Current through Reg. 50, No. 187; September 24, 2024
(1)
Reporting Instructions.
(a) Any health
maintenance organization authorized to transact business in the state under
chapter 641, F.S., as of January 1 of the report year shall report access and
quality indicator data for Florida members to the Agency as identified in this
rule and specified in the Healthcare Effectiveness Data and Information Set
(HEDIS) Volume 2: Technical Specifications for Health Plans developed by the
National Committee for Quality Assurance (NCQA), 1100 13th St. NW, Third Floor,
Washington, DC 20005.
(b) Beginning
with calendar year 2018 data, each health maintenance organization shall submit
indicator data for each calendar year period no later than October 1 of the
following year.
(c) Extensions to
the indicator data due date will be granted by the Agency for a maximum of 30
days from the due date in response to a written request signed by the chief
executive officer of the health maintenance organization or his/her designee.
The request must be received prior to the due date and the delay must be due to
unforeseen and unforeseeable factors beyond the control of the reporting health
maintenance organization. Extensions shall not be granted verbally.
(d) Each health maintenance organization must
submit the HEDIS measures from the NCQA Interactive Data Submission System
(IDSS) file as an Excel file.
(e)
Each health maintenance organization shall send indicator data by electronic
mail to HMOguide@ahca.myflorida.com and shall include in the electronic mailing
the following information:
1. "HMO Indicator
Data";
2. Health maintenance
organization identification number assigned by the Agency;
3. Health maintenance organization name;
and
4. File name in the format
HMOyyyy.xls where yyyy is the year of the indicator
data.
(2)
Definitions - "HEDIS" means the Healthcare Effectiveness Data and Information
Set 2019 Volume 2: Technical Specifications for Health Plans developed and
published by the National Committee for Quality Assurance, 1100 13th St. NW,
Third Floor, Washington, DC 20005. HEDIS Volume 2: Technical Specifications for
Health Plans includes technical specifications for the calculation of
indicators of access and quality of care.
(3) Measures Required to be Reported.
Each health maintenance organization shall submit Florida
member aggregate data for each HEDIS measure listed in paragraphs (a) through
(k) for each line of business included for that measure. For each measure, the
applicable guideline is HEDIS 2019 Volume 2: Technical Specifications for
Health Plans which is hereby incorporated by reference and effective at
adoption. The copyrighted material can be viewed at the Agency 2727 Mahan
Drive, Tallahassee, FL 32308 and the Department of State, R.A. Gray building
500 South Bronough Street, Tallahassee, FL 32399. A copy may also be obtained
from the National Committee for Quality Assurance (NCQA), 1100 13th St. NW,
Third Floor, Washington, DC 20005.
(a)
Adult BMI Assessment (ABA) Medicaid;
(b) Childhood Immunization Status (CIS)
Medicaid;
(c) Immunizations for
Adolescents (IMA) Medicaid;
(d)
Breast Cancer Screening (BCS) Medicaid, Commercial, Medicare;
(e) Cervical Cancer Screening (CCS) Medicaid,
Commercial;
(f) Chlamydia Screening
in Women (CHL) Medicaid, Commercial;
(g) Controlling High Blood Pressure (CBP)
Medicaid, Commercial, Medicare;
(h)
Comprehensive Diabetes Care (CDC) Medicaid, Commercial, Medicare;
(i) Prenatal and Postpartum Care (PPC)
Medicaid, Commercial;
(j)
Well-Child Visits in the First 15 Months of Life (W15) Medicaid,
Commercial;
(k) Well-Child Visits
in the Third, Fourth, Fifth and Sixth Years of Life (W34) Medicaid,
Commercial.
(4)
Certification.
A copy of the statement of certification from the HEDIS
auditor that includes report designations for each performance measure must
accompany the plan's report submission.
(5) Penalties for Report Deficiencies.
(a) For purposes of this rule, a report,
certification, or other information is incomplete when it does not contain all
data required by the Agency in this rule or when it contains inaccurate data. A
report or certification is "false" if done or made with the knowledge of the
preparer or a superior of the preparer that it contains information or data
which is not true or accurate.
(b)
A health maintenance organization that refuses to file, fails to timely file,
or files a false or incomplete report, certification or other information
required to be filed under the provisions of section
408.061, F.S., other Florida
law, or rules adopted thereunder, shall be subject to administrative penalties
pursuant to section 408.08(5),
F.S.
(c) The penalty period will
begin on the first work day following the due date for purposes of penalty
assessments.
(d) The penalty for
filing a false report or refusal to file a report is $1, 000 per day for each
day until the report is corrected. The penalty for filing an incomplete report
is $50 per day for each day until the complete report is filed. The penalty for
failing to file timely is $50 per day until the report is
filed.
(6) Uniform
Publication Format.
(a) The Agency shall
publish the following indicator data for each indicator no less frequently than
every two years:
1. Health maintenance
organization name;
2. Calendar year
of data;
3. Type of product
line;
4. Rate; and,
5. Notation that the health plan is new or
small (not measurable) if applicable.
(b) In each publication of indicator data,
the Agency shall include a title and a summary description of the
indicator.
Rulemaking Authority 408.15(8) FS. Law Implemented 408.061,
408.063(2), 408.08(5), 641.51(9) FS.
New 6-27-00, Amended 10-22-02,
7-25-19.
