Code of Vermont Rules
Agency 21 - DEPARTMENT OF FINANCIAL REGULATION
Sub-Agency 040 - DIVISION OF HEALTH CARE ADMINISTRATION
Chapter 010 - RULE H-2009-03: CONSUMER PROTECTION AND QUALITY REQUIREMENTS FOR MANAGED CARE ORGANIZATIONS
Section 21 040 010 - RULE H-2009-03: CONSUMER PROTECTION AND QUALITY REQUIREMENTS FOR MANAGED CARE ORGANIZATIONS
Universal Citation: VT Code of Rules 21 040 010
Current through August, 2024
Part 1 GENERAL PROVISIONS
Section 1.1 Purpose
The purpose of this rule is to set forth the consumer protection and quality requirements that managed care organizations shall meet in order to further the purposes of its enabling statutes.
Section 1.2 Authority
This rule is issued pursuant to the authority vested in the Commissioner of the Department of Financial Regulation by 18 V.S.A. § 9414 and 8 V.S.A. §§ 15, 4089a, 4089b, and 4724.
Section 1.3 Applicability, Scope and
Delegation
(A) All managed care organizations,
including but not limited to health insurers, health maintenance organizations,
preferred provider organizations, exclusive provider organizations, mental
health review agents and all other financing mechanisms, systems and other
entities that manage health care delivery for members or subscribers of any
comprehensive major medical health benefit plan subject to the Department's
jurisdiction shall:
1. participate in
Blueprint for Health as required under
18 V.S.A. §
706 or another program approved by the
Department;
2. be accredited by the
National Committee for Quality Assurance (NCQA) or other national independent
accreditation organization approved by the Department;
3. operate in compliance with Parts 1 and 2
of this rule; and
4. be responsible
for the activities of their delegates in meeting the applicable
standards.
(B) The
Department shall promulgate a list of approved independent accreditation
organizations that it has determined meet the following criteria:
1. The independent accreditation organization
has demonstrated to the satisfaction of the Department that it is capable of
reviewing and analyzing a managed care organization's quality management
program as required by Sections 6.2. and 6.3 of this rule;
2. The independent accreditation organization
has experience in assessing quality of care and quality improvement for managed
care organizations;
3. The
standards used by the independent accreditation organization are made available
to the Department; and
4. The
independent accreditation organization is capable of preparing and submitting
to the managed care organization a written report summarizing the scope of its
review, its findings, and its recommendations for improvement, if
any.
(C) In addition to
Subsection (A) above, managed care organizations that use or administer
utilization management mechanisms for members or subscribers of any
comprehensive major medical health benefit plan subject to the Department's
jurisdiction are also subject to Part 3 of this rule.
(D) In addition to Subsection (A) above,
managed care organizations that use or administer pharmaceutical benefit
management mechanisms for members or subscribers of any comprehensive major
medical health benefit plan subject to the Department's jurisdiction are also
subject to Part 4 of this rule.
(E)
In addition to Subsections (A), (C) and (D) above, managed care organizations
that contract with providers, use or administer networks, designate particular
providers as preferred to otherwise use or administer any restrictions or
incentives pertaining to use of certain providers by members or subscribers of
any comprehensive major medical health benefit plan subject to the Department's
jurisdiction are also subject to Part 5 of this rule. Such organization shall
post electronically and submit an annual attestation certifying the managed
care organization's compliance with the requirements of this part to the
Commissioner in writing on or before July 15th.
(F) In addition to Subsections (A), (C), (D)
and (E) above, Part 6 of this rule shall apply to managed care organizations
including, in relevant part, the mental health review agents under contract
with managed care organizations, when they issue and/or participate in
administering comprehensive major medical health benefit plans and products
subject to the Department's jurisdiction that use utilization management
mechanisms and financial incentives for members to use certain providers.
The Department in its sole discretion may choose to waive parts of the requirements in Part 6 for these managed care organizations and mental health review agents.
(G) Each managed care organization, including
a mental health review agent and any delegate subject to this rule, in whole or
in part, is accountable for ensuring that it operates in compliance with all
applicable requirements of
18 V.S.A. §
9414 and
8 V.S.A.
§§ 4089a § 4089b, and 4724, this rule and any other applicable
laws and rules, regardless of whether it is functioning as a delegate or the
delegating entity. If a managed care organization delegates any activities or
functions to other persons or entities, the managed care organization may not
delegate its responsibility for the activities or functions, is accountable for
ensuring that its delegates operate in compliance with all applicable
requirements and shall maintain effective oversight of those activities, which
shall include:
1. A written description of
the delegate's activities and responsibilities, including reporting
requirements;
2. Evidence of formal
approval of the delegate's program by the managed care organization;
and
3. A process by which the
managed care organization at least annually evaluates the performance of the
delegate and any sub-delegates, including but not limited to a process by which
the managed care organization documents, tracks, addresses and resolves
complaints from members and providers regarding the delegate's conduct and/or
the conduct of any other managed care organization that performs any activities
on its behalf.
Section
1.4 Definitions
(A) "Adverse
benefit determination" means a denial, reduction, modification or termination
of, or a failure to provide or make payment (in whole or in part) for, a
benefit, including but not limited to:
1. a
denial, reduction, termination or failure to provide or make payment that is
based on a determination of a participant's or beneficiary's eligibility to
participate in a health benefit plan;
2. a denial, reduction, modification or
termination of, or a failure to provide or make payment (in whole or in part)
for, a benefit resulting from the application of any utilization review;
and
3. a failure to cover an item
or service for which benefits are otherwise provided because it is determined
to be experimental or investigational or not medically necessary or
appropriate.
(B)
"Blueprint for Health" means the state's plan for chronic care infrastructure,
prevention of chronic conditions, and chronic care management program, and
includes an integrated approach to patient self- management, community
development, health care system and professional practice change, and
information technology initiatives.
(C) "Case management" means a coordinated set
of activities conducted to support the member and his/her health care provider
in managing serious, complicated, protracted or other health
conditions.
(D) "Chronic care"
means health services provided by a health care professional for an established
clinical condition that is expected to last a year or more and that requires
ongoing clinical management attempting to restore the individual to highest
function, minimize the negative effects of the condition, and prevent
complications related to chronic conditions. Examples of conditions that are or
may be considered chronic include diabetes, hypertension, cardiovascular
disease, cancer, asthma, pulmonary disease, substance abuse, mental illness,
spinal cord injury, and hyperlipidemia.
(E) "Chronic care management" means a system
of coordinated health care interventions and communications for individuals
with chronic conditions, including significant patient self-care efforts;
systemic supports for the physician and patient relationship; and a plan of
care emphasizing prevention of complications utilizing evidence-based practice
guidelines, patient empowerment strategies, and evaluation of clinical,
humanistic, and economic outcomes on an ongoing basis with the goal of
improving overall health.
(F)
"Clinical peer" means a health care provider in a specialty that typically
provides the procedure or treatment, or diagnoses or manages the medical
condition under review and who holds a non-restricted license in a state of the
United States. A general internist or family practitioner who does not
typically provide the procedure or treatment, or does not typically diagnose or
manage the medical condition does not meet the definition of clinical peer, nor
does a Pharm D meet the definition of clinical peer, but a. Pharm D could serve
on the first level grievance panel of reviewers and assist a clinical peer
during the first level grievance procedures.
(G) "Clinical review criteria" means the
written screening procedures, clinical protocols, practice guidelines and
utilization management and review guidelines used by the managed care
organization to determine the necessity and appropriateness of health care
services.
(H) "Commissioner" means
the commissioner of the Vermont Department of Financial Regulation or his or
her designee.
(I) "Concurrent
review" means utilization review conducted during a member's stay in a hospital
or other facility, or other ongoing course of treatment.
(J) "Confidentiality code" means the
confidentiality code adopted by the Department of Financial Regulation on
December 1, 1993 and any subsequent revisions.
(K) "Contracted provider" means a provider
employed by, under contract or subcontract with, in a network, designated as
preferred or otherwise in an arrangement with a managed care organization for
the purpose of furnishing health care services to the members of the managed
care organization, regardless of the specific terms of or the terminology
applied by the managed care organization to its relationship with the
provider.
(L) "Credentialing
verification" or "credentialing reverification" means the process of obtaining
and verifying information about a health care provider and evaluating that
health care provider relative to the managed care organization's standards when
that health care provider applies to become or remain a contracted provider
with the managed care organization.
(M) "Delegate" means an entity to which a
managed care organization gives authority to carry out certain functions that
the managed care organization would otherwise perform, or the act of giving
authority to carry out certain functions to another entity.
(N) "Department" means the Department of
Financial Regulation.
(O)
"Discharge plan" means the plan that results from the formal process for
determining, before discharge from a health care facility, the coordination and
management of the care that a member will receive following the
discharge.
(P) "Dose restriction"
means imposing a restriction on the number of doses of prescription drug that
will be covered during a specific time period.
"Dose restriction" does not include a restriction on the number of doses when the prescription drug that is subject to the restriction cannot be supplied by or has been withdrawn from the market by the drug's manufacturer.
(Q) "Emergency
medical condition" means a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) so that a prudent
layperson, who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in a
condition described in clause (i), (ii), or (iii) of section 1867(e)(l)(A) of
the Social Security Act (
42 U.S.C.
1395 dd(e)(l)(A)). (In that provision of the
Social Security Act, clause (i) refers to placing the health of the individual
(or, with respect to a pregnant woman, the health of the woman or her unborn
child) in serious jeopardy; clause (ii) refers to serious impairment to bodily
functions; and clause (iii) refers to serious dysfunction of any bodily organ
or part.
(R) "Emergency services"
means, with respect to an emergency medical condition:
1. A medical screening examination (as
required under section 1867 of the Social Security Act,
42 U.S.C.
1395 dd) that is within the capability of the
emergency department of a hospital, including ancillary services routinely
available to the emergency department to evaluate such emergency medical
condition, and
2. Such further
medical examination and treatment, to the extent they are within the
capabilities of the staff and facilities available at the hospital, as are
required under section 1867 of the Social Security Act (
42 U.S.C.
1395 dd) to stabilize the patient.
(S) "File'', where used in the
context of information to be provided to the Department by a managed care
organization, means to file an original document by delivering it, and any
copies as requested by the Department, to the Department of Financial
Regulation and, if requested by the Department, to an organization designated
by the Department under Section 1.6(D). The Department may also, at its
discretion, permit documents to be filed electronically.
(T) "Grievance" means a complaint submitted
by or on behalf of a member regarding the:
1.
Adverse benefit determination;
2.
Availability, delivery or quality of health care services;
3. Claims payment, handling or reimbursement
for health care services; or
4.
Matters relating to the contractual relationship between a member and a managed
care organization or the health insurer offering the health benefit
plan.
(U) "Gynecological
health care services" means preventive and routine reproductive health and
gynecological care, including annual screening, counseling, and treatment of
gynecological disorders and diseases in accordance with the most current
published recommendations of the American College of Obstetricians and
Gynecologists.
(V) "Gynecological
health care provider" means a health care provider or health care facility that
is primarily engaged in providing gynecological health care services.
(W) "Health benefit plan" means a policy,
contract, certificate or agreement entered into, offered or issued by a health
insurer to provide, deliver, arrange for, pay for, or reimburse any of the
costs of health care services.
(X)
"Health care facility" means all institutions, whether public or private,
proprietary or nonprofit, which offer diagnosis, treatment, inpatient or
ambulatory care to two or more unrelated persons, and the buildings in. which
those services are offered. The term shall not apply to any facility operated
by religious groups relying solely on spiritual means through prayer or
healing, but includes all institutions included in
18 V.S.A. §
9432, except health maintenance
organizations.
(Y) "Health care
provider" or "provider" means a person, partnership or corporation, other than
a facility or institution, licensed or certified or authorized by law to
provide professional health care services to an individual during that
individual's health care, treatment or confinement.
(Z) "Health care services" or "services"
means services for the diagnosis, prevention, treatment, cure or relief of a
health condition, illness, injury or disease.
(AA) "Health insurer" means any health
insurance company, nonprofit hospital and medical service corporation, managed
care organization, and, to the extent permitted under federal law, any
administrator of an insured, self- insured, or publicly funded health care
benefit plan offered by public and private entities.
(BB) "Independent accreditation organization"
means an organization recognized by the Department as qualified to review some
or all of a managed care organization's quality management and consumer
protection activities according to the criteria established in this
rule.
(CC) "Independent external
review" means a review of a health care decision, by an independent review
organization pursuant to
8
V.S.A. §
4089f, as applicable and as may
be amended.
(DD) "Manage health
care delivery" means to apply any design or mechanism to a health benefit plan
to affect access to or the quality, coordination or cost of the health care
available to members under the health benefit plan, including but not limited
to the use of any form of utilization management; pharmaceutical benefit
management networks, preferred providers or any other restrictions or
incentives for members to use certain providers; and/or disease, care or case
management.
(EE) "Managed care
organization" means any financing mechanism or system that manages health care
delivery for its members or subscribers, including but not limited to health
maintenance organizations, preferred provider organizations, exclusive provider
organizations and any other health care delivery system or organization that
manages health care delivery for its members or subscribers, or that issues a
health insurance policy, plan, or subscriber contract which operates to manage
health care delivery. The term managed care organization includes a mental
health review agent as defined in
8 V.S.A. §
4089a, a health insurer as defined in
18 V.S.A. §
9402, a managed care organization as defined
in
18 V.S.A. §
9402, a delegate of a health insurer or
managed care organization, and any person or entity that meets the definition
of a managed care organization under law.
(FF) "Medical director" means a
Vermont-licensed physician who is board- certified or board-eligible in his or
her field of specialty as determined by the American Board of Medical
Specialties (ABMS) or the American Osteopathic Association (AOA), and who is
charged by a managed care organization with responsibility for overseeing all
clinical activities of the health benefit plan, or his or her
designee.
(GG) "Medical or
scientific evidence" means the following sources:
1. Peer-reviewed scientific studies published
in or accepted for publication by medical journals that meet nationally
recognized requirements for scientific manuscripts and that submit most of
their published articles for review by experts who are not part of the
editorial staff.
2. Peer-reviewed
literature, biomedical compendia and other medical literature that meet the
criteria of the National Institutes of Health's National Library of Medicine
for indexing in Excerpta Medica (EMBASE), Medline, and PubMed Medline, and
resources from the Cochrane Library, HSTAT, and the National Guideline
Clearinghouse.
3. Medical journals
recognized by the federal Secretary of Health and Human Services, under Section
1861(t)(2) of the federal Social Security Act.
4. The following standard reference
compendia: the American Hospital Formulary Service-Drug Information (AHFS Drug
Information), the American Dental Association Accepted Dental Therapeutics and
Monograph Series on Dental Materials and Therapeutics, The United States
Pharmacopeia, The National Formulary and the USPDI.
5. Findings, studies or research conducted by
or under the auspices of federal government agencies and nationally recognized
federal research institutes, including the Agency for Health Care Research and
Quality, National Institutes of Health, National Cancer Institute, National
Academy of Sciences, Centers for Medicare and Medicaid Services, and any
national board recognized by the National Institutes of Health for the purpose
of evaluating the medical value of health services.
6. Peer-reviewed abstracts accepted for
presentation at major medical association meetings.
(HH) "Medically-necessary care" means health.
care services, including diagnostic testing, preventive services and aftercare,
that are appropriate in terms of type, amount, frequency, level, setting, and
duration to the member's diagnosis or condition. Medically-necessary care must
be informed by generally accepted medical or scientific evidence and consistent
with generally accepted practice parameters as recognized by health care
professions in the same specialties as typically provide the procedure or
treatment, or diagnose or manage the medical condition; must be informed by the
unique needs of each individual patient and each presenting situation; and
1. Help restore or maintain the member's
health; or
2. Prevent deterioration
of or palliate the member's condition; or
3. Prevent the reasonably likely onset of a
health problem or detect an incipient problem.
(II) "Member" means any individual who has
entered into a contract with a health insurer or managed care organization for
the provision of health care services, or on whose behalf such an arrangement
has been made, as well as the individual's dependents covered by the
contract.
(JJ) "Mental health care
provider" means any person, corporation, facility or institution certified or
licensed by this state to provide mental health care or substance abuse
services, including but not limited to a physician, a nurse with recognized
psychiatric specialties, hospital or other health care facility, psychologist,
clinical social worker, mental health counselor, alcohol or drug abuse
counselor.
