Sec. 10.25.08.03. Health Benefit Plan Quality and Performance Evaluation System — Implementation

Carrier Participation.

(1) Each carrier may participate in the health benefit plan quality and performance evaluation system.

(2) Each carrier that meets the criteria of Regulation .01B of this chapter is required to participate.

(3) A carrier that chooses not to participate in the health benefit plan quality and performance evaluation system must present clear evidence to the Commission that shows that the carrier has no more than $1,000,000 in annual premium volume by category of health benefit plan and no more than 65 percent of its Maryland enrollees covered through the Medicaid and Medicare programs.

Performance Measures. The Commission shall choose performance measures that are important, feasible, scientifically sound, and actionable, including performance measures that:

(1) Are related to the quality and performance of medical services provided by a health benefit plan;

(2) Allow for comparisons among health benefit plans;

(3) Can be of interest to purchasers, consumers, providers, carriers, or health officials;

(4) Can be used to affect changes in performance; and

(5) Can be validated through an audit conducted by an independent party for validity, reliability, and comparability.

Notice by the Commission.

(1) Beginning in November 2011, and each November thereafter, the Commission shall provide a dated notice posted on the Commission’s website and a written notice to each carrier required to report under Regulation .01A. of this chapter regarding the following:

(a) The required categories of health benefit plans for which HEDIS and other performance measures must be submitted for the upcoming measurement year;

(b) The selected HEDIS and other performance measures for each category of health benefit plan to be included in the reporting period; and

(c) Quality and performance measures that will be subject to audit.

(2) Beginning in December 2011, and each December thereafter, the Commission shall provide a dated notice posted on the Commission’s website and a written notice to each carrier required to report under Regulation .01A of this chapter regarding the following:

(a) The required categories of health benefit plans for which HEDIS and other performance measures must be submitted for the upcoming measurement year;

(b) The selected HEDIS and other performance measures for each category of health benefit plan to be included in the reporting period;

(c) Quality and performance measures that will be subject to audit; and

(d) The HEDIS and other performance measures anticipated to be required in the measurement year occurring after the current measurement year.

Performance Measures Collection.

(1) Beginning in January of each reporting period, a carrier that is required to participate or elects to participate in the health benefit plan quality and performance evaluation system shall collect all required performance measures as follows:

(a) Collecting HEDIS measures, a carrier shall follow the specifications contained in the latest version or technical update of HEDIS applicable to the measurement year;

(b) Collecting other performance measures, a carrier shall follow specifications published by a nationally recognized organization involved in quality and performance measurement, and in accordance with the notice provided by the Commission in November for the measurement year; and

(c) A carrier shall use the specifications, templates, and other documents provided by the Commission, which shall be consistent with those published by the National Committee for Quality Assurance for HEDIS measures and, for non-HEDIS performance measures, required by the Commission, consistent with specifications, templates, or documents published by nationally recognized organizations involved in quality of care and performance measurement.

(2) A carrier is not required to submit HEDIS or other performance measures regarding proprietary information contained in descriptive information on health plan management and activities.

(3) The Commission shall provide technical assistance and auditing services to a carrier required to report the HEDIS and other performance measures.

Commission Publication of Health Benefit Plan Quality and Performance Evaluation Reports. On or before November 1 of each year, the Commission shall publish on its website one or more reports for use by consumers and purchasers who make health benefit plan enrollment and contracting decisions. The reports shall:

(1) Compare quality and performance evaluation results of each health benefit plan on the various HEDIS and other performance measures required by the Commission; and

(2) Include information on valid and reliable HEDIS and other performance measures that are comparable on a health benefit plan level, as determined by the Commission.