Administrative Rules of the State of Montana

BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES

OF THE STATE OF MONTANA

In the matter of the amendment of ARM 37.108.507 pertaining to Components of Quality Assessment Activities

)

)

)

)

)

NOTICE OF PROPOSED AMENDMENT

NO PUBLIC HEARING CONTEMPLATED

TO: All Concerned Persons

1. On February 14, 2011 the Department of Public Health and Human Services proposes to amend the above-stated rule.

2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require an accommodation, contact Department of Public Health and Human Services no later than 5:00 p.m. on February 7, 2011 to advise us of the nature of the accommodation that you need. Please contact Gwen Knight, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena MT 59604-4210; telephone (406) 444-9503; fax (406) 444-1970; or e-mail dphhslegal@mt.gov.

3. The rule as proposed to be amended provides as follows, new matter underlined, deleted matter interlined:

37.108.507 COMPONENTS OF QUALITY ASSESSMENT ACTIVITIES

(1) Annually, the health carrier shall evaluate its quality assessment activities by using the following HEDIS year ~~2010~~ 2011 measures:

(a) childhood immunization;

(b) breast cancer screening;

(d) comprehensive diabetes care; and

(e) HEDIS/Consumer Assessment of Health Plan Survey (CAHPS) for adults.

(2) The health carrier shall record organizational components that affect accessibility, availability, comprehensiveness, and continuity of care, including:

(a) referrals;

(b) case management;

(d) appointment scheduling and waiting periods for all types of health care services;

(e) second opinions, as applicable;

(f) prior authorizations, as applicable;

(g) provider reimbursement arrangements that contain financial incentives that may affect the care provided; and

(h) other systems, procedures, or administrative requirements used by the health carrier that affect the delivery of care.

(3) The health carrier may meet the requirements in (2) by submitting information to the department regarding network adequacy as specified in ARM 37.108.201, et seq., as long as the information is consistent with what is required in (2).

(4) The department adopts and incorporates by reference the HEDIS year ~~2010~~ 2011 measures for the categories listed in (1)(a) through (e). The HEDIS year ~~2010~~ 2011 measures are developed by the National Committee for Quality Assurance and provide a standardized mechanism for measuring and comparing the quality of services offered by managed care health plans. Copies of HEDIS ~~2010~~ 2011 measures are available from the National Committee for Quality Assurance, 1100 13th St. NW, Suite 1000, Washington, D.C. 20005 or on the internet at www.ncqa.org.

AUTH: 33-36-105, MCA

IMP: 33-36-105, 33-36-302, MCA

4. REASONABLE NECESSITY: The Managed Care Plan Network Adequacy and Quality Assurance Act (Title 33, chapter 36, MCA) establishes standards for health carriers offering managed care plans and for the implementation of quality assurance standards in administrative rules. ARM 37.108.501 et seq. were adopted in 2001 to establish mechanisms for the department to evaluate quality assurance activities of health carriers providing managed care plans in Montana. ARM 37.108.507 requires health carriers to report their quality assessment activities to the department using healthcare effectiveness data and information set (HEDIS) measures, nationally utilized measures that are updated annually. Since the HEDIS standards change somewhat every year, the rule must also be updated annually to reflect the current year's measures and ensure that national comparisons are possible, since the other states will also be using the same updated measures. The changes from adopted 2010 measures to the proposed 2011 measures are quoted below:

"Changes to HEDIS 2011

Childhood Immunization Status

a) Revised dosing requirements for HiB Rotavirus vaccines.

b) Defined 6 months of age for influenza as "180 days".

c) Clarified that the prior year's audited, product line-specific rate may be used for sample size reduction.

Breast Cancer Screening

a) Deleted CPT codes 76090-76092 from Table BCS-A

Cervical Cancer Screening

a) Added CPT codes 57540, 57545, 57550, 57555, 57556, 58548 to Table CCS-B

Comprehensive Diabetes Care

a) Clarified that the "HbA1c control (<7.0%) for a selected population" indicator will result in a different eligible population from all other indicators after the required exclusion criteria is applied.

b) Clarified Table CDC-1/2/3 for reporting "HbA1c Control (<7.0%) for a Selected Population" indicator.

c) Deleted UB Revenue code 022x, 077x from Table CDC-C.

d) Renamed Table CDC-P to Codes to Identify Required Exclusion for HbA1c Control <7% for a Selected Population.

e) Deleted CPT code 67038 from Table CDC-G.

f) Added LOINC codes 56553-1, 57369-1, 58448-2 to Table CDC-J.

g) Added LOINC code 57735-3 to Table CDC-K.

h) Clarified HbA1c Control (<7.0%) for a Selected Population required exclusion requirements under Note in the Hybrid Specification.

i) revised the Data Elements for Reporting table.