(KK) "Mental health
condition" means any condition or disorder involving mental illness or alcohol
or substance abuse that falls under any of the diagnostic categories listed in
the mental disorders section of the international classification of disease, as
periodically revised.
(LL) "Mental
health professional" means any person, certified or licensed by this state to
provide mental health care services, including but not limited to a physician,
a nurse with recognized psychiatric specialties, psychologist, clinical social
worker, mental health counselor, alcohol or drug abuse counselor.
(MM) "Peer review committee" means a
committee as defined in
26 V.S.A. §
1441, and for purposes of this rule includes
any quality management, credentialing or other similar committee established by
a managed care organization pursuant to
18 V.S.A. §
9414(c)(l) and this
rule.
(NN) "Person" means a natural
person, partnership, unincorporated association, corporation, limited liability
company, municipality, the state of Vermont or a department, agency or
subdivision of the state, or other legal entity.
(OO) "Pharmaceutical benefit management
program" ("PBMP") means any mechanisms or procedures used to manage
prescription drug benefits, including but not limited to formularies, dose
restrictions, prior or other authorization requirements, step therapy and/or
substitution requirements.
(PP)
"Post-service Review" means review of any claim for a benefit that is not a
pre-service or concurrent review claim as defined by this rule.
(QQ) "Pre-service Review" means review of any
claim for a benefit with respect to which the terms of coverage condition
receipt of the benefit, in whole or in part, on approval of the benefit in
advance of obtaining health care.
(RR) "Primary care provider" means a health
care provider who, within that provider's scope of practice as defined under
the relevant state licensing law, provides primary care services, and who is
designated as a primary care provider by a managed care organization.
(SS) "Primary care services" include services
provided by providers specifically trained for and skilled in first-contact and
continuing care for persons with undiagnosed signs, symptoms or health
concerns, not limited by problem origin (biological, behavioral or social),
organ system or diagnosis. Primary care services include health promotion,
disease prevention, health maintenance, counseling, patient education, self-
management support, care planning and the diagnosis and treatment of acute and
chronic illnesses in a variety of health care settings.
(TT) "Primary verification" means
verification of a health professional's credentials based upon evidence
obtained from the issuing source of the credential.
(UU) "Provider Directory" means a
comprehensive list of all of the health care providers employed by, under
contract or subcontract with, in a network, designated as preferred or
otherwise in an arrangement with the managed care organization and available to
members or subscribers of a particular health benefit plan.
(VV) "Provider List" means a subset of the
provider directory created by the managed care organization to meet a
particular member's health care and geographic accessibility needs, usually
generated in response to a request from the member or the member's
representative.
(WW) "Quality
management program" means a set of procedures and activities designed to
safeguard or improve the quality of health care and the quality of the managed
care organization's service to members and providers by assessing the quality
of care or service, usually against a set of established standards, and taking
action to improve it.
(XX) "Quality
improvement" means the effort to improve the quality of health care services
and outcomes of treatment for members as well as the quality of the managed
care organization's service to members and providers. Opportunities to improve
care and service are found primarily by continual examination of, and continual
feedback and education about how services are provided and the results they
produce.
(YY) "Quality of care"
means the degree to which health care services for individuals and populations
increase the likelihood of desired health outcomes, decrease the probability of
undesired health outcomes, and are consistent with current professional
knowledge.
(ZZ) "Referral" means a
prior authorization from the managed care organization or contracted provider
that allows a member to have one or more appointments with a health care
provider for consultation, diagnosis, or treatment of a medical condition, to
be covered as a benefit under the member's health benefit plan
contract.
(AAA) "Relevant document,
record or other information" means, for the purposes of Section 3.3, that a
document, record or other information shall be considered relevant if such
document, record or other information was relied upon in making the benefit
determination or the determination of a grievance, or was submitted, considered
or generated in the course of making the benefit determination or the
determination of a grievance, without regard to whether such document, record
or other information was relied upon in making the benefit determination or the
determination of a grievance.
(BBB)
"Secondary verification" means verification of a health professional's
credentials based on evidence obtained by means other than direct contact with
the issuing source of the credential.
(CCC) "Service area" means the geographic
region in or for which a health benefit plan subject to Part 5 or 6 of this
rule is, consistent with applicable law, marketed, sold, intended by the issuer
and described in the policy and certificate as the region in which the travel
and waiting time standards in Section 5.1 of this rule are met and in which
certificate holders are expected to and are able to access all or most of the
covered benefits at the benefit level most advantageous to the member. That a
health benefit plan subject to Part 5 or 6 of this rule may be required to
authorize coverage for services for individual members in a location outside of
the service area at the benefit level most advantageous to the member does not
subject that location to the travel and waiting time requirements of this
rule.
(DDD) "Stabilize" means, with
respect to an emergency medical condition, the meaning given in section
1867(e)(3) of the Social Security Act (
42 U.S.C.
1395 dd(e)(3).
(EEE) "Step therapy" means a type of protocol
that specifies the sequence in which different prescription drugs are to be
tried for treating a specified medical condition.
(FFF) "Urgently-needed care" or "urgent care"
means those health care services that are necessary to treat a condition or
illness of an individual that if not provided promptly (within twenty-four
hours or a time frame consistent with the medical exigencies of the case)
presents a serious risk of harm.
(GGG) "Utilization management" means the set
of organizational functions and related policies, procedures, criteria,
standards, protocols and measures used by a managed care organization or
pharmaceutical benefit management program to ensure that it is appropriately
managing access to and the quality and cost of health care services, including
prescription drug benefits, provided to its members.
(HHH) "Utilization review" means a set of
formal techniques designed to monitor the use of, or evaluate the clinical
necessity, appropriateness, efficacy, or efficiency of, health care services,
procedures, or settings, including prescription drugs.
(III) "Utilization review guidelines" mean
the normative standards and clinical review criteria for resource utilization
for various clinical conditions and medical services that are used by managed
care organizations in deciding whether to approve or deny health care
services.
Section 1.5
Confidentiality of Quality Management and Peer Review Information
(A) Except as otherwise required by
18 V.S.A. §
9414, each managed care organization shall
take the appropriate steps necessary to ensure that information gathered by it
in its peer review and quality management activities, including those conducted
in relation to credentialing, recredentialing and associated monitoring, shall
be maintained as confidential and privileged.
(B) Peer review, quality management and other
similar information made available to the Department or other designated
organizations under
18 V.S.A. §
9414 shall be furnished in a manner that does
not disclose the identity of individual patients, health care providers or
other individuals, unless otherwise specified by the Department.
(C) The minutes or records of the peer review
or quality management committee formed under Parts 5 or 6 of this rule are
confidential and privileged under
26 V.S.A. §
1443, except as otherwise provided in
18 V.S.A. §
9414 and this rule.
(D) The Department's confidentiality code
shall apply to the collection and review of information by the Department or
its designated organization under
18 V.S.A. §
9414 and this rule.
(E) Peer review, quality management and other
similar information disclosed to the Department pursuant to this rule shall be
confidential and privileged and shall not be subject to subpoena or available
for public disclosure, except as otherwise required by
18 V.S.A. §
9414 or this rule.
(F) The Department is authorized to use any
information gathered in the course of its review, including confidential or
privileged information, in the course of any legal or regulatory action against
a managed care organization. Information used in a legal or regulatory
proceeding that is required to be kept confidential, including the records of
the peer review or quality management committee designated under Parts 5 or 6
of this rule, shall be filed with the court or appropriate administrative body
under seal and shall not be available for public disclosure.
Section 1.6 Compliance Assessment
and Review Generally
(A) The Department in its
sole discretion may assess and review the performance of managed care
organizations not otherwise subject to Part 6 7 of this rule by:
1. Applying all or part of the annual and/or
periodic filing and/or review requirements in Part 6 to a managed care
organization subject to this rule but not otherwise subject to Part 6, with at
least one year's notice from the Department to the managed care organization;
or
2. Assessing data, reports,
inquiries, complaints, independent external review requests and other
information available to or requested by the Department. In exercising this
discretion, the Department may consider factors such as but not limited to the
nature and extent of care management mechanisms or financial incentives used,
baseline performance, performance over time, accreditation status, anticipated
changes in the number of covered lives and/or any other information regarding
the managed care organization, the affiliated mental health review agent and
any delegates of these organizations.
(B) Compliance assessment and enforcement
with respect to delegates, except for mental health review agents subject to
Part 6 of this rule, that manage health care delivery for members or
subscribers of any comprehensive major medical health benefit plan subject to
the Department's jurisdiction may be conducted through the Department's
assessment of the delegating entity, subject to the Department's discretion.
The Department may determine that direct examination of a delegate is warranted
and may elect to directly assess compliance and/or commence enforcement action
7 against a delegate based on factors such as but not limited to the number of
Vermont members affected, data and reports regarding the delegate's
performance, and the volume and severity of complaints regarding the
delegate.
(C) The Department may at
any time conduct an evaluation of a managed care organization's performance in
specific areas of operations. Such focused reviews may be performed in response
to periodic review findings, a complaint or grievance, a pattern of complaints
or grievances or other information that has come to the attention of the
Department. The Department shall advise the managed care organization of the
specific areas of operations that will be the subject of the review and the
statutory or regulatory provisions under examination. This review will be
carried out through the assessment of documentation submitted by the managed
care organization as required by this rule and by review of any other records
or other examination as deemed necessary by the Department, and may include an
on-site review of the managed care organization and/or its delegate.
(D) The Department may, in its discretion,
designate another organization to review baseline, annual, periodic or other
filings and to conduct baseline, periodic or focused reviews of a managed care
organization. Any such organization shall have a confidentiality code
acceptable to the Department, or shall be subject to the Department's
confidentiality code. The Department shall notify a managed care organization
of the identity of such an organization before commencing the
evaluation.
(E) The Department in
its capacity as a health oversight agency pursuant to federal law and as
authorized by
18 V.S.A. §
9414 or its designated organization may
examine and review information protected by the patient's privilege established
in
12 V.S.A. §
1612(a) or otherwise
required by law to be held confidential.
1.
Notwithstanding the provisions of
26 V.S.A. §
1443, the Department or its designated
organization shall have reasonable access to the minutes or records of the
managed care organization's peer review, quality management and any other
committee for the sole purpose of reviewing the managed care organization's
compliance with this rule and other applicable law.
2. Records or minutes of the peer review,
quality management and any other committees reviewed by the Department or its
designated organization under this section shall not disclose the identity of
patients, health care providers or other individuals.
(F) The Department may examine and review the
data reported or required to be reported to the Department under Titles 8 or 18
of the Vermont Statutes Annotated, this rule and any other applicable rule, as
well as examine and review the methodologies used by the managed care
organization to compute measures used by the managed care organization to
comply with such laws or rules.
(G)
The Department or its designated organization shall prepare and keep on file a
written report summarizing the scope of its review, its findings, its
recommendations for improvement and determinations regarding areas of
non-compliance, if any. If prepared by an organization designated by the
Department, the written report shall include findings and recommendations for
improvement. The Department shall review the report and shall make a final
determination on the findings, recommendations for improvement and
determinations regarding areas of non-compliance, if any.
(H) In addition to making a determination
under paragraph (G) of this subsection, the Department may require a managed
care organization to amend or modify its quality management program or other
programs or activities in order to comply with this rule and other applicable
law. Failure of the managed care organization to comply with the requirement
shall be deemed a violation of law.
Section 1.7 Implementation Manual
Implementation of this rule will be guided by the Implementation Manual effective as of January 1, 2015, except where the Implementation Manual is in conflict with the most recent rule, other Department guidance, or Federal or State law. Any portion of the Implementation Manual that was effective January 1, 2015 that was based on language in the previous version of this rule (2009-03 effective December 17, 2009) that has been repealed shall no longer be applicable.
Section 1.8 Payment for Baseline, Annual,
Periodic and Focused Compliance Reviews
(A)
Each managed care organization subject to examination, investigation or review
by the Department under
18 V.S.A. §
9414 and this rule shall pay the Department
the reasonable costs of such activities in an amount to be determined by the
Commissioner.
(B) A managed care
organization shall pay the costs due under this subsection within thirty (30)
days of receipt of an invoice from the Department. The Department, in its sole
discretion, may offer a payment plan to managed care organizations if costs are
greatly in excess of anticipated amounts.
(C) Failure of a managed care organization to
pay any costs assessed under
18 V.S.A. §
9414(h) and this rule is a
violation of Vermont law and shall be subject to any and all sanctions allowed
by law.
Section 1.9
Coordination with Other Relevant State Functions
If any department of the Agency of Human Services is designated by statute to conduct activities that specifically relate to any function of a managed care organization specified in this rule, the Commissioner, in the Commissioner's sole discretion, may accept all or part of the agency's assessment of the managed care organization's compliance with requirements pertaining to that function, in whole or in part.
Section 1.10 Enforcement
The Department has the power and responsibility to ensure that each managed care organization acts in accordance with applicable law. In exercising this jurisdiction, the Department may use any or all of the powers granted to it under Title 8 of the Vermont Statutes Annotated and Chapter 221 of Title 18 of the Vermont Statutes Annotated in the course of monitoring, investigating or 7 otherwise ensuring compliance by managed care organizations with the requirements of this regulation and any other applicable law or regulation. Approval of a filing or review does not preclude investigation and/or enforcement action by the Department if indicated.
Section 1.11 Severability
If any provision of this rule or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of such provisions to other persons or circumstances shall be not affected thereby.
Section 1.12 Effective Date
This rule shall take effect 15 days after adoption.
Part 2 BASIC CONSUMER PROTECTIONS REQUIRED OF ALL MANAGED CARE ORGANIZATIONS
Section 2.1 Maintenance of Health Care
Information; Confidentiality Procedures
(A)
Each managed care organization shall establish and implement policies,
standards and procedures to protect the confidentiality, security and integrity
of individually:- identifiable health care information in its possession or
used by it in order to ensure that the information is not negligently,
inappropriately or unlawfully disclosed. For purposes of this section,
"individually-identifiable health care information" means any data or
information, whether oral or recorded, in any form or medium, that identifies
an individual or can reasonably identify an individual by reference to
publicly-available information; relates to the individual's health history,
health care or health status, and is obtained by or from a health care
provider, a health care facility, a health insurer, or an employer. These
policies, standards and procedures shall include:
1. the use of nondisclosure and
confidentiality policies and agreements, which shall include guidelines for
access to health care information on a need to know basis only, and safeguards
to enforce those guidelines;
2.
periodic training for all employees as to the policies, standards and
procedures established under this provision, applicable state or federal laws
or regulations as to the confidential handling of health care information, and
any related licensing rules or professional ethical standards;
3. disciplinary measures for violations of
the managed care organization's confidentiality policies, standards or
procedures;
4. the identification
of individuals who are authorized to disclose individually-identifiable health
care information;
5. methods for
handling, disclosing, storing and disposing of individually identifiable health
care information, including procedures for appropriate responses to
court-ordered legal process, legal or regulatory process from a governmental
entity or legal process issued by an attorney; and
6. if the managed care organization is an
employer of or contracts with the individual whose information is being
collected or used for health care services purposes, policies, standards and
procedures to ensure that the individual's health care information is
maintained separately and apart from the individual's other records and is used
only for the lawful health care purposes for which the information was
acquired.
(B) All managed
care organizations shall comply with HIPAA privacy and security guidelines and
recommendations. Such compliance shall constitute compliance with this
section.
Section 2.2
Disclosure of Information
(A) Policy Forms,
Certificates and Handbooks: Each managed care organization that issues, is the
plan administrator for or is a delegate responsible for the plan documents
specified below that relate to a comprehensive major medical health benefit
plan subject to the Department's jurisdiction shall ensure that the policy form
or certificate, and handbook if used, are approved by the Department prior to
use and meet the following requirements in addition to any other requirements
specified by the Department:
1. The text
shall be in at least eleven-point font in hard copy; in plain language at no
greater than an eighth-grade reading level, or less if required by other law;
shall be organized in a way that is visually easy to read and use; and shall
include a table of contents and a definitions section. The Department, in its
sole discretion, may waive the eighth-grade reading level requirement for parts
of the text for good cause shown.
