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| Montana Administrative Register Notice 37-874 | No. 4 02/22/2019 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
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 March 8, 2019, 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 (a) through (3) remain the same. (4) The department adopts and incorporates by reference the HEDIS
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, ARM 37.108.507 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 measures was considered and rejected because these are national quality measures which allow comparisons among health plans. If the measures are not kept current, this function is lost.
Changes to HEDIS 2019 Measures
(1) Childhood Immunization Status (a) Revised the MMR, VZV, and HepA numerators in the Administrative Specification to indicate that vaccinations administered on or between the child's first and second birthdays meet numerator criteria. (b) Removed "Lower 95% confidence interval" and "Upper 95% confidence interval" data elements from the Data Elements for Reporting tables. (2) Breast Cancer Screening (BCS) (a) Added instructions to report the rates stratified by CMS-assigned LIS/DE and Disability status for the Medicare product line. (b) Revised the age requirements for the Exclusions for Medicare members enrolled in an I-SNP or living long-term in an institution. (c) Changed reference of "Medicare Part C monthly membership file" to "Monthly Membership Detail Data File." (d) Clarified that organizations should use the run date of the Monthly Membership Detail Data File to determine if a member had an LTI flag during the measurement year. (e) Added exclusions for members with advanced illness and frailty. (f) Added methods to identify bilateral mastectomy for the optional exclusion. (g) Removed the "Number of required exclusions (Medicare only)" row in the Data Elements for Reporting tables. (h) Removed "Lower 95% confidence interval" and "Upper 95% confidence interval" data elements from the Data Elements for Reporting tables. (i) Added a new data elements table for Medicare stratification reporting. (3) Cervical Cancer Screening (CCS) (a) Removed "Lower 95% confidence interval" and "Upper 95% confidence interval" data elements from the Data Elements Reporting tables. (4) Comprehensive Diabetes Care (CDC) (a) Incorporated telehealth into the measure specifications. (b) Added instructions to report the "Eye Exam (retinal) performed" indicator rate stratified by LIS/DE and Disability status for Medicare product line. (c) Added exclusions for members with advanced illness and frailty. (d) Added exclusions for the Medicare product line for members 65 years of age and older enrolled in an I-SNP or living long-term in institutional settings. (e) Added methods to identify bilateral eye enucleation. (f) Added blood pressure readings taken from remote patient monitoring devices that are electronically submitted directly to the provider for numerator compliance. (g) Updated the Notes to clarify that BP readings taken the same day as lidocaine injections and wart or mole removals should not be excluded for the numerator. (h) Removed "Lower 95% confidence interval" and "Upper 95% confidence interval" data elements from the Data Elements Reporting tables. (i) Added Data Element table CDC-3-B: Data Elements for Comprehensive Diabetes Care and clarified that it is for the "Eye Exam (retinal) performed" indicator only. (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 2019, Volume 3: Specifications for Survey Measures.
Corrections, policy changes, and clarifications to HEDIS 2019, Quality Rating System and Volume 2, Technical Specifications
(1) Breast Cancer Screening: (a) Eligible Population - Stratification. Add the following text as a new bullet under the bullet that reads "Other": Unknown. (b) Eligible Population - Stratification. In the Note, replace the reference to "five" with "six." (c) Exclusions. Replace the text in this section with the following text: Exclude members who meet any of the following criteria: Note: Supplemental and medical record data may not be used for these exclusions. (i) Medicare members 66 years of age and older as of December 31 of the measurement year who meet either of the following: (A) Enrolled in an Institutional SNP (I-SNP) any time during the measurement year. (B) Living long term in an institution any time during the measurement year as identified by the LTI flag of the Monthly Membership Detail Data File. Use the run date of the file to determine if a member had an LTI flag during the measurement year. (ii) Members 66 years of age and older as of December 31 of the measurement year (all product lines) with frailty and advanced illness. Members must meet BOTH of the following frailty and advanced illness criteria to be excluded. (A) At least one claim/encounter for frailty (Frailty Value Set) during the measurement year. (B) Any of the following during the measurement year or the year prior to the measurement year (count services that occur over both years): (I) At least two outpatient visits (Outpatient Value Set), observation visits (Observation Value Set), ED visits (ED Value Set) or nonacute inpatient encounters (Nonacute Value Set) on different dates of service, with an advanced illness diagnosis (Acute Illness Value Set). Visit type need not be the same for the two visits. (II) At least one acute inpatient encounter (Acute Inpatient Value Set) with an advanced illness diagnosis (Advanced Illness Value Set). (III) A dispensed dementia medication (Dementia Medications List). (d) Administrative Specification - Exclusion (optional). Replace all references of "without a modifier" with "without a right, left, or bilateral modifier (Right Modifier Value Set, Left Modifier Value Set, Bilteral Modifier Value Set.)" (e) Table BCS-3: Data Elements for Breast Cancer Screening. Replace all references to "Each of the 5 stratifications and total" with "Each of the 6 stratifications and total." (2) Childhood Immunization Status: (a) Administrative specification - Numerators, MMR. Replace the text in this section with the following text: Any of the following meet criteria: (i) At least one MMR vaccination (Measles, Mumps, and Rubella (MMR) Vaccine Administered Value Set) on or between the child's first and second birthdays. (ii) At least one measles and rubella vaccination (Measles/Rubella Vaccine Administered Value Set) and at least one mumps vaccination or history of the illness (Mumps Vaccine Administered Value Set; Mumps Value Set) on the same date of service or on different dates of service. Only count vaccinations that are administered on or between the child's first and second birthdays (e.g., "Vaccine Administered" Value Sets). History of illness (Mumps Value Set) can occur on or before the child's second birthday. (iii) At least one measles vaccination or history of the illness (Measles Vaccine Administered Value Set; Measles Value Set) and at least one mumps vaccination or history of the illness (Mumps Vaccine Administered Value Set: Mumps Value Set) and at least one rubella vaccination or history of the illness (Rubella Vaccine Administered Value Set; Rubella Value Set) on the same date of service or on different dates of service. Only count vaccinations that are administered on or between the child's first and second birthdays (e.g., "Vaccine Administered" Value Sets). History of illness (Measles Value Set, Mumps Value Set, Rubella Value Set) can occur on or before the child's second birthday. Note: General Guideline 26 (i.e., the 14-day rule) does not apply to MMR. (b) Administrative Specification - Numerators, VZV. Replace the text in this section with the following text: Either of the following meets criteria: (i) At least one VZV vaccination (Varicella Zoster (VZV) Vaccine Administered Value Set) with date of service on or between the child's first and second birthdays. (ii) History of varicella zoster (e.g., chicken pox) illness (Varicella Zoster Value Set) on or before the child's second birthday. (c) Administrative Specification - Numerators, Hepatitis A. Replace the text in this section with the following text: Either of the following meets criteria: (i) At least one hepatitis A vaccination (Hepatitis A Vaccine Administered Value Set) with a date of service on or before the child's first and second birthdays. (ii) History of hepatitis A illness (Hepatitis A Value Set) on or before the child's second birthday. (d) Hybrid Specification - Numerators, Medical Records. Add the following text as a new paragraph after the fourth paragraph: Immunizations documented using a generic header (e.g., polio vaccine) or "IPV/OPV" can be counted as evidence of IPV. The burden on organizations to substantiate the IPV antigen is excessive compared to a risk associated with data integrity. (3) Comprehensive Diabetes Care (a) Eligible Population - Stratification (i) Add the following bullet under the bullet that reads "Other": Unknown (ii) In the Note, replace the reference to "five" with "six." (b) Eligible Population - Stratification. In the Note, replace the reference to "five" with "six." (c) Eligible Population - Exclusions. Replace the text in this section with the following text: Exclude members who meet any of the following criteria: Note: Supplemental and medial record data may not be used for these exclusions. (i) Members 66 years of age and older as of December 31 of the measurement year (all product lines) with frailty and advanced illness. Members must meet BOTH of the following frailty and advanced illness criteria to be excluded: (A) At least one claim/encounter for frailty (Frailty Value Set) during the measurement year. (B) Any of the following during the measurement year or the year prior to the measurement year (count services that occur over both years): (I) At least two outpatient visits (Outpatient Value Set), observation visits (Observation Value Set), ED visits (ED Value Set) or nonacute inpatient encounters (Nonacute Inpatient Value Set) on different dates of service, with an advanced illness diagnosis (Advanced Illness Value Set). Visit type need not be the same for the two visits. (II) At least one acute inpatient encounter (Acute Inpatient Value Set) with an advanced illness diagnosis (Advanced Illness Value Set). (d) A dispensed dementia medication (Dementia Medications List). (e) Table CDC-3-B: Data Elements for Comprehensive Diabetes Care: Eye Exam (Medicare SES Stratifications only. Report the Total Medicare population in Table CDC-1/1/3). Replace all references to "Each of the 5 stratifications" with "Each of the 6 stratifications."
5. The department intends to adopt these rule amendments to be applied retroactively to January 1, 2019. There is no negative impact to the affected health insurance company 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 March 22, 2019. 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., March 22, 2019.
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/ Erica Johnston for Flint Murfitt Sheila Hogan, Director Rule Reviewer Public Health and Human Services
Certified to the Secretary of State February 12, 2019.
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A directory of state agencies is available online at http://www.mt.gov/govt/agencylisting.asp.
For questions about the organization of the ARM or this web site, contact [email protected].
