) determines that these changes will not create any cost or savings impact to the state budget or UDOH's budget, since the changes will not increase workload and can be carried out with existing budget.
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.
None--Small businesses are not impacted by this rule change, with all potentially impacted having 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:
Minor technical changes in Rule R428-12 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 R428-12. 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:
No effect on business because it makes no material change in current practices.
David Patton, PhD, 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 firstname.lastname@example.org
- Rex Olsen at the above address, by phone at 801-538-9498, by FAX at 801-536-0940, or by Internet E-mail at email@example.com
- Norman Thurston at the above address, by phone at 801-538-7052, by FAX at 801-237-0787, or by Internet E-mail at firstname.lastname@example.org
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:
This rule may become effective on:
David Patton, Executive Director
R428. Health, Center for Health Data, Health Care Statistics.
R428-12. Health Data Authority Survey of Enrollees in Health Plans.
R428-12-1. Legal Authority.
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 [
Health Plan ]enrollee satisfaction data from Utah
[ licensed health plans. The data] are needed to promote informed 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 plan" means:
(a) "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;
(b) a "Health Maintenance Organization (HMO)"
defined as any person or entity operating in Utah which is
licensed under Title 31A, Chapter 8, Utah Code;
(c) a non-electing church plan as described in Section
410 (d), Internal Revenue Code; and
(d) a "Preferred Provider Organization (PPO)"
is defined as 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 an 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) "NCQA" means the National Committee for
Quality Assurance, a not-for-profit organization committed to
evaluating and reporting on the quality of managed care
(4) "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
(5) "Eligible Enrollee" means an enrollee who
meets the criteria outlined by HEDIS 2012, Volume 3,
Specifications for Survey Measures published by NCQA.
(6) "Sampling Frame" means the health plan
enrollment file as described criteria outlined by HEDIS 2012,
Volume 3, Specifications for Survey Measures published by NCQA.
The sampling frame includes only records that meet the
eligibility criteria in R428-12-3(4).
(7) "Sample file" means the data file
containing records of selected eligible enrollees drawn by the
survey agency from the health plan's sampling frame.
(8) "Survey agency" means an independent
contractor on contract with the Office of Health Care
4]. Creating the Sampling Frame.
(1) The sources for enrollment data are [
health plan] carriers[ licensed in Utah.] Each [ health plan] shall include in the sampling frame all eligible
enrollees.[ The health plan may not exclude any record except those
that do not meet eligibility criteria as specified in
(2) Each [
health plan] shall create the sampling frame according to the
criteria outlined [ by HEDIS 2012, Volume 3,] Specifications[ for Survey Measures published by NCQA].
(3) The sampling frame and procedures used
by the reporting [
health plan] are subject to audit by the Office of Health Care
against aggregate statistics for the submitting health
5]. Sampling Frame Submission.
(1) The [
health plan shall create the sampling frame according to
the eligibility criteria in R428-12-3(4). The health plan] shall copy the sampling frame[ (formatted as described by HEDIS 2012, Volume 3,
Specifications for Survey Measures published by NCQA)]
using an electronic medium acceptable to the survey agency and then
send to the survey agency.
(2) The [
health plan] shall fill out the "Sample Description"
sheet to be provided by the survey agency and send it with the
electronic sample file. Each [ health plan] shall submit to the survey agency the sampling frame
for each of its[ health plan] products no later than four weeks
after the receipt of the sampling memo from the survey agency.
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.
7]. Administration of Survey.
Each year, the Utah Department of Health,
in consultation with [
health plans], will determine the target survey population and
the scope of the survey.
KEY: health maintenance organization, performance measurement, health care quality, preferred provider organization
Date of Enactment or Last Substantive Amendment: [
July 2, 2012]
Notice of Continuation: November 30, 2011
Authorizing, and Implemented or Interpreted Law: 26-33a-104; 26-33a-108
More information about a Notice of Proposed Rule is available online.
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2014/b20140615.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
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For questions regarding the content or application of this rule, please contact 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@example.com; Rex Olsen at the above address, by phone at 801-538-9498, by FAX at 801-536-0940, or by Internet E-mail at firstname.lastname@example.org; Norman Thurston at the above address, by phone at 801-538-7052, by FAX at 801-237-0787, or by Internet E-mail at email@example.com. For questions about the rulemaking process, please contact the Division of Administrative Rules.