2. The documents shall be made available in
hard copy, on the internet and in a format suitable for electronic mailing;
provided to each member in the format requested upon enrollment and upon any
changes thereafter and shall also be made available upon request to prospective
members prior to enrollment. A managed care organization may satisfy the
requirements of this section by giving a copy of the approved policy form and
the handbook, if used, to each subscriber rather than to each individual
member. Information shall be provided to members regarding how to obtain
necessary translation or interpretation of the document.
3. At least the following information shall
be contained in the policy form or certificate and, if a handbook is used, in
the handbook:
a. The health benefit plan's
coverage provisions, including a clear description of the service area, if
applicable, health care benefits, benefit maximums, benefit limitations,
exclusions from coverage (including procedures deemed experimental or
investigational by the managed care organization), restrictions on referral or
treatment options, requirements for prior authorization, utilization review,
notification of hospital admission or other member obligations to notify the
managed care organization, the use of formularies, and any other limitations on
the services covered under the member's enrollment plan. All plan materials,
including a handbook if one is used, shall clearly explain the legal effect of
each plan document.
b. If prior
authorization or utilization review is required before obtaining treatment or
services, the process of a member must use to obtain that authorization or
review, including any time lines that apply and how to obtain an expedited
review.
c. The financial
inducements offered to any health care provider or health care facility for the
reduction or limitation of health care services. Nothing in this paragraph
shall be construed to require disclosure of individual contracts or the
specific details of any financial arrangement between a managed care
organization and a health care provider unless otherwise required by
law.
d. The member's responsibility
for payment of premiums, coinsurance, co-payments, deductibles and any other
charges, annual limits on a member's financial responsibility, caps on payments
for covered services, and the member's financial responsibility for non-covered
procedures, treatments or services.
e. The member's financial responsibility for
payment when services are provided by a health care provider who is not a
contracted provider with the managed care organization, as applicable, or by
any provider after an adverse benefit determination by the managed care
organization.
f. A description of
the grievance process used to resolve disputes between a member and the managed
care organization, and how the member can access that process.
g. A summary of the managed care
organization's quality management program.
h. An explanation that emergency services do
not require prior authorization; that coverage for emergency services outside
of the service area will be the same as for emergency services within the
service area; that it is the responsibility of the managed care organization or
health insurer to respond to, defend against and resolve any request or claim
by a non-contracted provider of emergency services for payment exceeding the
amount it was paid or reimbursed by the member's managed care organization or
health insurer and the point of contact at the managed care organization or
health insurer for a member who receives any such request or claim.
i. How members seeking information or
authorization can contact the appropriate department or staff member of the
managed care organization.
j. How
the member may obtain the most current provider directory and provider lists in
a manner and format readily accessible to the member.
k. The process for selecting primary care
providers (if selection is encouraged or required) and for obtaining access to
other providers under contract with the managed care organization, including
any restrictions on the use of contracted specialists.
l. The procedure for changing primary and
specialty care providers under contract with the managed care organization,
including any restrictions on changing providers, where applicable.
m. How members can obtain standing referrals
to contracted specialists, or use specialists or specialized facilities to
provide and coordinate their primary and specialty care pursuant to the
requirements of this rule, where applicable.
n. The waiting time and travel time standards
established by this rule.
o.
Opportunities for member participation in the development of managed care
organization policies and in the managed care organization's quality management
activities.
p. Information
regarding consumer information and services, including local and toll-free
consumer or member services telephone numbers for the managed care
organization, the Department and the Vermont Office of Health Care Advocate,
with an explanation of each organization's respective role.
q. A list of all information available to the
member upon request, as required by this rule.
r. If the managed care organization manages
pharmaceutical benefits, the disclosure shall also explain in a clear and
prominent manner that pharmaceutical benefit management with respect to
particular drugs may change frequently; and how and where members and providers
can access the primary source of up-to-date pharmaceutical benefit information,
including but not limited to lists of the specific drugs subject to
pharmaceutical benefit management; whether, how and under what conditions a
particular drug is or is not covered by the plan; and the process by which
grievances and exceptions to pharmaceutical benefit management decisions may be
made
(B) Oral
and Written Communications With Members:
1.
Managed care organizations shall ensure that all communications in response to
inquiries regarding access to and reimbursement for covered services explain to
the member or person contacting the managed care organization on the member's
behalf, unless clearly not applicable:
a. that
coverage and the extent and level of coverage are governed by the plan
documents and are not guaranteed until all requirements for utilization review
and grievance, if relevant have been completed and documentation of
authorization has been issued;
b.
how documentation of the authorization, including the extent and level of
coverage, will be issued; and
c.
when applicable, that a member may be billed by a non- contracted provider(s)
for any balance between the provider's charges and the amount paid by the
health benefit plan. Whether or not in response to an inquiry, all
communications to a member regarding payment or reimbursement for emergency
services rendered by a non- contracted provider shall include clear notice that
it is the responsibility of the managed care organization or health insurer to
respond to, defend against and resolve any request or claim by a non-contracted
provider of emergency services for payment exceeding the amount it was paid or
reimbursed by the member's managed care organization or health insurer and
shall include information regarding the point of contact at the managed care
organization or health insurer for a member who receives any such request or
claim.
2. Managed care
organizations shall meet the following additional requirements with respect to
communications regarding mental health and substance abuse services:
a. The managed care organization shall
explain that the member (and/or the member's representative) may obtain active
assistance from the managed care organization, including from a clinical
representative if preferred and requested, to locate a provider list that will
assist them in identifying providers who are qualified to deliver the type of
care being sought, are currently taking new patients, and provide services that
are generally considered to be covered benefits.
b. The managed care organization shall
explain that if a member wishes to access a provider of mental health or
substance abuse services not currently under contract with the managed care
organization, a provider willing to meet the terms and conditions for
participation may apply for contracted status and may become a contracted
provider after successful completion of credentialing;
c. In the case of any inquiry or request for
a provider list regarding a level of mental health or substance abuse care more
intense than office-based outpatient services or that otherwise indicates an
urgent, medically complex or unique situation related to mental health or
substance abuse, the managed care organization shall transfer the member to a
clinical representative of the managed care organization for assistance;
and
d. When a clinical
representative response is required under paragraphs a, b, or c of this
subsection, the representative shall offer assistance, as appropriate, to
initiate utilization management and, if relevant, inform the person making the
inquiry whether a relevant case management or chronic care program is
available, the benefits of participation and how the member may obtain the
service.
3. The managed
care organization shall maintain evidence of compliance with the requirements
of this section for all of its communications with or on behalf of members.
Failure to produce evidence of compliance shall result in a presumption
favoring the member's position in the event of an internal grievance and any
complaint to or enforcement action by the Department.
Section 2.3 Access to and
Continuity of Care: Generally
(A) Managed care
organizations shall ensure that their policies and procedures facilitate the
provision of health care services to their members in a manner informed by
generally accepted medical or scientific evidence consistent with prevailing
standards of medical practice as recognized by health care professions in the
same specialties as typically provide the procedure or treatment, or diagnose
or manage the medical condition, and shall take into account the unique needs
of each individual patient and each presenting situation.
(B) Each managed care organization shall
ensure timely access to effective, medically necessary care and shall monitor
and take action, as necessary, to improve coordination and continuity of care
for its members across service providers. For purposes of this section,
"coordination and continuity of care" means that a member's health care
services are managed by the managed care organization(s) in a manner that
facilitates collaborative and effective treatment of a condition, illness or
other medical condition, including but not limited to ensuring that the managed
care organization:
1. manages the benefits
available for treatment of mental health and substance abuse conditions in a
manner that allows for the effective provision of medically necessary care in
urgent, medically complex, and unique situations, including but not limited to
situations involving children and adolescents;
2. has authorized covered benefits necessary
for a medically safe and appropriate discharge or transition plan developed
after consultation with the treating health care provider or the provider's
designee before the managed care organization renders a decision that will
result in discharge or transfer from a facility; and
3. collaborate with health care providers to
monitor and improve coordination between mental health and other health
care.
Section
2.4 Access to and Continuity of Care: Emergency and Urgent
Services
(A) Each managed care organization
shall ensure that its members have access to emergency services twenty-four
(24) hours per day, seven (7) days per week inside the health benefit plan's
service area, and coverage for such services whether the member is inside or
outside the health benefit plan's usual service area at the time such services
are needed.
(B) If a prudent
layperson or provider would have believed that an emergency medical condition
existed, a managed care organization shall cover emergency services provided in
a hospital or other medically appropriate setting necessary to evaluate,
stabilize and provide medically necessary emergency transport for a member. A
managed care organization shall not require prior authorization of such
services or the use of contracted providers. Coverage for the member shall be
consistent with the terms and conditions for coverage of services obtained from
a contracted provider within the service area whether or not the emergency
services were obtained from contracted providers within or outside of the
health benefit plan's service area. There shall be no additional liability to
the member. The liability of a managed care organization or health insurer to a
non-contracted provider for emergency services rendered to a member shall be
limited to the reasonable and customary value for the health care services
rendered, except that it shall be the responsibility of the managed care
organization or health insurer to respond to, defend against and resolve any
provider request or claim for payment exceeding the amount it paid or
reimbursed the provider pursuant to this subsection. Nothing in this section
shall be construed to prohibit a managed care organization from:
1. holding members financially responsible
pursuant to the terms of the insurance policy or certificate if they obtain
services that do not meet the definition of "emergency services" set forth in
this rule;
2. advising members that
they may contact the managed care organization in advance to ascertain whether
the presenting condition meets the definition of "emergency medical condition"
set forth in this rule;
3.
requiring a contracted provider or facility to contact the managed care
organization to initiate utilization review within twenty-four (24) hours of an
emergency admission; or
4. if the
health benefit plan makes such notification an obligation of the member, or in
the event of admission to a facility not under contract with the managed care
organization, requiring member contact to initiate utilization review within
twenty-four (24) hours of admission or as soon after admission as is reasonably
possible for the member.
(C) A managed care plan shall cover emergency
services if the managed care organization, acting through a contracted provider
or through any other authorized representative, has authorized the provision of
emergency services. In the event such authorization has been given or obtained,
the managed care organization shall not subsequently retract its authorization
after the emergency services have been provided, or reduce payment for an item
or service furnished in reliance on the authorization, unless the authorization
was based on a material misrepresentation about the member's health condition
made by the member or by the provider of emergency services.
(D) Coverage of emergency services shall be
subject to applicable copayments, coinsurance and deductibles.
(E) Each managed care organization shall
ensure that its members have access to urgently-needed care as defined in this
rule inside the health benefit plan's service area, and coverage for such
services whether the member is inside or outside the health benefit plan's
usual service area at the time such services are needed.
Section 2.5 Grievance Procedures for Managed
Care Organizations Not Subject to Part 3
A managed care organization that does not use or administer utilization management mechanisms and that is therefore not subject to Part 3 of this rule shall have a review process available to address and resolve member grievances that meets the timeframes and other applicable requirements in Section 3.3 of this rule.
Part 3 ADDITIONAL REQUIREMENTS IF UTILIZATION MANAGEMENT MECHANISMS ARE USED
Section 3.1
General Requirements for Utilization Management Programs
(A) Each managed care organization shall be
responsible for monitoring all utilization management activities carried out by
it or on its behalf and for ensuring that all requirements of this rule and
other applicable laws and rules are met.
(B) A managed care organization that conducts
utilization management shall implement a written utilization management program
that describes all utilization management activities, both delegated and
non-delegated, for services provided to members. The program document shall
describe, and, where applicable, the managed care organization shall ensure
implementation of, the following:
1.
Procedures to evaluate whether the requested service is a covered benefit. In
the case of new technology, services or treatment; or new application of
existing technology, services or treatment, the managed care organization shall
have a mechanism to evaluate its inclusion in the benefit package based on
reviews of information from appropriate bodies, using professionals with
appropriate specialty expertise in the new technology, services, or treatment
and including consideration of determinations made by independent review
organizations pursuant to
8
V.S.A. §
4089f.
2. Procedures to evaluate the medical
necessity, appropriateness, efficacy or efficiency of health
services;
3. The data sources and
utilization review guidelines used in utilization management;
4. The process by which individual clinical
case data, assessments and information are used together with utilization
review guidelines during pre-service, concurrent and post-service reviews in
making decisions to approve or deny requested health care services;
5. The process for conducting reviews of
adverse determinations;
6.
Mechanisms to ensure the consistent application of utilization review
guidelines and consistency in decisions such that, within the scope of coverage
limits, decisions are compatible with the definition of "medically necessary
care" in this rule and with the unique needs of each individual patient and
each presenting situation. The mechanisms shall include annual training in
utilization review guidelines and annual accuracy and interrater reliability
testing for and with all reviewers;
7. The data collection processes and
analytical methods used in assessing the utilization of health care services by
members;
8. Provisions for ensuring
the confidentiality of clinical and proprietary information;
9. The organizational structure (for example,
utilization management committee, quality management committee, or other
committee) that periodically assesses utilization management activities and
reports to the managed care organization's governing body; and
10. The staff position functionally
responsible for the day-to-day management of the utilization management
function.
(C) Each
managed care organization's utilization management program shall use documented
utilization review guidelines that are informed by generally accepted medical
and scientific evidence and consistent with clinical practice parameters as
recognized by health care professions in the same specialties as typically
provide the procedure or treatment, or diagnose or manage the medical
condition. The managed care organization shall demonstrate to the satisfaction
of the Commissioner that the utilization review guidelines have been
periodically reviewed and updated, taking into account input from practicing
physicians and other health care providers, including providers under contract
with the managed care organization, if any. Relevant utilization review
guidelines shall be made available to all providers under contract with the
managed care organization, if any, and shall be made available to members and
any of their treating providers upon request. With respect to utilization
review guidelines for services related to mental health and/or substance abuse
conditions and disorders, the Commissioner may consult with the Vermont
Department of Health, the Vermont Department of Mental Health and/or other
clinical experts in mental health and substance abuse conditions and disorders
in assessing compliance with this subsection. This subsection shall not be
construed to require managed care organizations to make modifications to
nationally-recognized guidelines based on input from their contracted
providers.
(D) Utilization
management mechanisms shall:
1. not deter
timely access to or compromise the effectiveness of medically necessary care
for any condition;
2. not result in
any compromise to a member's safety;
3. be of a nature, frequency and periodicity
that is clinically reasonable in view of the diagnosis or condition generally,
the nature of the service(s) under review and, with respect to concurrent
review or other review during an ongoing course of treatment, that takes into
account the member's past history, current condition and progress during the
course of treatment; and
4. take
into account and make reasonable accommodations when a member's condition
impacts the member's ability to follow utilization management
procedures.
(E) In
addition to the other requirements in this part, utilization management
mechanisms applied to mental health and/or substance abuse benefits shall:
1. be prospective or concurrent with the
treatment unless otherwise requested by a member or his/her representative, or
by a provider on behalf of a member;
2. not result in an adverse benefit
determination until the reviewer has directly communicated with the member's
treating mental health provider or the treating mental health provider's
designee, unless the treating provider or designee has refused or repeatedly
failed to engage in such communication when it has been offered at a time and
in a manner reasonably convenient to the provider;
3. ensure that any adverse benefit
determination shall include the evaluation, findings, and concurrence of a
Vermont-licensed mental health professional whose training and expertise is at
least comparable to that of the treating provider;
4. be designed to allow a member to initiate
a course of outpatient mental health or substance abuse treatment by directly
accessing a contracted provider. The managed care organization shall ensure
that the financial requirements and treatment limitations applicable to such
primary mental health or substance use disorder benefits shall apply in the
same manner and to the same extent as primary care services;
5. be based on the complexity of the
individual case and shall not require greater burden to the member or the
treating health care provider than would be required for utilization management
of similar benefits, including, but not limited to requiring additional steps
on the part of the member or provider, or requiring a greater investment of
time by the member or provider in fulfilling requirements for utilization
management; and
6. take into
account and be tailored to at least the following factors: the patient's
clinical acuity; intoxication and/or withdrawal potential; biomedical, mental
health and/or substance abuse co- morbidities; functional status; relapse
potential; treatment and recovery history; and assessment of coping skills in
view of the anticipated recovery environment.
(F) Each managed care organization shall have
a registered nurse or physician and, for mental health and substance abuse
utilization management, a qualified licensed mental health care provider
readily available by telephone seven (7) days a week, twenty-four (24) hours
each day, to render utilization review determinations to members and treating
providers.
(G) With regard to
utilization management determinations, each managed care organization shall
ensure that:
1. Individual clinical case
assessments and clinical data reported by the treating provider are given equal
or greater weight than utilization review guidelines in making decisions to
approve or deny care, with the former taking precedence over the latter when
there is a conflict between the two.
