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 update of the Healthcare Effectiveness Data and Information Set (HEDIS)

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NOTICE OF PROPOSED AMENDMENT   NO PUBLIC HEARING CONTEMPLATED

 

TO: All Concerned Persons

 

1. 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 the Department of Public Health and Human Services no later than 5:00 p.m. on May 11, 2018 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) 444-4094; fax (406) 444-9744; or e-mail [email protected].

 

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 2017 2018 measures:

            (a) through (3) remain the same.

            (4) The department adopts and incorporates by reference the HEDIS 2017 2018 measures for the categories listed in (1)(a) through (e). The HEDIS 2017 2018 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 2017 2018 measures are available from the National Committee for Quality Assurance, 1100 13th St. NW, Suite 1000, Washington, D.C. 20005 or at www.ncqa.org.

 

AUTH: 33-36-105, MCA

IMP:     33-36-105, 33-36-302, MCA

 

            4. STATEMENT OF 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 through ARM 37.108.521 were adopted in 2001 and established 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 each year, the rule must also be updated annually to reflect the current year′s measures and ensure that national comparisons are possible, since other states will be using the same updated measures.

 

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.

 

             Changes to HEDIS 2018 Measures, Volume 2

 

            (1) Childhood Immunization Status

            (a) Revised the Data Elements for Reporting table to reflect removal of the Final Sample Size (FSS) when reporting using the hybrid methodology.

            (2) Breast Cancer Screening

            (a) Added required exclusions to the Medicare product line for members 65 years of age and older, living long-term in institutional settings.

            (b) Added digital breast tomosynthesis as a method for meeting numerator criteria.

            (c) Revised the Note Section.

            (3) Cervical Cancer Screening

            (a) Revised the Data Elements for Reporting table to reflect removal of the Final Sample Size (FSS) when reporting using the hybrid methodology.

            (4) Comprehensive Diabetes Care

            (a) Added bilateral eye enucleation to the Eye exam (retinal) performed indicator.

            (b) Revised the language in step 1 of the BP Control ‹140/90 mm Hg Numerator and added Notes clarifying the intent when excluding BP readings from the numerator.

            (c) Clarified the medical record requirements for evidence of ACE inhibitor/ARB therapy (for the Medical Attention for Nephropathy indicator).

            (d) Replaced medication table references with references to medication lists.

            (e) Added ″sacubitril-valsartan″ to the description of Antihypertensive combinations in the ACE Inhibitor/ARB Medications List.

            (f) Revised the Data Elements for Reporting table to reflect the removal of the Final Sample Size (FSS) when reporting using the hybrid methodology.

            (5) 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 2018, Volume 3: Specifications for Survey Measures.

 

           Corrections, policy changes, and clarifications to HEDIS 2018, Volume 2, Technical Specifications

 

           (1) Breast Cancer Screening – Required (optional)

(a) Required Exclusion

Replace the text in this section with the following text:

Exclude from Medicare reporting members age 65 and older as of January 1 of the measurement year who meet either of the following:

(i) Enrolled in an Institutional SNP (I-SNP) any time during the measurement year.

(ii) Living long-term in an institution any time during the measurement year as identified by the LTI flag in the Medicare Part C monthly membership file.

(b) Table BCS-1/2/3: Data Elements for Breast Cancer Screening – Add the following row under the ″Eligible population″ row in Table BCS-1/2/3: 

(i) Number of required exclusions (Medicare only). Place a checkmark in second column.

(a) Replace the second bullet with the following text:

Unilateral mastectomy (Unilateral Mastectomy Value Set) with a bilateral modifier (Bilateral Modifier Value Set.) Codes must be on the same claim.

(b) in the first row of bullets in the table, replace both references to ″(same date of service)″ with ″(same claim)″.

(c) Replace the Note with the following text:

This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, MRIs or tomosynthesis (3D mammography), because they are not appropriate methods for primary breast cancer screening.

(2) Comprehensive Diabetes Care Hybrid Specification – Denominator

(a) Add the following text as the second sentence in the third paragraph. 

(i) Members from the oversample should be added to the denominator for al measure indicators. Administrative Specification – Numerators, Eye exam

(a) Replace the second bullet with the following text.

Two unilateral eye enucleations (Unilateral Eye Enucleation Value Set) with service dates 14 days or more apart. For example, if the service date for the first unilateral eye enucleation was February 1 of the measurement year, the service date of the second unilateral eye enucleation must be on or after February 15.

 

5. The department intends the proposed rule amendment to be applied retroactively to January 1, 2018. There is no negative impact to the affected health insurance company 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 May 25, 2018. Comments may also be faxed to (406) 444-9744 or e-mailed to [email protected].

 

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., May 25, 2018.

 

8. If the agency receives requests for a public hearing on the proposed action from either 10 percent 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 1 person based on the one health insurance provider affected by this proposed rule amendment.

 

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

 

11. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment of the above-referenced rule will not significantly and directly impact small businesses.

 

 

 

/s/ Flint Murfitt                                               /s/ Sheila Hogan                                         

Flint Murfitt                                                    Sheila Hogan, Director

Rule Reviewer                                               Public Health and Human Services

 

Certified to the Secretary of State April 17, 2018.