HEDIS/Consumer Assessment of Health Plan Survey (CAHPS) for Adults

a) This measure is collected using survey methodology. Detailed specifications and summary of changes are contained in HEDIS 2011, Volume 3: Specifications for Survey Measures.

Corrections, policy changes and clarification to HEDIS 2011, Volume 2, Technical Specifications

Updated Random Number Table for Measures Using the Hybrid Method

Comprehensive Diabetes Care

Throughout measure specification

(a) Replace "BP Control (<130/80 mm Hg)" with "BP Control (<140/80 mm Hg)". This indicator changed effective HEDIS 2011.

· Table CDC-P. Add CPT code 36147 to the CRF/ESRD description.

· Table CDC-D. Add LOINC code 59261-8.

· Table CDC-J. Add LOINC codes 58992-9, 59159-4.

· Table CDC-K. Add CPT code 36147 to the "Evidence of treatment for nephropathy" description.

· Table CDC-M. Delete CPT² Category II code 3075F from the Not numerator compliant (BP≥140/80 mm Hg) row under "Systolic" and add it to the Numerator compliant (BP<140/80 mm Hg) row under "Systolic."

· Hybrid Specification – Denominator. Add the following sentence to the end of the first paragraph. If the organization chooses not to report the HbA1c Control <7% for a Selected Population indicator, it may use a sample size of 411.

· Exclusions (optional).

Replace the Exclusion text with the following:

(a) Exclusionary evidence in the medical record must include a note indicating a diagnosis of polycystic ovaries at any time in the member's history, but must have occurred by December 31 of the measurement year. The member must not have a face-to-face encounter in any setting, with a diagnosis of diabetes, during the measurement year or year prior to the measurement year.

(b) Exclusionary evidence in the medical record must include a note indicating a diagnosis of gestational or steroid-induced diabetes during the measurement year or the year prior to the measurement year. The member must not have a face-to-face encounter in any setting, with a diagnosis of diabetes, during the measurement year or the year prior to the measurement year."

The option of not updating the HEDIS measure was considered and rejected because these are national quality measures which allow comparison among health plans. If the measures are not kept current, this function is lost.

5. The department intends the proposed rule amendments to be applied retroactively to January 1, 2011. There is no negative impact to the affected health insurance companies by applying the rule amendment retroactively.

6. Concerned persons may submit their data, views, or arguments concerning the proposed action in writing to: Gwen Knight, Office of Legal Affairs, Department of Public Health and Human Services, P.O. Box 4210, Helena MT 59604-4210, no later than 5:00 p.m. on February 11, 2011. Comments may also be faxed to (406) 444-1970 or e-mailed to dphhslegal@mt.gov.

7. If persons who are directly affected by the proposed action wish to express their data, views, or arguments orally or in writing at a public hearing, they must make written request for a hearing and submit this request along with any written comments to Gwen Knight at the above address no later than 5:00 p.m., February 11, 2011.

8. If the agency receives requests for a public hearing on the proposed action from either 10% or 25, whichever is less, of the persons directly affected by the proposed action; from the appropriate administrative rule review committee of the Legislature; from a governmental subdivision or agency; or from an association having not less than 25 members who will be directly affected, a hearing will be held at a later date. Notice of the hearing will be published in the Montana Administrative Register. Ten percent of those directly affected has been determined to be one based on the two health insurance providers affected by this rule change.

9. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 6 above or may be made by completing a request form at any rules hearing held by the department.

10. An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of this notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.

11. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.

/s/ Lisa A. Swanson /s/ Anna Whiting Sorrell

Rule Reviewer Anna Whiting Sorrell, Director

Public Health and Human Services

Certified to the Secretary of State January 3, 2011.