2. All determinations to deny, limit, reduce,
terminate or modify an admission, service, procedure or extension of stay are
rendered by a physician under the direction of the medical director responsible
for medical services provided to the managed care organization's members,
except when the denial is based on eligibility for coverage or is a denial of a
service that is clearly excluded from coverage and that could not in any way be
considered an appealable decision pursuant to
8
V.S.A. §
4089f or any other Vermont laws
or rules regarding independent external review.
3. If services that require prior
authorization have been authorized and the services are either currently being
provided to a member in a health care facility or are another type of ongoing
course of treatment and the treating provider has determined that it is
medically necessary for the ongoing course of treatment to continue without
disruption or delay, the services shall continue to be covered until:
a. the exhaustion of all internal expedited
grievances, if requested within twenty-four (24) hours of receipt of the
denial(s); or until the independent external review decision is issued, if
expedited independent external review is requested within twenty-four (24)
hours of the receipt of the final grievance decision and notice of appeal
rights by the member and is conducted in accordance with the time frames
specified by law; and
b. the
managed care organization has authorized coverage for a medically safe and
appropriate discharge or transition plan developed after consultation with the
member's treating health care provider or the treating health care provider's
designee. For purposes of this subsection, a treating health care provider may
select a hospital discharge planner as his or her designee.
4. If the denial is upheld by an
independent external review conducted pursuant to Vermont law, the managed care
organization is not responsible for payment for the services that were the
subject to the independent external review beyond the date the independent
external review decision is issued. If the member nonetheless elects to
continue the current level of treatment, the managed care organization may
require that the member or treating provider contact the managed care
organization in advance of discharge for the purpose of initiating utilization
management regarding the discharge plan described in Subsection
3.b.
above.
5. Except in cases where
there was material misrepresentation or fraud, the managed care organization
shall not retroactively deny or limit reimbursement for the services described
below. Nothing in this subsection prohibits managed care organizations from
requiring utilization management mechanisms permitted by law or from
communicating those requirements to members.
a. A covered service the managed care
organization determines, either upon receipt of the claim or upon grievance
review, to have been medically necessary but the member failed to fulfill the
member's obligation to obtain prior authorization. If the managed care
organization chooses to issue an initial administrative denial when a member
fails to obtain prior authorization, it shall also provide the member with
clear notice that coverage will be provided if the managed care organization
finds the service to be covered and medically necessary during grievance
review. This subsection does not apply to a provider's obligation. Nothing in
this subsection shall be construed to relieve a contracted provider from its
obligation to comply with the managed care organization's utilization
management mechanisms or to relieve a contracted provider of the consequences
for failure to comply with such mechanisms;
b. Any covered service provided to an
eligible member by a provider who relied upon the written or oral authorization
of the managed care organization or its agents prior to providing the service
to the member; or
c. A covered
service provided to a member by his or her primary care provider or another
contracted provider who relied upon the written or oral referral of the primary
care provider when the health benefit plan requires primary care physician
referrals for members to use specialists.
(H) Each managed care organization shall
routinely assess the clinical and cost outcomes of its utilization management
program, measure provider satisfaction with the utilization management program,
and identify opportunities to improve provider satisfaction with the
utilization management program.
(I)
Each managed care organization shall have a data system sufficient to support
utilization management program activities, to generate management reports to
enable it to effectively monitor and manage health care services provided to
its members, and sufficient to meet the filing requirements of this
rule.
(J) Each managed care
organization shall coordinate the utilization management program with its other
medical management activities, including quality management, credentialing
verification, provider contracting, data reporting, grievance procedures,
processes for assessing member satisfaction, and risk management.
(K) Each managed care organization shall
provide members and providers with access to its review staff by a toll-free
number or such other secure mechanism with the goal of facilitating
transmission of the information necessary for utilization review during a
single, initial contact. Evidence that managed care organization reviewers are
not promptly available when a provider or member initiates or schedules a
required utilization review contact, that members or providers are required to
initiate repeated telephone calls or voice mail transfers or are being required
to submit duplicates of or redundant documentation, or similar evidence of
repeated failure to facilitate reasonable utilization review practices may be
considered a violation of this rule.
(L) When conducting utilization review, the
managed care organization shall collect only the information necessary to
certify the admission, procedure or treatment, length of stay, frequency and
duration of services, including, for mental health and substance abuse
services, information on the factors described in Section 3.1(E) 6 of this
rule.
(M) Compensation to persons
providing utilization review services for a managed care organization shall not
contain incentives, direct or indirect, for those persons to limit access to
medically necessary care. Compensation to such persons may not be based,
directly or indirectly, on the quantity or type of adverse determinations
rendered.
Section 3.2
Utilization Review Procedures
(A) Each managed
care organization shall maintain written procedures for making utilization
review decisions and for notifying members, representatives of members, and
providers acting on behalf of members of its decisions consistent with the
requirements of this rule. For purposes of this Part, the term "member" shall
include an authorized representative of the member.
(B) For purposes of this section, the
following reviews shall be treated as urgent:
1. all pre-service requests related to mental
health and substance abuse conditions, unless the member or treating provider
informs the managed care organization that the request is not urgent;
2. all pre-service pharmacy benefit
determinations, unless the member or treating provider informs the managed care
organization that the request is not urgent;
3. all pre-service requests related to
whether use of a prescription drug for the treatment of cancer is medically
necessary or is an experimental or investigational use; and
4. all requests designated as urgent by a
member's health care provider or by the member.
(C) Concurrent Review - Timeframe for
Completion and Notification:
1. If an ongoing
course of treatment has been approved, a decision by a managed organization to
deny, limit, reduce, modify or terminate coverage or payment for such course of
treatment, or to deny a request by or on behalf of a member to extend the
course of treatment, in whole or in part, shall constitute an adverse benefit
determination.
2. A request to
continue or extend a facility stay or other ongoing course of treatment as
described in subsection 3.1(G) 3 of this rule shall be decided as soon as
possible consistent with the medical exigencies of the case. A managed care
organization shall notify the member and treating provider (if known) in
accordance with paragraph (G) of this section of the managed care
organization's benefit determination (whether adverse or not) as soon as
possible consistent with the medical exigencies of the case.
a. Urgent Concurrent Care Review Requests at
least 24 hours prior to the expiration of treatment:
1. A request by a member or provider is
considered an urgent concurrent care request if it meets the following
criteria: involves an extension of benefits or course of treatment beyond the
previously approved time period or number of treatments, meets the definition
for a claim involving urgent care in 29 C.F.R. 2560.503 - 1(m)(l), and is made
at least 24 hours prior to the expiration of the previously approved prescribed
period of time or number of treatments.
2. An urgent concurrent care request must be
decided as soon as possible based on the exigencies of the case and the managed
care organization shall notify the member and provider of the determination,
whether adverse or not, within 24 hours of the receipt of the
request.
b. Non-Urgent
Concurrent Care Review Requests must be made sufficiently in advance, but at
least 24 hours prior to the expiration of the previously approved course of
treatment. The managed care organization shall notify the member and the
provider of the determination, whether adverse or not, utilizing non-urgent
pre-service notification requirement of this rule.
c. Urgent or Non-Urgent Concurrent Care
Review Requests made prior to the expiration of the prescribed period of time
but less than 24 hour for urgent concurrent care or that is not made
sufficiently in advance of the expiration of a previously approved non-urgent
course of treatment are considered pre-service and decided based on the
exigencies of the case, within the notification timeframes for urgent
pre-service or non-urgent pre-service reviews under this rule.
3. In the case of an adverse
concurrent review benefit determination regarding a facility stay or other
ongoing course of treatment as described in subsection 3.1(G) 3 of this Rule,
when the grievance is requested and conducted consistent with the requirements
of Section 3.1(G) 3 of this rule, neither the member nor the provider shall be
liable for any services provided before notification to the member of the
adverse benefit determination and the final outcome of any grievance or
independent external review, unless the treating provider or designee has
refused or repeatedly failed to engage in communication with the managed care
organization when it has been offered at a time in a manner reasonably
convenient for the provider, in which case the provider and not the member
shall be liable for any services provided.
4. The managed care organization shall notify
the treating provider and member of the determination orally as soon as the
determination has been made. Written (either hard copy, or, if elected by the
member or treating provider, appropriately secure electronic) confirmation of
the determination shall be sent to the treating provider and the member within
twenty-four (24) hours of the oral notification. In the event the member is an
inpatient, no oral notification to the member is required, provided timely
notice is provided to the treating provider.
(D) Urgent, Pre-Service Review - Timeframe
for Completion and Notification:
1. For
urgent pre-service review determinations, a managed care organization shall
notify the member and treating provider (if known) in accordance with paragraph
(G) of this section of the managed care organization's benefit determination
(whether adverse or not) as soon as possible consistent with the medical
exigencies of the case, but not later than forty-eight (48) hours after receipt
of the request.
2. This period may
be extended by not less than forty-eight (48) hours by the managed care
organization if such extension is necessary due to a failure of the member or
provider to submit the information necessary to decide the request. Oral and
written notification of the need for additional information shall be provided
to the member and the treating provider (if known) as soon as possible, but not
later than twenty-four (24) hours after receipt of the request.
3. The managed care organization shall notify
the treating provider (if known) and member of the determination orally as soon
as the determination has been made. Written (either hard copy, or if elected by
the member or treating provider, appropriately secure electronic) confirmation
of the determination shall be sent to the treating provider (if known) and the
member within twenty-four (24) hours of the oral notification. In the event the
member is an inpatient, no oral notification to the member is required,
provided timely notice is provided to the treating provider.
(E) Non-Urgent, Pre-Service Review
- Timeframe for Completion and Notification:
1. For non-urgent, pre-service review
determinations, a managed care organization shall notify the member and
treating provider (if known) in accordance with paragraph (G) of this section
of the managed care organization's benefit determination (whether adverse or
not) as soon as possible consistent with the medical exigencies of the case,
but not later than two (2) business days after receipt of the request. Written
(either hard copy or, if elected by the member or treating provider,
appropriately secure electronic) confirmation of the determination shall be
sent to the treating provider (if known) and the member. Weekend days and legal
holidays do not count as business days. Non-urgent requests received after
normal business hours are deemed to have been received on the next business
day.
2. This period may be extended
one time by the managed care organization for up to fifteen (15) calendar days,
provided that the managed care organization both determines that such an
extension is necessary due to matters beyond its control and notifies the
treating provider (if known) and member prior to the expiration of the initial
fifteen (15) calendar day period, of the circumstances requiring the extension
of time and the date by which the managed care organization expects to render a
decision. If such an extension is necessary due to a failure of the member or
treating provider to submit the information necessary to decide the request,
the notice of extension shall specifically describe the required information,
and the member or treating provider shall be afforded at least forty-five (45)
calendar days from receipt of the notice within which to provide the specified
information.
(F)
Post-Service Review -Timeframe for Completion and Notification:
1. For post-service review determinations, a
managed care organization shall notify the member and treating provider (if
known), in accordance with paragraph (G) of this section, of the managed care
organization's benefit determination (whether adverse or not) within a
reasonable period of time, but not later than thirty (30) calendar days after
receipt of the request. Written (either hard copy or, if elected by the member
or treating provider, appropriately secure electronic) confirmation of the
benefit determination shall be sent to the treating provider (if known) and the
member.
2. This period may be
extended one time by the managed care organization for up to fifteen (15)
calendar days, provided that the managed care organization both determines that
such an extension is necessary due to matters beyond its control and notifies
the member and treating provider (if known), prior to the expiration of the
initial thirty (30) calendar day period, of the circumstances requiring the
extension of time and the date by which the managed care organization expects
to render a decision. If such an extension is necessary due to a failure of the
member or treating provider to submit the information necessary to decide the
request, the notice of extension shall specifically describe the required
information, and the member or treating provider shall be afforded at least
forty-five (45) calendar days from receipt of the notice within which to
provide the specified information.
(G) Contents of Notice of Benefit
Determination: A written or electronic notification of a benefit determination
shall set forth the following information in a manner calculated to be
understood by the member:
1. a statement of
the reviewer's understanding of the request;
2. if applicable, a description of any
additional material or information necessary for the member to perfect the
request and an explanation of why such material or information is
necessary;
3. if the review
resulted in authorization, a clear and complete description of the service(s)
that were authorized and all applicable limitations or conditions;
4. if the review resulted in an adverse
benefit determination, in whole or in part:
a. the specific reason or reasons for the
adverse benefit determination:
b.
the text of the specific health benefit plan provisions on which the
determination is based;
c. if the
adverse benefit determination is based on medical necessity, an
experimental/investigational exclusion, is otherwise an appealable decision
pursuant to Vermont's independent external review laws, or is otherwise a
medically-based determination, an explanation of the scientific or clinical
judgment for the determination, and an explanation of how the clinical review
criteria and the terms of the health benefit plan apply to the member's medical
circumstances;
d. if an internal
rule, guideline, protocol, or other similar criterion was relied upon in making
the adverse benefit determination, either the specific rule, guideline,
protocol or other similar criterion; or a statement that such a rule,
guideline, protocol, or other similar criterion was relied upon in making the
adverse benefit determination and that a copy of such rule, guideline,
protocol, or other criterion will be provided to the member upon request and
free of charge within two (2) business days or, in the case of a concurrent or
urgent pre-service review, immediately upon request;
e. if the review is a concurrent or
pre-service review, that the member is advised that he or she should discuss
alternative treatments with his or her treating provider; 7
f. a description of the managed care
organization's grievance procedures and the time limits applicable to such
procedures;
g. in the case of a
concurrent review determination or an urgent, pre-service request, a
description of the expedited grievance review process that may be applicable to
such requests;
h. a description of
the requirements and timeframes for filing grievances and/or a request for
independent external review in order for the member or provider to be held
harmless pending the outcome, where applicable;
i. notice of the right to request independent
external review after a grievance determination, in the language, format and
manner prescribed by the Department; and
j. local and toll-free numbers for the
Department's health care consumer assistance section and the Vermont Office of
Health Care Advocate.
Section 3.3 Grievance Procedures
(A) Each managed care organization shall
establish and maintain a grievance review process that provides a member with a
reasonable opportunity for a full and fair review of the grievance, for members
who are dissatisfied with the availability, delivery or quality of their health
care services, including adverse benefit determinations, claims payments, the
handling of or reimbursement for such services, or any other matter pertaining
to their contractual relationship with the managed care organization.
(B) For purposes of this section, the
following grievances shall be treated as urgent:
1. Pre-service mental health.
a. All pre-service grievances related to
mental health and substance abuse conditions that were handled as urgent at the
review level, unless:
i. the member has
authorization for the treatment in dispute such that treatment can continue
uninterrupted for the duration of any non-expedited grievance(s) and
independent external review, if any;
ii. the request is for a service scheduled
sufficiently in the future such that non-expedited grievance(s) and independent
external review, if any, can be completed prior to the date scheduled for the
service; or
iii. the managed care
organization otherwise has good cause to believe that it is not medically
necessary to expedite the timeframe for grievance review, and the member and
provider agree;
b. If a
grievance request has been determined not urgent, based on 3.3(B)l (i-iii),
above, the time frame shall be as specified in 3.31.
2. Pre-service pharmacy benefits.
a. All pre-service pharmacy benefit
grievances are urgent, unless:
i. the member
has a sufficient supply of the medication in dispute to ensure that treatment
can continue uninterrupted for the duration of any non- expedited grievance(s)
and independent external review, if any; or
ii. the managed care organization otherwise
has good cause to believe that it is not medically necessary to expedite the
timeframe for grievance review, and the member and provider agree; or
iii. the grievance is related to contract
terms, limitations or exclusions.
3. Certain prescription drugs for cancer
treatment. All pre-service requests related to whether use of a prescription
drug for the treatment of cancer is medically necessary or is an experimental
or investigational use shall be treated as urgent; and
4. Grievances designated as urgent by the
provider or member. Any grievance designated as urgent by a member's health
care provider or by the member shall be treated as urgent.
(C) Managed care organizations shall provide
no more than two (2) levels of grievance for group health plan members, the
second level of which shall be voluntary to the member. Individual plans,
however, shall be limited to only the first level grievance as required by
federal law,
45 C.F.R.
§
147.136(b)(2)(ii)(G).
