Current through Register Vol. 63, No. 9, September 1, 2024
(1) To comply with the requirements of ORS
743.814(2) and (3), an insurer offering a managed health benefit plan shall
electronically submit on or before June 30 of each calendar year an annual
quality assessment program summary for the previous calendar year to the
Division of Financial Regulation in the format required by the director of the
Department of Consumer and Business Services as set forth on the website of the
Division of Financial Regulation of the Department of Consumer and Business
Services. Filing and reporting requirements in this rule apply to:
(a) A domestic insurer; and
(b) A foreign insurer transacting $2 million
or more in health benefit plan premium in Oregon during the calendar year
immediately preceding the due date of a required report.
(2) For calendar year 2014 and each
subsequent calendar year the annual summary required under section (1) of this
rule must:
(a) Identify current quality
assessment program accreditations, accrediting organization, accreditation
level and date. If the quality assessment program is not accredited, describe
plans and timelines, if any, to gain accreditation.
(b) Describe the insurer's quality assessment
program that enables the insurer to evaluate, maintain and improve the quality
of health services provided to enrollees.
(c) Identify the frequency of internal
quality assessment program review, evaluation, and update.
(d) List quality improvement goals the
insurer has identified, measures of success towards meeting those goals and
outcomes demonstrated by selected measures.
(e) Provide a summary of policies and
monitoring activities established for each of the following program areas:
(A) Internal program monitoring and
oversight;
(B) Credentialing of
providers;
(C) Provider program
participation procedures;
(D)
Clinical practice guidelines;
(E)
Identification of priorities;
(F)
Assessment of enrollee satisfaction; and
(G) Enrollee and provider communication
processes
(3)
For calendar year 2014 and each subsequent calendar year the annual summary
required under section (1) of this rule must provide:
(a) The results of all publicly available
federal Health Care Financing Administration reports and accreditation surveys
by national accreditation organizations; and
(b) The reporting of the insurer's health
promotion and disease prevention activities, if any, as defined in the
Healthcare Effectiveness Data Information Set maintained by the National
Committee for Quality Assurance, including:
(A) The following preventive measures:
(i) Childhood immunizations, including the
percentage of children in the insurer's managed care health plans who have
received appropriate immunizations by their second birthdays; and
(ii) Tobacco use cessation, including the
percentage of adult smokers and the percentage of those who have ceased tobacco
use after receiving advice to quit smoking from a health professional in health
plans of the insurer.
(B) The chronic condition of diabetes as
specified in the Healthcare Effectiveness Data Information Set maintained by
the National Committee for Quality Assurance.
(C) The acute condition of pregnancy care.
The information must include the percentage of pregnant women in the insurer's
health plans that began prenatal care during the first 13 weeks of
pregnancy.
(4) To minimize duplicative reporting
requirements, the insurer may satisfy the reporting requirements of sections
(2) and (3) of this rule by submitting either of the following:
(a) Information prepared by the insurer for
another purpose if the information contains the information required by
sections (2) and (3) of this rule and the insurer highlights the relevant
information to satisfy the reporting requirement; or
(b) An addendum to an annual filing of the
immediately preceding year:
(A) Stating, if
applicable, that no information has changed since the previous annual filing;
or
(B) Identifying, if applicable,
only the information that has changed since the previous annual
filing.
(5)
Summary information described in sections (2) and (3) of this rule may include
information prepared by the insurer for the Healthcare Effectiveness Data
Information Set maintained by the National Committee for Quality Assurance and
may be submitted on the basis of any sampling method recognized by the
Healthcare Effectiveness Data Information Set maintained by the National
Committee for Quality Assurance. A multi-state or regional Healthcare
Effectiveness Data Information Set maintained by the National Committee for
Quality Assurance report may be used for reporting under this subsection if the
insurer furnishes with the report the number or an estimate of the number of
regional members and Oregon members to whom the report applies.
(6) An insurer may not submit addenda
described in sections (2) and (3) of this rule in two consecutive
years.
(7) Nothing in this rule
prohibits an insurer from submitting additional information that is significant
in relation to its quality assessment and improvement activities.
Publications: Publications referenced are available from the
agency.
Statutory/Other Authority: ORS 731.244, 743.814 &
743.819
Statutes/Other Implemented: ORS 743.804 &
743.814
