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

)

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 January 10, 2020, to advise us of the nature of the accommodation that you need. Please contact Heidi Clark, 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 ~~2019~~ 2020 measures:

(a) through (3) remain the same.

(4) The department adopts and incorporates by reference the HEDIS ~~2019~~ 2020 measures for the categories listed in (1)(a) through (e). The HEDIS ~~2019~~ 2020 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 ~~2019~~ 2020 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, ARM 37.108.507 must 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 2020 Measures

(1) Childhood Immunization Status (CIS)

(a) Modified value sets to make them compatible with digital measure formatting.

(b) Added live attenuated influenza vaccine (LAIV) as numerator compliant for the influenza rate.

(d) Added the Rules for Allowable Adjustments of HEDIS section.

(2) Breast Cancer Screening (BCS)

(a) Modified value sets to make them compatible with digital measure formatting.

(b) Updated value sets used to identify advanced illness.

(d) Added the Rules for Allowable Adjustments of HEDIS section.

(e) For measures collected using electronic clinical systems (BSC-E) first-year ECDS version of the measure.

(3) Cervical Cancer Screening (CCS)

(a) Updated screening methods to include primary high-risk human papillomavirus testing.

(b) Modified value sets to make them compatible with digital measure formatting.

(d) Added the Rules for Allowable Adjustments of HEDIS section.

(4) Comprehensive Diabetes Care (CDC)

(a) Modified value sets to make them compatible with digital measure formatting.

(b) Removed "with or without a telehealth modifier" language; refer to General Guideline 43.

(d) Updated value sets used to identify advanced illness.

(e) Updated value sets to identify IVD acute inpatient events.

(f) Updated value sets to identify thoracic aortic aneurysm inpatient events.

(g) Clarified telehealth requirements.

(h) Removed the telehealth exclusion from ESRD.

(i) Reformatted the denominator of the Hybrid Specification.

(j) Added the Rules for Allowable Adjustments of HEDIS section.

(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 2020, Volume 3: Specifications for Survey Measures.

Corrections, policy changes, and clarifications to HEDIS 2020, Volume 2, Technical Specifications

(1) Childhood Immunization Status:

(a) Administrative Specification – Numerators, MMR.

(i) Replace the second bullet with the following text (do not delete the dashed sub-bullets below the second bullet): At least one measles and rubella vaccination (Measles Rubella Immunization Value Set; Measles Rubella Vaccine Procedure Value Set) on or between the child's first and second birthdays and one of the following:

(2) Comprehensive Diabetes Care

(a) Administrative Specification – Numerators, HbA1c Poor Control >9%.

(i) Add the following rows to the table:

(1) HbA1c Level Greater Than or Equal To 7.0 and Less Than 8.0 Value Set – Not compliant

(2) HbA1c Level Greater Than or Equal To 8.0 and Less Than or Equal To 9.0 Value Set – Not compliant

(a) Administrative Specification – Numerators, HbA1c Control <8%

(i) Add the following rows to the table:

(1) HbA1c Level Greater Than or Equal To 7.0 and Less Than 8.0 Value Set – Not compliant

(2) HbA1c Level Greater Than or Equal To 8.0 and Less Than or Equal To 9.0 Value Set – Compliant

(i) Add the following rows to the table:

(1) HbA1c Level Greater Than or Equal To 7.0 and Less Than 8.0 Value Set – Not compliant

(2) HbA1c Level Greater Than or Equal To 8.0 and Less Than or Equal To 9.0 Value Set – Not compliant

(d) Exclusions

(i) Replace the first sentence of the dashed sub-bullet, which reads, "At least one acute inpatient discharge with an advanced illness diagnosis (Advanced Illness Value Set)." with "At least one acute inpatient discharge with an advanced illness diagnosis (Advanced Illness Value Set) on the discharge claim."

(e) Exclusions

(i) In the first dashed sub-bullet under "2", replace "(instructions below)" with "(instructions below; the diagnosis must be on the discharge claim.)"

5. The department intends to adopt these rule amendments to be applied retroactively to January 1, 2020. 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: Heidi Clark, 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 January 24, 2020. 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 Heidi Clark at the above address no later than 5:00 p.m., January 24, 2020.

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 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 December 17, 2019.