1. With respect to the voluntary second level
grievance, the managed care organization shall:
a. waive any right to assert that a member
has failed to exhaust administrative remedies because the member did not elect
to pursue the voluntary second level grievance;
b. agree that any statute of limitations or
other defense based on timeliness is tolled during the time that a voluntary 7
second level grievance is pending;
c. require that members who choose to elect
the voluntary second level grievance may do so only after exhaustion of the
required first level grievance process;
d. provide sufficient information regarding
the voluntary second level grievance process to enable the member to make an
informed judgment about whether to pursue the voluntary second level grievance,
including a statement that the decision of a member as to whether or not to
pursue the voluntary second level grievance will have no effect on the member's
rights to any other benefits;
e.
not impose any fees or costs on a member or provider who. elects to pursue a
voluntary second level grievance;
f. include the right of the member to meet
with one (1) or more of the reviewers, at the member's request, before a final
determination is made on the voluntary second level grievance. The managed care
organization shall provide for either an in-person meeting or a telephone
meeting; however, if it is inconvenient for the member to participate in the
manner offered by the managed care organization, the other method of meeting
must be made available to the member. The member's treating provider(s) and any
other person(s) requested by the member is (are) entitled but not required to
participate in such a meeting or call. The meeting date shall be arranged in
consultation with the member. The managed care organization shall not
unreasonably deny a request for postponement of the review made by a member.
The right to have a voluntary second level grievance considered shall not be
made conditional on a member's appearance either in person or by telephone at
such a meeting.
2.
Provided further, however, that if the provider is acting on behalf of the
member, the member is not entitled to another grievance at the same level. The
member retains the right to proceed to a second level grievance or an external
appeal. A member must explicitly and in writing authorize a provider to submit
a grievance on the member's behalf in non-urgent pre-service and post-service
situations.
(D) The
grievance process of a managed care organization will not be deemed to provide
a member with a reasonable opportunity for a full and fair review of a
grievance unless the grievance process:
1.
provides members at least one hundred eighty (180) calendar days following
receipt of a notification of an adverse benefit determination within which to
request a first level grievance and at least ninety (90) calendar days
following receipt of notification of an adverse determination on a first level
grievance within which to request a voluntary second level grievance;
2. provides members the opportunity to submit
written comments, documents, records, and other information relating to the
grievance;
3. provides that a
member shall be provided reasonable access to, and copies of, all documents,
records and other information relevant to the member's grievance upon request
and free of charge within two (2) business days or, in the case of a concurrent
or urgent pre- service review, immediately upon request. Whether a document,
record, or other information is relevant to a grievance shall be determined by
reference to the definition of "relevant document, record or other information"
in this rule;
4. provides for a
review that takes into account all comments, documents, records, and other
information submitted by the member relating to the grievance, without regard
to whether such information was submitted or considered in the initial benefit
determination or during the first level grievance, in the case of a voluntary
second level grievance;
5. provides
for a review that does not afford deference to the initial adverse benefit
determination or the adverse determination on first level grievance, in the
case of a voluntary second level grievance;
6. ensures that the person or persons
reviewing a first level grievance on behalf of the managed care organization
shall not have been involved with the adverse benefit determination or other
issue that is the subject of the grievance, nor shall such person or persons be
the subordinate(s) of any individual who was involved with the initial
determination or other issue that is the subject of the grievance;
7. ensures that the person or persons
reviewing a voluntary second level grievance on behalf of the managed care
organization shall not have been involved with the adverse benefit
determination or other issue that is the subject of the grievance, or the
adverse determination in the first level grievance; nor shall such person or
persons be the subordinate(s) of any individual who was involved with the
initial determination or other issue that is the subject of the grievance or
the first level grievance;
8.
provides that, in deciding a first level grievance of an adverse benefit
determination that is based in whole or in part on a medical judgment,
including determinations with regard to whether a particular treatment, drug,
or other item is experimental, investigational, or not medically necessary or
appropriate, or based in whole or in part on any other adverse benefit
determination that is an appealable decision pursuant to Vermont's independent
external review laws, the reviewers shall include at least one (1) clinical
peer of the member's treating provider as defined in this rule. However, if
clinical information has been requested by the managed care organization from a
treating provider subsequent to the first level grievance having been initiated
and the clinical information has not been provided, this requirement shall not
apply. The managed care organization's medical director or the medical
director's designee shall offer to, and if the offer is accepted, shall
directly communicate with the member's treating provider or the treating
provider's designee before a resolution of the grievance is made. A grievance
is resolved when the managed care organization has made a decision and provided
a written description of the action it intends to take or the decision to the
member and provider whether in the member's favor or not. Upon a member
appealing to an external review entity, that entity's decision will also
constitute a resolution of the grievance;
9. provides for the identification of any
clinical expert(s) whose advice was obtained on behalf of the managed care
organization in connection with a member's adverse benefit determination
without regard to whether the advice was relied upon in making the
determination;
10. provides that
any clinical expert(s) engaged for purposes of a consultation related to a
grievance shall be an individual who is neither an individual who was consulted
in connection with the adverse benefit determination that is the subject of the
grievance, or in connection with the first level grievance if the managed care
organization elects to engage any clinical expert(s) for a voluntary second
level grievance, nor the subordinate of any such individual;
11. in the case of a grievance involving
concurrent review or a pre- service grievance involving urgent care, provides
for a review process consistent with the time frames required by this rule and
permits a request for a concurrent or expedited first or voluntary second level
grievance of an adverse benefit determination to be submitted orally or in
writing by the member. All necessary information needed by or to be
communicated by the managed care organization, including the managed care
organization's benefit determination upon review, shall be accepted by the
managed care organization and transmitted between it and the treating provider
(if known) and/or the member in the most expeditious form and manner
available.
12. provides members who
have a disability reasonable accommodations for filing grievances and for
participating in the grievance process;
13. ensures that the managed care
organization waives any right to assert that a member has failed to exhaust
administrative remedies because the member did not elect to submit a grievance
to the voluntary second level of grievance;
14. provides members for whom English is not
a primary language with information in their primary language, if requested,
about how to file a grievance and how to participate in the grievance process;
and
15. ensures that persons who
are unable to file written grievances may notify the managed care organization
of a grievance orally or through another alternative mechanism. The managed
care organization shall be responsible for documenting such grievances and
providing copies to the members for their use, or the use of the member's
representatives.
(E) For
any grievances relating to an adverse benefit determination, a managed care
organization shall promptly authorize and/or otherwise arrange for coverage for
any covered service that had been denied or restricted and as to which a
reversal has been made by its reviewers under this section.
(F) For purposes of 3.3(G)-(O):
1. "Treating provider" means the referring or
rendering provider who is submitting the appeal on the member's
behalf.
2. Notification of
grievance resolution should not occur if the subject of the grievance relates
to multiple providers and the managed care organization has reason to believe
notification will cause confusion or result in HIPAA violations.
3. "If known" means the managed care
organization has the treating providers' contact information or it may be
obtained by routine methods such as phone calls, provider directory searches,
or internet research. A search which may impose an unreasonable burden is not
required.
(G) First-Level
Concurrent Review Grievance - Timeframe for Completion and Notification:
1. A grievance related to a request to
continue or extend a course of treatment shall be decided as soon as possible
consistent with the medical exigencies of the case. A managed care organization
shall notify the member and treating provider (if known) in accordance with
paragraph (Q) of this section of the managed care organization's determination
(whether adverse or not) as soon as possible consistent with the medical
exigencies of the case, but not later than twenty-four (24) hours after receipt
of the grievance.
2. Consistent
with the requirements of Section 3.1(G) 3 of this rule, in the case of a
grievance related to an adverse concurrent review determination, neither the
member nor the provider shall be liable for any services provided before
notification to the member of the adverse benefit determination and the final
outcome of any grievance or independent external review, unless the treating
provider or designee has refused or repeatedly failed to engage in
communication with the managed care organization when it has been offered at a
time in a manner reasonably convenient for the provider, in which case the
provider and not the member shall be liable for any services
provided.
3. The managed care
organization shall notify the treating provider, if known, and member of the
determination orally as soon as the determination has been made. Written
(either hard copy or, if elected by the member or treating provider,
appropriately secure electronic) confirmation of the determination shall be
sent to the treating provider and member within twenty-four (24) hours of the
oral notification.
(H)
First-Level Urgent, Pre-Service Grievance - Timeframe for Completion and
Notification:
1. In the case of a grievance
relating to an urgent, pre-service request, the managed care organization shall
notify the member and the member's treating provider (if known) in accordance
with paragraph (Q) of this section of the managed care organization's
determination (whether adverse or not) as expeditiously as the member's medical
condition requires, but not later than seventy- two (72) hours after receipt of
the grievance.
2. The managed care
organization shall notify the treating provider (if known) and member of the
determination orally as soon as the determination has been made. Written
(either hard copy, or if elected by the member or treating provider,
appropriately secure electronic) confirmation of the determination shall be
sent to the treating provider (if known) and the member within twenty-four (24)
hours of the oral notification.
(I) First-Level Non-Urgent, Pre-Service
Grievance - Timeframe for Completion and Notification:
1. In the case of a grievance relating to a
non-urgent, pre-service request, the managed care organization shall notify the
member and the member's treating provider (if known) in accordance with
paragraph (Q) of this section of the managed care organization's determination
(whether adverse or not) as expeditiously as the member's medical condition
requires, but not later than thirty (30) calendar days after receipt of the
grievance.
2. Written (either hard
copy or, if elected by the member or treating provider, appropriately secure
electronic) confirmation of the determination shall be sent to the treating
provider (if known) and the member.
(J) First-Level Post-Service Grievance
-Timeframe for Completion and Notification:
1. In the case of a post-service grievance,
the managed care organization shall decide and notify the member and the
member's treating provider (if known) in accordance with paragraph (Q) of this
section of the managed care organization's determination (whether adverse, or
not) within a reasonable period of time but not later than sixty (60) calendar
days after receipt of the grievance.
2. Written (either hard copy or, if elected
by the member or treating provider, appropriately secure electronic)
confirmation of the determination shall be sent to the treating provider (if
known) and the member.
(K) First-Level Grievance Unrelated to an
Adverse Benefit Determination - Timeframe for Completion and Notification:
1. For grievances not related to adverse
benefit determinations, members shall be notified within sixty (60) calendar
days after receipt of the grievance.
2. Written (either hard copy or, if elected
by the member, appropriately secure electronic) confirmation of the
determination shall be sent to the member.
(L) Voluntary Second-Level Concurrent Review
Grievance - Timeframe for Completion and Notification:
1. A grievance related to a request to
continue or extend a course of treatment shall be decided as soon as possible
consistent with the medical exigencies of the case. A managed care organization
shall notify the member and treating provider (if known) in accordance with
paragraph (Q) of this section of the managed care organization's determination
(whether adverse or not) as soon as possible consistent with the medical
exigencies of the case, but not later than twenty-four (24) hours after receipt
of the grievance.
2. Consistent
with the requirements of Section 3.1(G) 3 of this rule, in the case of a
grievance related to an adverse concurrent review determination, neither the
member nor the provider shall be liable for any services provided before
notification to the member of the adverse benefit determination and the final
outcome of any grievance or independent external review, unless the treating
provider or designee has refused or repeatedly failed to engage in
communication with the managed care organization when it has been offered at a
time in a manner reasonably convenient for the provider, in which case the
provider and not the member shall be liable for any services
provided.
3. The managed care
organization shall notify the treating provider and member of the determination
orally as soon as the determination has been made. Written (either hard copy,
or, if elected by the member or treating provider, appropriately secure
electronic) confirmation of the determination shall be sent to the treating
provider and the member within twenty-four (24) hours of the oral
notification.
(M)
Voluntary Second-Level Urgent, Pre-Service Grievance - Timeframe for Completion
and Notification:
1. In the case of a
voluntary second-level grievance relating to an urgent, pre-service request,
the managed care organization shall notify the member and the member's treating
provider (if known) in accordance with paragraph (Q) of this section of the
managed care organization's determination (whether adverse or not) as
expeditiously as the member's medical condition requires, but not later than
seventy-two (72) hours after receipt of the voluntary second-level
grievance.
2. The managed care
organization shall notify the treating provider (if known) and member of the
determination orally as soon as the determination has been made. Written
(either hard copy, or, if elected by the member or treating provider,
appropriately secure electronic) confirmation of the determination shall be
sent to the treating provider and the member within twenty-four (24) hours of
the oral notification.
(N) Voluntary Second-Level Non-Urgent,
Pre-Service Grievance - Timeframe for Completion and Notification:
1. In the case of a voluntary second-level
grievance relating to a non- urgent, pre-service request, the managed care
organization shall notify the member and the member's treating provider (if
known) in accordance with paragraph (Q) of this section of the managed care
organization's determination (whether adverse or not) as expeditiously as the
member's medical condition requires, but not later than thirty (30) calendar
days after receipt of the grievance.
2. Written (either hard copy or, if elected
by the member or treating provider, appropriately secure electronic)
confirmation of the determination shall be sent to the treating provider (if
known) and the member.
(O) Voluntary Second-Level Post-Service
Grievance - Timeframe for Completion and Notification:
1. In the case of a voluntary second-level
post-service grievance, the managed care organization shall notify the member
and the member's treating provider (if known) in accordance with paragraph (Q)
of this section of the managed care organization's determination (whether
adverse or not) within a reasonable period of time but not later than sixty
(60) calendar days after receipt of the grievance.
2. Written (either hard copy or, if elected
by the member or treating provider, appropriately secure electronic)
confirmation of the determination shall be sent to the treating provider (if
known) and the member.
(P) Voluntary Second-Level Grievance
Unrelated to an Adverse Benefit Determination - Timeframe for Completion and
Notification:
1. For voluntary second-level
grievances not related to adverse benefit determinations, members shall be
notified within sixty (60) calendar days after receipt of the
grievance.
2. Written (either hard
copy or, if elected by the member, appropriately secure electronic)
confirmation of the determination shall be sent to the member.
(Q) Contents of Notice of
Determination on Grievance: A written or electronic notification of a
determination of a grievance shall set forth the following information in a
manner calculated to be- understood by the member:
1. if the grievance resulted in
authorization, a clear and complete description of the service(s) that were
authorized and all applicable limitations or conditions;
2. unless the previous adverse benefit
determination has been completely overturned:
a. the title and qualifying credentials of
the person or persons reviewing the grievance on behalf of the managed care
organization;
b. a statement of the
reviewers' understanding of the member's grievance;
c. the specific reason or reasons for the
adverse determination;
d. the text
of the specific health benefit plan provisions on which the determination is
based;
e. if the adverse benefit
determination is based on medical necessity, an experimental/investigational
exclusion, is otherwise an appealable decision pursuant to Vermont's
independent external review laws, or is otherwise a medically-based
determination, an explanation of the scientific or clinical judgment for the
determination, and an explanation of how the clinical review criteria and the
terms of the health benefit plan apply to the member's medical
circumstances;
f. if the grievance
is concurrent or pre-service, what, if any, alternative covered benefits the
managed care organization considers to be medically necessary and would
authorize if requested;
g. a
statement that the member is entitled to receive, upon request and free of
charge, reasonable access to, and copies of, all documents, records, and other
information relevant to the member's grievance within two (2) business days,
or, in the case of a concurrent or urgent pre-service grievance, immediately
upon request. Whether a document, record, or other information is relevant to a
grievance shall be determined by reference to the definition of "relevant
document, record or other information" in this rule;
h. if an internal rule, guideline, protocol,
or other similar criterion was relied upon in making the adverse benefit
determination, either the specific rule, guideline, protocol, or other similar
criterion or a statement that such a rule, guideline, protocol, or other
similar criterion was relied upon in making the adverse benefit determination
and that a copy of such rule, guideline, protocol, or other criterion will be
provided to the member upon request and free of charge within two (2) business
days or, in the case of a concurrent or urgent pre-service review, immediately
upon request;
i. notice of the
right to obtain independent external review, in the language, format and manner
prescribed by the Department;
j.
the local and toll-free numbers for the Department's health care consumer
assistance section and the Vermont Office of the Health Care
Advocate;
k. in the notice of
decision after a first level grievance, a statement describing the voluntary
second level of grievance that is available to the member, with sufficient
information to enable the member to make an informed judgment about whether to
pursue the voluntary second level grievance, including:
i. a statement that the decision of a member
as to whether or not to pursue the voluntary second level grievance will have
no effect on the member's rights to any other benefits or to pursue independent
external review;
ii. a description
of the requirements and timeframes for filing the voluntary second level
grievance and/or a request for independent external review in order for the
member or provider to be held harmless pending the outcome;
iii. information regarding the voluntary
second level grievance, including the applicable rules, the member's right to
representation, the process for selecting the decision maker, and the
circumstances, if any, that may affect the impartiality of the decision
maker;
iv. a statement that there
are no fees or costs for a member or provider who elects to pursue a voluntary
second level grievance;
v. the time
limits applicable to the voluntary second level grievance.
