Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 407. Procedures for the Submission of Health Maintenance Organization Quality of Care Performance Information

12VAC5-407-100. Duties of the nonprofit organization.

The contract entered into by the board and the nonprofit organization pursuant to Chapter 7.2 (§ 32.1-276.2 et seq.) of Title 32.1 of the Code of Virginia shall provide:

1. The nonprofit organization shall compile, store, and make available to consumers the data submitted by HMOs.

2. The nonprofit organization shall assist the board in developing a summary plan and budget to collect and make available HMO HEDIS or any other quality of care performance information set results for consumers. The nonprofit organization shall present the summary plan and budget on a biennial basis to the board for approval. The commissioner, at his discretion, shall also review the summary plan on a periodic basis to determine its effectiveness.

3. The nonprofit organization shall collect the HEDIS data in the most cost-effective manner available.

4. The nonprofit organization shall prepare a biennial summary plan in identifying the measures selected for reporting. The summary plan shall include:

a. The rationale for selecting each measure to be made available to consumers;

b. The goal of reporting each measure;

c. The cost and benefit of collecting the measures and making them available to consumers; and

d. The scope of dissemination of information in paper or electronic format and the target audience.

5. The nonprofit organization shall prepare a biennial budget that includes a cost-benefit analysis of purchasing HEDIS data from NCQA or obtaining the information performance sets directly from the HMOs.

6. The nonprofit organization shall present the summary plan and budget to the board for review and approval on a biennial basis.

7. The nonprofit organization shall organize, present, and make available to consumers all data required by the board to be reported to the commissioner. This data shall also be available on the nonprofit's website.

Statutory Authority

§§ 32.1-12 and 32.1-276.5 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 19, Issue 26, eff. October 8, 2003; amended, Virginia Register Volume 32, Issue 8, eff. February 1, 2016.

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