Texas Administrative Code
Title 25 - HEALTH SERVICES
Part 1 - DEPARTMENT OF STATE HEALTH SERVICES
Chapter 421 - HEALTH CARE INFORMATION
Subchapter B - COLLECTION AND REPORTING OF HEALTH PLAN EMPLOYER DATA AND INFORMATION SET (HEDIS) FROM HEALTH MAINTENANCE ORGANIZATIONS (HMOS)
Section 421.23 - Collection and Reporting of Health Plan Employer Data and Information Set (HEDIS) Data by Health Maintenance Organizations (HMOs)

Universal Citation: 25 TX Admin Code § 421.23

Current through Reg. 49, No. 38; September 20, 2024

(a) Any health maintenance organization (HMO) operating in the State of Texas on December 1, 1996, and on that date each year thereafter, shall have a system in place to collect the full HEDIS data set, and shall be required to report HEDIS data, collected during the next calendar year. Single service HMOs which contract as secondary providers with other HMOs to provide services to covered lives which are the same lives covered by the primary HMO, shall report data as necessary to fulfill data reporting requirements under this rule to the primary HMO, which will report HEDIS data to the Council. Single service HMOs, which contract directly with employers to provide specific services, shall report HEDIS data directly to the Council. Basic HMOs which contract as secondary providers with other basic HMOs to provide a range of health care services normally considered to be full health coverage on a specified group of covered lives, e.g., ages 0 to 18 year olds, shall report complete HEDIS data to primary HMOs, with which the secondary HMOs have contracted to provide services, which, in turn, shall report directly to the Council.

(b) HMOs shall report HEDIS data, by Service area division. Data to be reported shall be a subset of the "Reporting Set Measures" (i.e., this excludes data specified as "Testing Set Measures"), as specified by the Council by November 15th of the year for which the data are collected. Reporting by any specific subpopulation (e.g., Medicare, Medicaid) will be specified by the Council by November 15th of the year for which the data are collected.

(c) The HMO shall report HEDIS data to the Council by the reporting deadline as specified by NCQA or as specified by the executive director (should the date be incompatible with the Council's goals) in the current year.

(d) HEDIS data shall be reported to the Council or its agents at physical or telephonic addresses specified by the executive director. The executive director shall notify all HMOs in writing and by publication in the Texas Register at least 30 days before any change in the address.

(e) Any HMO which judges that it cannot meet required performance measure specifications due to either low enrollment (such that sample size requirements are not met) or short time of existence (such that length of time requirements are not met) shall provide the Council with a narrative that documents the reason for not reporting the data for that performance measure. Single service HMOs shall notify the Council to address which measures are applicable to the services they provide. All requests for exemptions from reporting data for any performance area(s) required by this chapter shall be submitted by the HMO on an annual basis, prior to November 15th of the year for which the data are collected, and processed by the executive director using the following procedures.

(1) An HMO requesting an exemption from reporting any required performance measure prescribed by this chapter shall submit to the executive director a letter requesting the exemption and provide all information necessary to establish the HMO's entitlement to the exemption. The exemption request shall be signed by the chief executive officer of the HMO who shall certify that all information contained in the request is true and correct.

(2) The executive director shall review the request for exemption. The executive director may request additional information from the HMO relevant to the exemption request. Within 30 days of receipt of a request for exemption, the executive director shall issue a letter granting or denying the exemption. If denied, the letter shall state in detail the reasons for the denial. The executive director shall notify Council members of exemptions requested and the disposition of these requests for information purposes only.

(3) If the executive director denies an exemption request, the HMO may resubmit the request along with any additional information or analysis the HMO deems relevant to the executive director. The resubmission shall be considered in the same manner as the initial submission.

(4) If the executive director denies the resubmitted exemption request, the HMO may appeal the executive director's decision to the Council. In making its determination, the Council will consider only those facts and issues which have been previously presented to the executive director. The Council will decide exemption appeals by majority vote of members present.

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