Part 4 ADDITIONAL REQUIREMENTS IF PHARMACEUTICAL BENEFIT MANAGEMENT MECHANISMS ARE USED
Section 4.1 Required
Disclosures Specific to Pharmaceutical Benefits
In addition to providing the information required by Section 2.2(A) 3r of this rule, a managed care organization and any responsible delegate shall ensure that the primary source of information for members and providers regarding drugs subject to a pharmaceutical benefit management program (PBMP) includes a description of or reference to:
(A) where applicable, the particular clinical
indications for which the PBMP applies (or does not apply) for use of a drug
that has multiple indications for use;
(B) the nature of the clinical information
required; by whom, how and where the information must be submitted; how to
confirm receipt; and contact information for customer service as well as
telephone, fax and other contact information for the reviewing entity(ies), in
order to request:
1. prior
authorization;
2. exceptions from
PBMP criteria; and
3. a grievance
related to a PBMP.
Section
4.2 Procedures Regarding Changes to Pharmaceutical Benefits
(A) Whenever a change is made in a PBMP that
applies a new or revised dose restriction that causes a prescription for a
particular drug not to be covered for the number of doses prescribed, or
applies a new or revised substitution, step therapy, prior authorization or any
other requirement that causes a particular drug not to be covered until the
requirements of that PBMP have been met, the managed care organization and any
responsible delegate shall ensure:
1. the
change is published in the primary source of PBMP information for members and
providers as long in advance as possible but no less than ninety (90) days
prior to the effective date of the change;
2. each member who is known to have an active
prescription for the drug is individually notified in writing at least ninety
(90) days prior to the effective date of the change; and,
3. that if a member requests a fill or refill
of a prescription written prior to publication of the change or receipt of the
notice required by Subsection (A) 1 or 2 of this section; the prescription
remains valid; and it is not possible to timely obtain a prescription
consistent with the changed requirement, coverage will be provided for an
interim supply of the drug and, if relevant, any additional supply that is
medically necessary to safely discontinue the drug for up to ninety (90) days
or until the prescribing provider can order a new prescription; or, if
necessary, until the grievance and independent review process can be initiated
and completed. A managed care organization shall not be required to cover an
interim supply if:
a. member's prescribing
provider explicitly consents to the change; or
b. the drug has been determined to be unsafe
for the treatment of the member's disease or medical condition, has been
discontinued from coverage for safety reasons or cannot be supplied by or has
been withdrawn from the market by the drug's manufacturer.
Section 4.3 Utilization
Management and Grievance Programs and Procedures Specific to Pharmaceutical
Benefits
(A) A managed care organization and
any responsible delegate shall review relevant clinical evidence, consult with
individual(s) with relevant expertise in pharmacology and/or pharmacy and with
health care providers in the same or similar specialties that typically provide
and manage the drug regimens subject to the PBMP and proactively assess, on an
ongoing basis:
1. the appropriateness of its
selection of particular PBMP procedures for particular drugs in particular
medical situations;
2. whether the
PBMP procedures it has applied to particular drugs may create a risk of
unintended detrimental clinical outcomes in particular medical situations
and
3. whether complaints, appeals
or other feedback from members and providers indicate a need to improve the
usability or reduce the burden of its PBMP procedures.
(B) A managed care organization shall grant
an exception to a PBMP requirement and shall provide coverage on the same terms
as it would have for the PBMP requirement if the member's prescribing health
care provider certifies, based on relevant clinical information about the
particular member and sound medical or scientific evidence or the known
characteristics of the drug, that the PBMP requirement:
1. has been ineffective or is reasonably
expected to be ineffective or significantly less effective in treating this
member's condition such that an exception is medically necessary; or
2. has caused or is reasonably expected to
cause adverse or harmful reactions in this member.
(C) A managed care organization may require a
prescribing provider to submit the request for an exception and supporting
certification in writing in advance in non-emergency situations if the format
and process for submitting written certification facilitates the transmission
of necessary information without creating barriers to timely treatment or
requiring additional steps or a greater investment of time by the provider in
fulfilling other requirements for utilization management, except that:
1. A managed care organization shall accept
the advance certification telephonically in a situation designated by the
prescribing provider to be an emergency but may require that it later be
confirmed in writing.
2. A managed
care organization may accept but shall not require submission of actual medical
records that duplicate information provided in the certification unless there
is a reason to suspect that the information in the certification is
inaccurate.
(D) In
addition to the requirements of Sections
2,
2,
3.2 and 3.3 of this rule, plan documents and notices of an adverse benefit
determination related to a prescribed drug shall include a detailed explanation
of:
1. the information required to be
submitted to comply with PBMP requirements for requesting exceptions from PBMP
criteria and, if necessary, to file a grievance related to a PBMP;
2. by whom the request and clinical or other
required information is to be submitted;
3. how and where information must be
submitted, including telephone, fax and other contact information for the
reviewing entity(ies);
4. under
what circumstances and how an interim supply of medication may be obtained;
and
5. the fact that a denial of a
request for a PBMP exception is a determination subject to independent external
review under Vermont law, and shall include any applicable notice required by
the Department and a reference to descriptions of the independent external
review process in relevant plan documents.
(E) As long as a drug continues to be
prescribed for a member and is considered safe for the treatment of the
member's condition, a member who has previously been prescribed an otherwise
covered drug that is the subject of PBMP prior authorization, other review
and/or denial shall be entitled to coverage for a supply of the drug sufficient
to continue treatment through the following time periods, as well as any
additional supply that is medically necessary to safely discontinue the drug if
the denial is ultimately upheld:
1. until the
PBMP has completed the prior authorization or other review process;
2. if applicable, until all requested
internal expedited grievances have been exhausted; and
3. until the independent external review
decision is issued, if expedited independent external review is requested
within twenty- four (24) hours of the receipt of the final grievance decision
and notice of appeal rights by the member, and expedited independent external
review is conducted in accordance with the time frames specified by
law.
(F) Whenever an
exception has been made or a denial of coverage for a prescription drug is
overturned as a result of a grievance or independent external review, the
managed care organization shall not require utilization review for a refill or
a new prescription to continue using the same drug as long as:
1. the member's prescribing provider
continues or reinstitutes treatment with the same drug regimen to treat the
same condition of the member in the same or similar circumstances and there has
been no significant change in the medical or scientific evidence supporting the
exception or overturn of the denial; and
2. the drug continues to be considered safe
and effective for treating the member's condition.
(G) A managed care organization shall not
establish a higher tier or increase a drug's tier, co-payment or other
cost-sharing requirement solely because a drug was approved for coverage
following a grievance or independent external review.
(H) Nothing in this Part shall be construed
to prohibit dispensing of prescriptions consistent with applicable law
regarding generic substitution.
Part 5 ADDITIONAL REQUIREMENTS IF THERE ARE ANY RESTRICTIONS OR INCENTIVES PERTAINING TO MEMBER USE OF CONTRACTED OR CERTAIN OTHER PROVIDERS
Section 5.1 Ensuring
Adequacy of Access to Providers and Continuity of Services
Each managed care organization, either directly or through its provider contracts, shall ensure that covered health care services are accessible to members on a timely basis, as follows. Each managed care organization shall contract with sufficient numbers and types of providers to ensure that all covered health care services for which there are restrictions or incentives for members to use contracted or certain other providers will be provided without unreasonable delay. This requirement must be met in all service areas where the managed care organization has members. The commissioner shall grant an exception to the requirements of this section if the managed care organization can demonstrate with specific data that the requirement of subdivision (A) or (B) is not feasible in a particular service area or part of a service area.
(A) Travel time
standards. Travel times for members of a managed care organization to
contracted providers, under normal conditions from their residence or place of
business, generally should not exceed the following:
1. Thirty (30) minutes to a primary care
provider;
2. Thirty (30) minutes to
routine, office-based mental health and substance abuse services;
3. Sixty (60) minutes for outpatient
physician specialty care; intensive outpatient, partial hospital, residential
or inpatient mental health and substance abuse services; laboratory; pharmacy;
general optometry; inpatient; imaging; and inpatient medical rehabilitation
services;
4. Ninety (90) minutes
for major trauma treatment; neonatal intensive care; and tertiary-level cardiac
services, including procedures such as cardiac catheterization and cardiac
surgery; and
5. Reasonable
accessibility for other specialty services, including major burn care, organ
transplantation, and specialty pediatric care. This section shall not be
construed as restricting or prohibiting a managed care plan from offering such
services at so-called "centers of excellence" inside or outside of the service
area, as long as the selection of a center of excellence is based on objective
quality of care indicators and as long as the benefits are such that it does
not create foreseeable medical, practical or financial impediments for the
member to be able to timely obtain access to related immediate, episodic and/or
ongoing care.
(B) Waiting
time standards. Waiting times should generally not exceed the following:
1. Immediate access to emergency care for
conditions that meet the definition of "emergency medical condition" set forth
in this rule, subject to the provisions of Section 2.4 of this rule;
2. Twenty-four (24) hours or a time frame
consistent with the medical exigencies of the case for urgent care (for the
purposes of this subsection, outpatient mental health and substance abuse care
designated by the member or provider as non-urgent is not considered to be
urgent care);
3. Two (2) weeks for
non-emergency, non-urgent care;
4.
Ninety (90) days for preventive care (including routine physical examinations);
and
5. Thirty (30) days for routine
laboratory, imaging, general optometry, and all other routine
services.
(C) Each
managed care organization shall develop and implement written standards or
guidelines that address the assessment of contracted provider capacity to
provide timely access to health care services.
(D) Each managed care organization shall
annually attest that it is in compliance with Part 5 to the Commissioner and
post electronically a current and accurate provider directory consistent with
the requirements of Part 6.4 or any other applicable law.
(E) Each managed care organization shall,
either directly or through contracts or other arrangements, provide the
services of primary care providers sufficient to respond to initial and basic
care needs of members.
(F) Each
managed care organization shall permit its member to make at least two (2)
visits per calendar year to a contracted gynecological health care provider for
reproductive or gynecological care, as well as visits relating to follow-up
care for problems identified during such visits, without a referral from the
members' primary care providers. All such visits shall be subject to the
utilization review procedures used by the managed care organization in
accordance with Section 3.2 of this rule.
(G) Each managed care organization shall
permit certain new members to continue to use their previous providers, so long
as those providers agree to abide by the health benefit plan's payment rates,
quality-of-care standards and protocols, and to provide the necessary clinical
information to the managed care organization, as follows:
1. New members with life-threatening,
disabling or degenerative conditions shall be allowed to continue to see their
providers for sixty (60) days from the date of enrollment or until accepted by
a contracted provider, whichever is shorter, and
2. Women in their second or third trimester
of pregnancy shall be allowed to continue to obtain care from their previous
provider until the completion of postpartum care.
(H) The managed care organization shall
establish policies and procedures to ensure the orderly transfer of those
members whose providers' contracts with the health benefit plan have expired or
been terminated, with or without cause, to other contracted providers. In so
doing, each managed care organization shall permit certain members receiving an
ongoing course of treatment to continue to use providers whose contracts have
been terminated without cause, or whose contracts have not been renewed without
cause, so long as those providers agree to abide by the health benefit plan's
payment rates, quality-of-care standards and protocols, and to provide the
necessary clinical information to the managed care organization, as follows:
1. Members with life-threatening, disabling
or degenerative conditions shall be allowed to continue to see their providers
for sixty (60) days from the date of termination or non-renewal or until
accepted by a contracted provider, whichever is shorter; and
2. Women in their second or third trimester
of pregnancy shall be allowed to continue to obtain care from their previous
provider until the completion of postpartum care.
(I) In the event that a primary care provider
referral is needed for access to specialty care, a managed care organization
shall establish policies and procedures through which a member with a condition
that requires ongoing care from a specialist may obtain a standing referral to
a contracted specialist, subject to the utilization review procedures used by
the managed care organization in accordance with Section 3.2 of this rule. For
purposes of this provision, "standing referral" means a referral for ongoing
care to be provided by a contracted specialist that authorizes a series of
visits with the specialist for either a specific time period or a limited
number of visits, and which is provided according to a treatment plan developed
by the member's primary care provider, the specialist, the member and the
managed care organization(s). The term "specialist" includes specialists in the
treatment of mental health and/or substance abuse conditions and
disorders.
(J) In the event that a
primary care provider referral is needed for access to specialty care, a
managed care organization shall establish policies and procedures through which
a member who has either a life-threatening condition or disease, or a
degenerative or disabling condition or disease, that requires specialized
health care over a prolonged period of time may receive a referral to a
contracted specialist or a contracted specialized facility with expertise in
treating the condition or disease, who shall be responsible for and capable of
providing and coordinating the member's primary and specialty care. The
specialist or specialized facility shall be permitted to treat the member
without a referral for the member's primary care provider and may authorize
such referrals and health care services as the member's primary care provider
would otherwise be permitted to provide or authorize, subject to the
utilization review procedures used by the managed care organization in
accordance with this rule.
(K) A
managed care organization shall ensure that members may obtain covered services
from contracted or non-contracted health care providers within or outside of
the service area of the member's health benefit plan when the managed care
organization or an independent external review process conducted pursuant to
Vermont law determines that the managed care organization does not have a
contracted health care provider with appropriate training and experience to
provide the services that are medically necessary to meet the particular health
care needs of the member, subject to the utilization review procedures used by
the health benefit plan in accordance with this rule. In this circumstance:
1. The managed care organization shall assist
the member by locating a provider that is contracted, otherwise affiliated or
willing to arrange a single case agreement and that has the appropriate
training and experience to provide the services that are medically necessary to
meet the particular health care needs of the member. Any such provider shall be
in a location that is reasonably accessible to the member consistent with the
member's medical circumstances if the provider does not meet the travel time
standards specified in this rule.
2. If no provider meeting the specifications
described in Subsection (K) 1 of this section is available and accessible to
the member on a timely basis, the managed care organization shall provide the
member with coverage for services from a non-contracted provider. Coverage
shall be consistent with the terms and conditions for coverage of services
obtained from a contracted provider within the service area.
3. Coverage required pursuant to this
subsection shall be without any additional liability to the member whether the
service is provided by a contracted or non-contracted provider. The member
shall not be responsible for any additional costs incurred by the managed care
organization under this paragraph other than any copayment, coinsurance or
deductible applicable to the level of coverage required by this
subsection.
(L) When a
member or subscriber temporarily lives, works, attends school or otherwise
temporarily resides outside of the service area, requires medically necessary
services that would be covered under the health benefit plan if the member were
able to access care from contracted providers within the service area, and it
is medically necessary that the services be provided promptly, locally and not
delayed until the member's return to the service area, the managed care
organization shall:
1. Assist the member in
locating a provider in the member's location that is contracted, otherwise
affiliated or willing to arrange a single case agreement and that has the
appropriate training and experience to provide the services that are medically
necessary to meet the particular health care needs of the member. Coverage
shall be consistent with the terms and conditions of the member's certificate
for coverage of services obtained from a contracted provider within the service
area. There shall be no additional liability to the member.
2. If no provider that has the appropriate
training and experience to provide the services that are medically necessary to
meet the particular health care needs of the member in the member's 7 location
is contracted, affiliated or willing to arrange a single case agreement, the
managed care organization shall:
a. provide
clear notice to the member that the member may be liable for any balance
between the amount paid or reimbursed by the managed care organization and the
non- contracted provider's charges, and provide the member with coverage
consistent with the terms and conditions in the member's certificate, if the
certificate allows for coverage of the service outside of the service area;
and
b. provide clear notice to the
member that the member may be liable for any balance between the amount paid or
reimbursed by the managed care organization and the non- contracted provider's
charges, and provide the member with coverage consistent with the terms and
conditions in the member's certificate for coverage of services within the
service area, if the certificate does not ordinarily allow for coverage of the
service outside of the service area; and
c. pay or reimburse the non-contracted
provider for services provided subject to this subsection the reasonable and
customary value for the health care services rendered. If the managed care
organization has complied with its obligations under this section, it is not
required to assume liability if the non-contracted provider seeks additional
compensation.
