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 healthcare effectiveness data and information set (HEDIS) measures

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NOTICE OF PROPOSED AMENDMENT

NO PUBLIC HEARING CONTEMPLATED

TO: All Concerned Persons

1. On February 16, 2013, 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 6, 2013, to advise us of the nature of the accommodation that you need. Please contact Kenneth Mordan, 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 year ~~2012~~ 2013 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 ~~2012~~ 2013 measures for the categories listed in (1)(a) through (e). The HEDIS year ~~2012~~ 2013 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 ~~2012~~ 2013 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. STATEMENT OF REASONABLE NECESSITY

The Department of Public Health and Human Services (department) is proposing to amend ARM 37.108.507 to update the healthcare effectiveness data and information set (HEDIS).

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 521 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 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 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.

The changes from adopted 2012 measures to the proposed 2013 measures are indicated below:

Changes to HEDIS 2013

(1) Childhood Immunization Status

(a) Revised dosing requirement for hepatitis A.

(b) Added ICD-9-CM Diagnosis code 999.42 to Table CIS-B.

(c) Added a footnote to Table CIS-B that 999.4 (without a fifth digit) is valid only if the date of service is prior to October 1, 2011.

(2) Breast Cancer Screening

(a) Added CPT modifier codes RT and LT to Table BCS-B and revised the optional exclusion for bilateral mastectomy to include instances where a mastectomy is performed on the right side and the left side of the body on the same date of service.

(3) Cervical Cancer Screening

(a) No changes to this measure.

(4) Comprehensive Diabetes Care

(a) Added sitagliptin-simvastatin to the description of "Antidiabeteic combinations" in Table CDC-A.

(b) Deleted CPT codes 92002, 92004, 92012, 92014 from Table CDC-C.

(c) Added ICD-9-CM Diagnosis code 425 to Table CDC-P and clarified in the hybrid specification that cardiomyopathy is considered chronic heart failure (a required exclusion for HbA1c control [<7.0%] for a selected population).

(d) Added thoracic aortic aneurysm to the required exclusions for HbA1c control (<7.0%) for a selected population and added corresponding codes to Table CDC-P.

(e) Added instructions to use only facility claims to identify CABG for the required exclusion for the HbA1c control (<7.0%) for a selected population (do not use professional claims).

(f) Clarified that codes from Table CDC-D should be used to identify the most recent HbA1c test for the HbA1c control indicators.

(g) Clarified that a negative dilated eye exam in the year prior to the measurement year meets criteria for the Eye Exam indicator.

(h) Deleted ICD-9-CM Procedure codes (which identify procedures that occur in an inpatient setting) from Table CDC-G: Codes to Identify Eye Exams. The intent of the measure is to identify eye visits performed in an outpatient setting, which are identified by CPT and HCPCS.

(i) Clarified that codes from Table CDC-H should be used to identify the most recent LDL-C test for the LDL-C control indicator.

(j) Deleted obsolete CPT code 36145 from Table CDC-K.

(k) Deleted obsolete HCPCS codes G0392, G0393 from Table CDC-K.

(l) Deleted Aliskiren-hydrochlorothiazide-amlodipine from the "Antihypertensive combinations" description in Table CDC-L.

(m) Clarified that an incomplete reading is not compliant for the BP control indicators.

(n) Clarified that the Friedewald equation may not be used if a direct or calculated result is present in the medical record for the most recent LDL-C test.

(5) HEDIS/Consumer Assessment of Health Plan Survey (CAHPS) Health Plan Survey 5.0H, Adult Version

(a) This measure is collected using survey methodology. Detailed specifications and summary of changes are contained in HEDIS 2013, Volume 3: Specifications for Survey Measures.

Corrections, policy changes and clarifications to HEDIS 2013, Volume 2, Technical Specifications

Updated Random Number Table for Measures using the Hybrid Method

(1) Cervical Cancer Screening

(a) Table CCS-B

(i) Add ICD-9-CM Diagnosis code 752.43 to Table CCS-B.

(2) Comprehensive Diabetes Care

(a) Administrative Specification—Required exclusions for HbA1c Control <7% for a Selected Population indicator

(i) Replace the second bullet with the following.

CABG or PCI. Members discharged alive for CABG or PCI in the measurement year or the year prior to the measurement year. Refer to Table CMC-A and use codes for PCI and CABG only. CABG cases should be from inpatient claims only. Use both facility and professional claims to identify CABG. Include all cases of PCI, regardless of setting (e.g., inpatient, outpatient, ED).

(b) Table CDC-D

(i) Add LOINC code 71875-9 to Table CDC-D.

(i) Add LOINC code 69419-0 to Table CDC-H.

5. The department intends the proposed rule amendments to be applied retroactively to January 1, 2013. 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: Kenneth Mordan, 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 14, 2013. 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 Kenneth Mordan at the above address no later than 5:00 p.m., February 14, 2013.

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 7 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/ Kurt R. Moser /s/ Wendy Nicolai, Acting Director

Rule Reviewer Anna Whiting Sorrell, Director

Public Health and Human Services

Certified to the Secretary of State January 7, 2013