Section 5.2 Credentialing Verification
Practices
(A) Each managed care organization
shall verify the credentials of all contracted health care providers. The
managed care organization shall establish procedures to review and evaluate
provider credentials both upon application of the health care provider to
become employed by or to contract with the managed care organization and at
least once every three (3) years thereafter. The initial verification of
credentials or provisional credentialing shall be completed before entering
into the employment or contractual relationship. Full credentialing shall be
completed prior to the managed care organization's listing a health care
provider as a contracted provider in any marketing and member
materials.
(B) Each managed care
organization shall establish a credentialing verification committee consisting
of licensed physicians and other health care providers to review credentialing
information and supporting documents and make decisions regarding credentialing
verification. The medical director of the managed care organization shall be
responsible for, and participate in, health care provider credentialing
verification.
(C) Each managed care
organization shall develop and maintain credentialing criteria to be used in
evaluating each provider application consistent with the requirements of this
rule. These criteria, and the managed care organization's credentialing
verification policies and procedures, shall be made available to contracted
providers and provider applicants upon written request.
(D) Except as otherwise provided by law, all
information obtained in the credentialing process shall be kept confidential,
except that it shall be subject to review and correction of any erroneous
information by the health care provider whose credentials are being verified.
Records and documents relating to a health care provider's credentialing
verification process shall be retained by the managed care organization for at
least three years.
(E) Initial
Credentialing: Prior to employing or contracting with a health care provider
seeking to become a contracted provider, a managed care organization shall:
1. obtain primary verification of at least
the following information regarding individual health care providers, to the
extent applicable: current license to practice; professional liability
coverage; at least five (5) years' history of professional liability claims
that resulted in settlements or judgments paid on behalf of the provider;
status of hospital privileges; specialty board or other certification status;
current Drug Enforcement Agency (DEA) registration or Controlled Dangerous
Substances (CDS) certificate, as applicable; graduation from an accredited
school; work history; and completion of post-graduate training;
2. obtain, through either primary
verification or secondary verification from an approved source, to the extent
applicable, the health care provider's license history in Vermont and all other
states, including dates, times, and places of all applications for license
privileges; any action taken on such applications; challenges to licensure or
registration; the voluntary or involuntary relinquishment of a license; any
state sanctions, restrictions or conditions on licensure or limitations on the
scope of practice; Medicare and Medicaid sanctions; and malpractice
history;
3. obtain and review an
application and signed attestation from the provider that includes a statement
that the application is correct and complete; addresses the provider's ability
to perform the essential functions of the position with or without
accommodation; indicates a lack of present illegal drug use; and includes any
history of loss of license, felony conviction, disciplinary action and any
loss/limitation of privileges;
4.
obtain a copy of the insurance policy declaration page from the malpractice
carrier to verify current malpractice insurance coverage;
5. with respect to a physician who has
completed residency or fellowship requirements within twelve (12) months prior
to anticipated employment or contract effective date and who the managed care
organization determines is eligible for provisionally credentialed status,
obtain primary-source verification of a current, valid license to practice; the
application and attestation described in Subsection 5.2(E) 3 of this rule; and
the past five (5) years of malpractice claims or settlements from the
malpractice carrier or the results of a National Practitioner Data Bank or
Healthcare Integrity and Protection Data Bank query. The managed care
organization shall ensure that no provider remains in provisionally
credentialed status for more than sixty (60) days; and
6. with respect to health care facilities,
obtains primary verification that confirms the provider is in good standing
with applicable state and/or federal regulatory bodies and, if accredited, with
the applicable accrediting entity.
(F) Recredentialing: At least once every
three (3) years after the initial verification of credentials, each managed
care organization shall recredential each of its contracted providers in the
following manner:
1. Obtain primary
verification of current license; current DEA registration or CDS certificate,
as applicable; history of professional liability claims that resulted in
settlement or judgment paid by or on behalf of the provider; and specialty
board certification status, to the extent applicable; and
2. Obtain and review the items specified in
Sub sections 5.2(E) 3 and 4 of this rule for individual providers; and, for
health care facilities, the items specified in Subsection 5.2(E) 6.
(G) Ongoing Monitoring of
Credentials: The managed care organization shall implement a process for
collecting and reviewing the following information between credentialing
cycles, within thirty (30) days of its release or at least every six (6)
months, as applicable, and shall have a policy that sets forth guidelines for
appropriate intervention or disposition when it identifies instances of poor
quality that could affect the health or safety of members:
1. sanctions or limitations on
licensure;
2. Medicare and Medicaid
sanctions;
3. complaints;
and
4. information known to the
managed care organization regarding injury that occurred while the member was
receiving care from the provider.
(H) Each managed care organization shall
require all health care providers to notify the managed care organization of
any changes in the status of any of the items enumerated in this section at any
time.
(I) Nothing in this section
shall be construed to require a managed care organization to contract with a
provider solely because the provider meets the managed care organization's
credentialing verification standards, or to prevent a managed care organization
from using separate or additional criteria in selecting the health care
providers it employs or with whom it contracts, unless otherwise prohibited by
law. However, no managed care organization shall refuse to initially
credential, or refuse to re-verify the credentials of, a health care provider
solely because the provider treats a substantial number of patients who require
expensive or uncompensated care.
(J) Each managed care organization shall
establish an appeal process through which a health care provider denied
participation in the managed care organization may obtain review of that
decision, as well as a process for the review of a decision by a managed care
organization to reduce, suspend, or terminate the privileges of a contracted
provider. The managed care organization shall communicate these processes to
providers who have been denied participation or continuing participation with
the managed care organization. The managed care organization shall document
information supporting credentialing and participation decisions in providers'
credentialing files.
Section
5.3 Provider Contracting, Fiscal Incentives and Disincentives
(A) Each managed care organization shall
contract in writing with each contracted health provider.
(B) Managed care organizations shall not
include any provision in a contract with a health care provider that:
1. prohibits the health care provider from
disclosing to members or potential members information about the contract or
the members' health benefit plan that may affect their health or any decision
regarding health;
2. prohibits a
contracted provider from, or penalizes a contracted provider for discussing
treatment options with members regardless of the managed care organization's
position on the treatment options, or advocating on behalf of members within
the utilization review or grievance processes established by the managed care
organization, nor shall it penalize a provider because the provider in good
faith reports to state or federal authorities any act or practice by the
managed care organization that jeopardizes patient health or welfare;
3. offers an inducement to a provider to
forego providing medically necessary services to a member or referring a member
to such services; or
4. transfers
to the provider, other than a medical group, by indemnification or otherwise,
any liability relating to activities, actions or omissions of the managed care
organization as opposed to those of the provider.
(C) Each managed care organization shall
develop selection standards for contracted providers, including primary care
providers and specialists, to be used in determining the selection of health
care providers with whom the managed care organization contracts, including
credentialing verification as required in Section 5.2 of this rule. Selection
criteria shall not be established in a manner that would exclude providers
because they treat or specialize in treating populations presenting a risk of
higher-than- average claims, losses or health services utilization or provide a
higher than-average level of uncompensated care. Copies of the selection
standards shall be made available to contracted providers and to the Department
on request. This provision shall not be construed to prohibit a managed care
organization from declining to select a provider who fails to meet other
legitimate selection criteria of the managed care organization, or as requiring
the managed care organization to employ specific providers or types of
providers who may meet its selection criteria, or as requiring the managed care
organization to contract with or retain more providers or types of providers
than are necessary to maintain an adequate network unless otherwise prohibited
by law.
(D) Each managed care
organization shall establish an appeal process through which a health care
provider denied a contract with the managed care organization, or whose
contract is not renewed based on its selection criteria, may obtain review of
that decision. The appeal process shall include written notification to the
provider of the decision against allowing contracting, or against renewal of a
contract, which shall include a statement of the reasons for the managed care
organization's decision not to contract or to renew the contract. It shall also
include reasonable time limits for taking and resolving the. appeals, and a
reasonable opportunity for providers to respond to the managed care
organization's statement of reasons supporting its decision not to contract or
to renew a contract.
(E) Each
provider contract shall contain or incorporate by reference provisions clearly
stating the requirements and responsibilities of the managed care organization
and contracted providers with respect to administrative policies and programs,
including but not limited to payment terms, utilization review, quality
improvement programs, chronic care programs, credentialing, grievance
procedures, data reporting requirements, confidentiality requirements, and any
other applicable provisions required by federal or state law. The contract must
allow the provider to participate in the managed care organization's quality
management program, dispute resolution process, and utilization management
program. The contract shall require contracted providers to notify the managed
care organization of any changes that would impact the provider's credentialing
status or ongoing availability to members.
(F) Each provider contract shall contain
provisions to ensure the availability and confidentiality of the health records
necessary to monitor and evaluate the quality of care, and to conduct medical
and other health care evaluations and audits to determine, on a concurrent or
retrospective basis, the necessity and appropriateness of care provided to
members. Each provider contract shall include provisions requiring the provider
to make health records available as required by law to appropriate state and
federal authorities involved in assessing the quality of care or investigating
the grievances or complaints of members, and to comply with the applicable
state and federal laws related to the confidentiality of medical or health
records.
(G) Each managed care
organization shall establish a mechanism for informing each contracted provider
on an ongoing and current basis of the specific covered health services for
which the provider will be responsible, including any limitations or conditions
on the services.
(H) Each managed
care organization shall inform its primary care providers of their
responsibility to provide referrals and any specific procedures that must be
followed in providing referrals.
(I) Every contract between a provider and a
managed care organization shall include a "hold harmless" provision specifying
protection for the managed care organization's members in a form substantially
similar to the following:
"Provider agrees that in no event, including nonpayment by the managed care organization, insolvency of the managed care organization, or breach of this agreement, shall the provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a member or a person (other than the managed care organization) acting on behalf of the member for services provided pursuant to this agreement. This agreement does not prohibit the provider from collecting coinsurance, deductibles or copayments, as specifically provided in the certificate of coverage, or fees for uncovered services delivered on a fee-for-service basis to members. This agreement does prohibit the provider from requesting payment from a member for any services that have been confirmed by independent external review obtained through the Department of Financial Regulation pursuant to Vermont law to be medically unnecessary, experimental, investigational or a medically inappropriate off-label use of a drug."
(J) Every contract between a
managed care organization and a provider shall provide that in the event of the
managed care organization's insolvency or other cessation of operations,
covered services to a member will continue through the period for which a
premium has been paid to the managed care organization on behalf of the member
or until the member's discharge from an inpatient facility, whichever period is
greater. Covered benefits to a member confined in an inpatient facility on the
date of insolvency or other cessation of operations will continue until the
member's continued confinement in the facility is no longer medically
necessary.
(K) The contract
provisions that satisfy the requirements of paragraphs (I) and (J) of this
section shall be construed in favor of the member, shall survive the
termination of the contract regardless of the reason for termination, including
the insolvency of the managed care organization, and shall supersede any oral
or written contrary agreement between a provider and a member or member's
representative if the contrary agreement is inconsistent with the "hold
harmless" and continuation of covered services provisions required in those
paragraphs.
(L) A managed care
organization and its contracted providers shall provide at least sixty (60)
days final written notice to each other before terminating a contract without
cause. Such notices shall not issue unless and until negotiations have
concluded and a final decision on termination has been reached. Within five (5)
working days of the date that the provider either gives or receives final
notice of termination, either for or without cause, the provider shall supply
the managed care organization with a list of his or her patients that are
members of the managed care organization.
(M) After issuance or receipt of the final
notice referenced in Subsection 5.3(L), the managed care organization shall
provide written notice of the termination of a provider contract to all members
who are patients seen on a regular basis by the provider whose contract is
terminating. This notice shall be provided at least six (6) weeks prior to the
anticipated date of a termination without cause, and shall be provided on or,
if possible, before the date the managed care organization or provider
terminates the contract for cause. Where a contract termination involves a
primary care provider, all members who are patients of that provider shall also
be notified. Each managed care organization shall establish procedures for the
resolution of administrative, payment or other disputes between providers and
the managed care organization.
(N)
Nothing in this section shall be construed to prohibit a managed care
organization from declining to select a provider, or from renewing the contract
of a contracted provider, based on that provider's failure to conform to the
managed care organization's quality of care standards and quality management
program.
(O) Provider contracts and
timeliness.
1. At the time the contract is
signed, a health carrier and, if appropriate, an intermediary shall timely
notify a participating provider of all provisions and other documents
incorporated by reference in the contract.
2. While the contract is in force, the
carrier shall timely notify a participating provider of any changes to those
provisions or documents that would result in material changes in the
contract.
3. For purposes of this
paragraph, the contract shall define what is to be considered timely notice and
what is to be considered a material change.
Section 5.4 Quality Management Requirements
for Managed Care Organizations Not Subject to Part 6
(A) Each managed care organization subject to
this Part but not to Part 6 of this rule shall have an internal quality
management program that includes at least the following components:
1. A peer review or quality management
committee or comparable designated committee responsible for quality management
activities;
2. Accountability of
the committee to the board of directors or other governing authority of the
organization;
3. Participation by
an appropriate base of providers and support staff;
4. Supervision by the medical director of the
organization;
5. Regularly
scheduled meetings; and
6. Minutes
or records of the meetings, which describe in detail the actions of the
committee, including problems discussed, data and other quality management
findings, recommendations made, quality improvement activities implemented, the
results of those activities and any other pertinent information.
Part 6 ADDITIONAL QUALITY AND CARE MANAGEMENT REQUIREMENTS FOR ALL MANAGED CARE ORGANIZATIONS
Section 6.1 Medical Records
Practices
(A) Each managed care organization
shall adopt written policies and procedures that shall be available to managed
care organization staff and providers in hard copy, on the internet, and in a
format suitable for electronic mailing, and that address the following:
1. Requirements that clinical records be
maintained in a manner that is current, detailed and organized and that permits
effective member care and quality review. In instances where managed care
organizations do not provide care directly, they shall require their providers
to maintain records in the same manner. Records may be written or electronic;
and
2. Minimum content,
confidentiality protections, retention, and access by members to their
individual records, which shall include the right of a member to see the
member's individual medical records upon request during regular business hours
and to copy those records for a fee that is consistent with legal requirements.
In addition, managed care organizations that provide direct patient care shall
include policies that address the processing and storage of records, disposal
procedures, and retrieval and distribution procedures.
(B) In cases where managed care organizations
do not provide direct patient care, clinical records shall be made available to
the Department promptly upon request by the Department to the managed care
organization, subject to the requirements of this rule.
Section 6.2 Filing Requirements
Baseline Review Filing: Each new managed care organization shall file baseline review documentation to be specified by the Department related to its policies, procedures, member communications and provider contracts.
Section 6.3
Network Adequacy Reporting
(A) On an annual
basis, insurers shall measure network adequacy in conformance with either the
standards described in this rule or standards from another State where the
majority of managed care organization business is located where standards are
at least as rigorous as Vermont's. Insurers will annually file with the
Department of Financial Regulation a report showing network availability and
opportunities for improvement.
Section
6.4 Provider Directors
(A) For
any comprehensive major medical health benefit plan subject to the Department's
jurisdiction, the managed care organization shall:
1. Post electronically a current and accurate
provider directory for each of its network plans.
a. In making the directory available
electronically, the managed care organization shall ensure that the general
public is able to view all of the current providers for a plan through a
clearly identifiable link or tab and without creating or accessing an account
or entering a policy or contract number.
b. The managed care provider shall update
each network plan provider directory whenever new information is submitted by
providers and at least monthly.
2. Provide a print copy, or print a copy of
the requested directory information, of a current provider directory upon
request of a covered person or a prospective covered person. Provider
directories must be updated whenever new information is submitted by providers
and at least once every six (6) months.
3. Periodically audit at least a reasonable
sample size of its provider directories for accuracy and retain documentation
of such an audit to be made available to the commissioner upon
request.
4. For each network plan,
include in plain language in both the electronic and print directory, the
following general information:
a. A
description of the criteria the managed care organization has used to build its
provider network;
b. If applicable,
a description of the criteria the managed care organization has used to tier
providers;
c. If applicable, how
the managed care organization designates the different provider tiers or levels
in the network and identify for each specific provider, hospital, or other type
of facility in the network the tier in which each is placed, for example, by
name, symbols or grouping, in order for a covered person or a prospective
covered person to be able to identify the provider tier; and
d. If applicable, note that authorization or
referral may be required to access some providers.
5. Provide a customer service email address
and telephone number or electronic link that covered persons or the general
public may use to notify the managed care organization of inaccurate provider
directory information.
6. Make it
clear for both its electronic and print directories what provider directory
applies to which network plan, such as including the specific name of the
network plan as marketed and issued in this state.
7. Accommodate the communication needs of
individuals with disabilities, and include a link to or information regarding
available assistance for persons with limited English proficiency.
8. Make available through an electronic
provider directory, for each network plan, the information under this
subsection in a searchable format:
a. For
health care professionals:
i. Name;
ii. Gender;
iii. Participating office
location(s);
iv. Specialty, if
applicable;
v. Medical group
affiliations, if applicable;
vi.
Facility affiliations, if applicable;
vii. Participating facility affiliations, if
applicable;
viii. Languages spoken
other than English, if applicable;. and
ix. Whether accepting new patients.
b. For hospitals:
i. Hospital name;
ii. Hospital type (i.e. acute,
rehabilitation, children's, cancer);
iii. Participating hospital locations;
and
iv. Hospital accreditation
status; and
c. For
facilities, other than hospitals, by type:
i.
Facility name;
ii. Facility
type;
iii. Types of services
performed; and
iv. Participating
facility location(s).
9. For the electronic provider directories,
for each network plan, a managed care organization shall make available the
following information in addition to all of the information available under
Subsection 8:
a. For health care
professionals:
i. Contact
information;
ii. Board
certification(s); and
iii.
Languages spoken other than English by clinical staff, if applicable.
b. For hospitals: Telephone
number; and
c. For facilities other
than hospitals: Telephone number.
10. Make available in print, upon request,
the following provider directory information for the applicable network plan:
a. For health care professionals:
i. Name;
ii. Contact information;
iii. Participating office
location(s);
iv. Specialty, if
applicable; and
v. Whether
accepting new patients.
b. For hospitals:
i. Hospital name;
ii. Hospital type;
iii. Participating hospital location and
telephone number; and
c.
For facilities, other than hospitals:
i.
Facility name;
ii. Facility
type;
iii. Types of services
performed; and
iv. Participating
facility location(s) and telephone number.
11. Include a disclosure in the printed
directory that the information is accurate as of the date of printing and that
covered persons or prospective covered persons should consult the managed care
organization's electronic provider directory on its website or call the managed
care organization to obtain current provider directory information.
12. Provider directories shall indicate at
least the following practice limitations if reported by contracted providers:
limitations as to patient age groups and specific conditions. This requirement
shall not be construed to require indication of practice limitations that are
evident based on a provider's specialty.
13. Provider directories shall explain that
the member (and/or the member's representative) may obtain active assistance
from the managed care organization to locate a provider, from a clinical
representative if preferred and requested. For the purposes of this subsection,
"active assistance" shall include but not be limited to generating a provider
list; assisting members in identifying providers who are qualified to deliver
the type of care being sought, who are currently taking new patients, and who
provide services that are generally considered to be covered benefits; and
facilitating appointments with providers if such assistance is required.
Provider directories shall explain that the member should contact the managed
care organization if the member has been unable to locate a provider using the
list or with assistance previously provided.
14. If a case or care management or chronic
care program is available, the provider directory shall explain the benefits of
participation and how the member may obtain the service or shall reference the
plan documents that contain tis information.
15. Provider directories shall explain that
coverage is not guaranteed until the requirements for utilization review have
been completed and documentation of authorization has been issued. Such
explanation shall include a description of or reference to certificate or
handbook provisions that explain how to seek authorization; how to seek
authorization if the member (and/or the member's representative) believes the
necessary care is not available from contracted providers; how to initiate a
grievance if coverage has been denied, reduced, modified or terminated and the
potential consequences if authorization is not obtained.
16. Provider directories shall also, with
respect to mental health and substance abuse services:
a. explain in a clear and prominent manner
that a given provider's availability to new patients may change
frequently;
b. clearly indicate
when there are program, clinic or similar organizationally-based requirements
that limit or prevent general plan membership from directly accessing a
provider practicing in such a setting. In such cases, the directory shall list
the program, clinic or organization name above or together with the individual
provider's name, and shall list the relevant intake phone number and address.
If the provider has a separate practice that may be accessed directly by
general plan membership, that practice shall be listed separately;
c. explain that any provider of mental health
or substance abuse services not currently under contract with the managed care
organization that is willing to meet the terms and conditions for participation
may apply for contracted status and may become contracted after successful
completion of credentialing; and
d.
in addition to being updated, audited and corrected whenever new information is
submitted by providers, be updated based on current information from individual
contracted providers that is obtained in response to active solicitation by the
managed care organization at least once every six (6) months.
17. Provider lists shall contain
the health care and geographic information requested by the member and be
provided telephonically, in hard copy or in a format suitable for electronic
mailing, whichever is requested by the member.
Section 6.5 Chronic Care Program Requirements
(A) Each managed care organization shall
develop and maintain a program under the direction of its medical director that
is designed to assist its members and their providers in managing chronic
conditions in a way that will improve the health status of members who have
chronic conditions. If a managed care organization participates in the
blueprint for health chronic care initiative, it is deemed to meet the
requirements of this section for those geographic areas in which the blueprint
for health is active. The Department, in its sole discretion, may determine
that the managed care organization is deemed to meet the requirements of this
section for the entire state if the managed care organization is participating
in the blueprint for health in communities covering a majority of the state's
population.
(B) The managed care
organization's program may use the managed care organization's own personnel,
or program resources may be provided through a contracted organization. The
managed care organization may also elect to support physician practices and/or
community care teams that are participating in the blueprint for health in
implementing the chronic care program. When such support and implementation
occurs, the Department in its sole discretion may determine that certain
requirements in this Section 6.5 are not applicable to the managed care
organization.
(C) In developing and
maintaining its chronic care program, each managed care organization shall:
1. Identify the prevalence of the chronic
conditions that have, or will have, the greatest impact on the health status of
the managed care organization's population and focus particular attention on
these when developing its chronic care program and services;
2. Recognize that a high percentage of
members have more than one chronic condition, and focus on supporting members
and health care providers in safely and effectively managing multiple chronic
conditions;
3. Ensure that chronic
care program activities are coordinated between and among the patient's
treating health care providers and case managers, including those providers and
case managers addressing mental health and substance abuse issues, unless
prohibited by law; and
4. Design
the program to accommodate the potential impact of program activities on
members with mental health conditions including substance abuse conditions or
disorders.
(D) The
managed care organization shall systematically and at least monthly identify
members who have, or who are at risk for developing, chronic conditions, using
the following data sources:
1. Claims or
encounter data;
2. Pharmacy data,
if applicable;
3. Health risk
appraisal results;
4. Laboratory
results, if applicable;
5. Data
collected through the UM or case management process, if applicable;
and
6. Member and provider
referrals.
(E) The
program shall:
1. Have a mechanism to assess
the accuracy of case finding prior to initiating contact with the
member;
2. Initiate contact with
members in writing and:
a. Convey clear
information regarding the financial or other benefits/consequences of the
choice to participate or decline;
b. Disclose the qualifications of program
staff;
c. Explain how the patient's
provider will be involved; and
d.
Elicit the member's preferences regarding telephone contacts and
messages.
3. Support
condition monitoring by the member and the health care provider;
4. Maximize member participation in and
engagement with the chronic care program and with self-management;
5. Consider and modify the managed care
organization's chronic care support services as needed in response to a
member's multiple health conditions; and
6. Address member lifestyle issues, as
indicated by practice guidelines, and also address environmental issues (e.g. -
characteristics of home and work settings).
(F) The managed care organization shall
provide members with written chronic care program information regarding:
1. How members become eligible to
participate;
2. How members use the
services; and
3. How members may
participate in the chronic care program, and opt in or opt out of the chronic
care support services offered by the managed care organization.
(G) The managed care organization
shall provide the most appropriate interventions after stratifying members
based on the severity of risk that each member faces and/or the member's
assessed readiness to change his or her behaviors.
(H) The managed care organization shall
provide:
1. All members with information
regarding community-based self-management support and self-management education
resources available to members.
2.
All members participating in chronic care programs with:
a. opportunities for office or telephone
visits, group meetings and/or written communication for the purpose of action
planning, problem solving and other active involvement in the development and
ongoing enhancement of their self-management plans. At the discretion of and
with the consent of the member, these activities may be implemented by and with
any or all of the following:
i. qualified
members of the primary care provider's practice, including the primary care
provider, the practice's care manager, and the practice's care
coordinator;
ii. a Blueprint
Community Care Team care manager, if available;
iii. a managed care organization care manager
or care coordinator;
b.
ongoing self-management education and self-management support to develop and
enhance the member's self-management skills; and
c. processes and tools to track adherence to
the member's self-management plan.
(I) The managed care organization shall
integrate information from the following systems to facilitate access to member
health information for continuity of care:
1.
A health information line or web-based health information resource;
2. A disease management program;
3. A case management program; and
4. A utilization management program, if
applicable.
(J) The
managed care organization shall provide written chronic care program
information to providers regarding:
1.
Instructions on how to access, use, and coordinate with the managed care
organization's chronic care program and services; and
2. How the chronic care program and services
work with the health care provider's patients in the program.
(K) The managed care organization
shall assist, support and provide incentives to all contracted primary care
practices to better manage chronic conditions by:
1. Offering access to provider and
practice-specific patient-level data and reports that will aid them in their
efforts to provide good chronic care, such as patients admitted to or
discharged from inpatient care, patients who have and have not received
recommended outpatient care;
2.
Providing information regarding community-based self-management support and
education resources available to members and providers;
3. Offering tools to track adherence by the
member to the member's self-management plan;
4. Motivating and supporting primary care
providers in:
a. Using office-based
information systems that support chronic care, such as electronic
registries;
b. Providing team-based
care by primary care providers;
c.
Providing services that support chronic care management, but have not
historically been covered;
d.
Conforming with evidence-based guidelines for chronic care;
e. Integrating a care coordination/care
management function within the primary care practice; and
f. Obtaining recognition through formal
programs that encourage the use of team-based, systematic, patient-centered,
coordinated care management processes such as the Physician Practice
Connections(R) - Patient-Centered Medical Home [TM ]program of the National
Committee for Quality Assurance.
(L) The managed care organization shall use
the following mechanisms to assess the effectiveness of the chronic care
program:
1. Annual measurement of member
participation rates;
2. Annual
measurement of the effectiveness of the chronic care program. Each measurement
shall:
a. address a relevant process and
outcome;
b. produce a quantitative
result;
c. be
population-based;
d. use data and
methodology that are valid for the process or outcome being measured;
and
e. be analyzed in comparison to
an established benchmark or goal;
3. Annual evaluation of perceptions of and
satisfaction with its chronic care program among members who participate as
well those who opt out of the chronic care support services offered by the
managed care organization; and
4.
Annual evaluation of contracted health care providers' perceptions of and
satisfaction with its chronic care program.
Section 6.6 Baseline, Annual and Periodic
Review Filing Requirements
(A) Baseline Review
Filing: Each managed care organization shall file baseline review documentation
to be specified by the Department related to its policies, procedures, member
communications and provider contracts.
(B) Annual Filing: Each managed care
organization shall file a copy of its quality improvement work plan prepared
pursuant to the requirements of this rule on an annual basis on or before March
31 or another date as determined by the Commissioner. Each managed care
organization shall file the following performance and other information in
accordance with the Department's specifications on an annual basis, on or
before July 15 or another date as determined by the Commissioner. The
Department may impose these annual filing requirements on a more frequent basis
as it determines is warranted:
1. Service
access indicators; for example, geographic proximity and wait time to obtain
services;
2. Specific utilization
indicators; for example, primary care physician and emergency room visits per
one thousand (1,000) members;
3.
Preventive care indicators; for example, the percentage of children and adults
who receive recommended preventive services, by type of service;
4. Coordination and continuity of care
indicators;
5. Acute and chronic
care indicators; for example, the percentage of diabetics who receive
recommended services, by type of service;
6. Indicators that assess provider adoption
of and managed care organization support for Blueprint for Health concepts and
practices; for example, the percentage of contracted primary care practices
that have been recognized for Blueprint adoption and the percentage of
practices that are receiving enhanced reimbursement to support Blueprint
implementation and operation;
7.
Indicators of member grievances, including but not limited to their frequency,
type, and the timeliness and nature of their disposition, and the managed care
organization's register or log of member grievances;
8. Indicators of utilization management
activities, including but not limited to their frequency, type, and the
timeliness and nature of their disposition;
9. Member enrollment and disenrollment
figures;
10. The numbers and
percentages of provider-initiated terminations and plan-initiated terminations
of providers in the prior year;
11.
The results of annual member and provider satisfaction surveys using, at a
minimum, a standardized state-approved member satisfaction survey instrument
and a standardized state-approved provider satisfaction survey
instrument;
12. Demographic
characteristics of its membership;
13. Efficiency indicators; for example,
relative resource use indicators or resources used to treat a commonly defined
condition or to perform a commonly defined procedure and related
services;
14. Provider
directories;
15. Any other health
status, outcome or performance measures specified by the Department;
and
16. Material changes to
policies, procedures, member communications, provider contracts or any other
documents required by this rule.
(C) Each managed care organization shall
cooperate with the Department to ensure that data reporting requirements are
standardized, to the extent possible, so that comparable data can be collected
on a statewide basis.
(D) Periodic
Review Filing: Each managed care organization shall file periodic review
documentation to be specified by the Department, related to its policies,
procedures, member communications, provider contracts and operational
practices. Periodic review requirements shall emphasize:
1. Documentation to be specified by the
Department related to requirements with which the managed care organization has
demonstrated non-compliance in prior Baseline and Periodic Review activities;
and
2. Demonstration that, in
addition to policies and procedures, the managed care organization's
operational practices are compliant with requirements of this rule.
Section 6.7 Baseline and
Periodic Review Procedures
(A) Baseline
Review:. Upon application of a managed care organization for authorization to
conduct business in Vermont or at any other time as determined by the
Department, the Department shall conduct a review to ascertain the managed care
organization's ability to comply with the requirements of this rule and to
ensure acceptable standards of quality for its members. This review will be
carried out through assessment of the documentation submitted by the managed
care organization as required by this rule and by review of any other records
or other examination as deemed necessary by the Department.
(B) Periodic Review.: The Department shall
conduct periodic reviews of managed care organizations at least once every
three (3) years, and more frequently as the Department in its discretion deems
proper to ascertain the managed care organization's compliance with the
requirements of this rule. This review will be carried out through the
assessment of documentation submitted by the managed care organization as
required by this rule and by review of any other records or other examination
as deemed necessary by the Department, and may include an on-site review of the
managed care organization and/or its delegate(s).
Section 6.8 Independent Accreditation
Organizations
(A) A managed care organization
may be deemed to have fulfilled the requirements of this rule that are
determined by the Commissioner to be able to be met through accreditation by an
independent accreditation organization approved by the Department. The
independent accreditation organization shall be capable of analyzing, in an
in-depth manner, a managed care organization's provision of quality health and
health care to its members.
(B) The
Department shall promulgate a list of approved independent accreditation
organizations that it has determined meet the following criteria:
1. The independent accreditation organization
has demonstrated to the satisfaction of the Department that it is capable of
reviewing and analyzing a managed care organization's quality management
program as required by Sections 6.2 and 6.3 of this rule;
2. The independent accreditation organization
has experience in assessing quality of care and quality improvement for managed
care organizations;
3. The
standards used by the independent accreditation organization are made available
to the Department; and
4. The
independent accreditation organization is capable of preparing and submitting
to the managed care organization a written report summarizing the scope of its
review, its findings, and its recommendations for improvement, if
any.
(C) The managed care
organization shall cooperate with the independent accreditation organization to
resolve any problems with its quality management program identified by the
organization in its report.
(D) A
copy of the independent accreditation organization's written report shall be
made available to the Department during baseline and periodic review(s), within
thirty (30) days of receipt of any updated report by the managed care
organization, and at any other time upon request by the Department, together
with a statement by the managed care organization as to how it intends to
address any problems identified in the written report and any applicable time
lines in so doing.
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