Administrative Code

Virginia Administrative Code
3/5/2024

Chapter 407. Procedures for the Submission of Health Maintenance Organization Quality of Care Performance Information

Part I
Definitions and General Information

12VAC5-407-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Board" means State Board of Health.

"Commissioner" means the State Health Commissioner.

"Consumer" means any person (i) whose occupation is other than the administration of health activities or the provision of health services; (ii) who has no fiduciary obligation to a health care institution or other health agency or to any organization, public or private, whose principal activity is an adjunct to the provision of health services; or (iii) who has no material financial interest in the rendering of health services.

"Department" means the Virginia Department of Health.

"Health maintenance organization" or "HMO" means any person who undertakes to provide or to arrange for one or more health care plans pursuant to Chapter 43 (§ 38.2-4300 et seq.) of Title 38.2 of the Code of Virginia.

"HEDIS" means the Health Employer Data and Information Set, also known as the Healthcare Effectiveness Data and Information Set, a set of standardized performance measures collected and maintained by the National Committee for Quality Assurance.

"NCQA" means the National Committee for Quality Assurance.

"Nonprofit organization" means a nonprofit, tax-exempt health data organization with the characteristics, expertise, and capacity to execute the powers and duties set forth for such entity in Chapter 7.2 (§ 32.1-276.2 et seq.) of Title 32.1 of the Code of Virginia and that enters into a contract for the compilation, storage, analysis, and evaluation of data pursuant to Chapter 7.2 of Title 32.1.

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.

12VAC5-407-20. Applicability.

This chapter shall apply to all HMOs with an active license to operate in this Commonwealth.

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.

Part II
Quality of Care Data Reporting

12VAC5-407-30. (Repealed.)

Historical Notes

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 October 8, 2003; repealed, Virginia Register Volume 32, Issue 8, eff.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

12VAC5-407-40. (Repealed.)

Historical Notes

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 October 8, 2003; repealed, Virginia Register Volume 32, Issue 8, eff.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

12VAC5-407-50. Reporting methods and exemption from reporting.

A. Every HMO with an active license in the Commonwealth shall be required to submit the HEDIS or any other quality of care or performance information set approved by the board unless granted a written exemption by the commissioner.

B. The following methods shall be used for data submission:

1. If the HMO submits data to NCQA, the commissioner may purchase HEDIS data or any other quality of care or performance information set from NCQA.

2. If the HMO does not submit data to NCQA, or the commissioner elects not to purchase HEDIS data from the NCQA, then the HMO shall submit the performance information sets approved by the board to the nonprofit organization in accordance with the timeframes established in 12VAC5-407-70.

C. An HMO may, in writing, petition the commissioner for an exemption. The commissioner, at his discretion, may grant a waiver from reporting the HEDIS or any other approved quality of care or performance information set. In considering a petition for waiver, the commissioner may give due consideration to the HMO's (i) sample size; (ii) number of covered lives; (iii) length of operating experience in Virginia; (iv) accreditation status with respect to NCQA or other national accrediting organizations; or (v) any other relevant factors he deems appropriate.

D. An HMO that can demonstrate that it does not meet NCQA's minimum sample size requirements to collect statistically valid information on at least 50% of the HEDIS effectiveness of care measures or performance information sets approved by the board shall be exempt from reporting the HEDIS quality of care or performance sets during the reporting period. The HMO shall submit documentation to the commissioner each reporting period to demonstrate that it meets the criteria for obtaining an exemption from reporting.

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.

12VAC5-407-60. Audited data required.

HMOs shall submit HEDIS or other quality of care or performance information set approved by the board that has been verified by an independent auditing organization with no financial interest in or managerial association with the HMO. The HMO shall submit an audit report with the data.

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.

12VAC5-407-70. Process for data submission.

A. Before January 1 of each year, the commissioner shall submit to each HMO in writing the process required for data submission, the fee associated with data submission, and the process for obtaining a waiver. HMOs providing HEDIS or any other quality of care or performance information set directly to the nonprofit organization shall submit the data by September 15 of each year.

B. The board shall direct the nonprofit organization to publish annually the quality information data before December 31.

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.

12VAC5-407-80. Fees.

A. For each HMO required to provide information pursuant to this chapter, the board shall prescribe a reasonable fee to cover the cost of collecting and making available such data. The commissioner may purchase HEDIS data or other quality of care or performance information set on behalf of all the actively licensed HMOs in the Commonwealth that are participating in HEDIS and divide the cost among the HMOs. Each HMO shall pay an equal share of the cost to the board for purchase of the HEDIS data directly from NCQA. The remainder of the cost associated with making the data available shall be divided among the participating HMOs in a tiered format based on the number of enrollees per HMO.

B. Fees described in subsection A of this section shall not exceed $3,000 per HMO per year.

C. The payment of such fees shall be on September 15 of each year or later if determined by an agreement between the board and the nonprofit organization. The nonprofit organization shall be authorized to charge and collect the fees prescribed by the board in subsection A of this section when the data are provided directly to the nonprofit organization. Such fees shall not exceed the amount authorized by the board.

D. The nonprofit organization shall be authorized to charge and collect reasonable fees approved by the board for making available to any individual or entity who requests the HEDIS data or other approved quality of care data; however, the commissioner, the State Corporation Commission, and the Commissioner of Behavioral Health and Developmental Services shall be entitled to receive relevant and appropriate data from the nonprofit organization at no charge.

E. The board shall direct the nonprofit organization to solicit input from the HMO industry to determine relevant and appropriate data that the industry shall receive at no charge.

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.

12VAC5-407-90. Late charge.

A. A late charge of $25 per working day shall be paid to the board by an HMO that has not received an exemption from the commissioner as provided for in 12VAC5-407-50 and that has not paid the assessed fees by September 15 or later if determined by an agreement between the board and the nonprofit. The late charge may not be assessed until completion of a 30-day grace period for submitting the data.

B. Late charges may be waived by the board, in its discretion, if an HMO can show that an extenuating circumstance exists. Examples of an extenuating circumstance may include, but are not limited to, the installation of a new computerized system, a bankruptcy proceeding, or change of ownership in the HMO.

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.

Part III
Duties of the Board and the Nonprofit Organization

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.

12VAC5-407-110. Biennial evaluation.

A. The board shall evaluate biennially the impact and effectiveness of collecting and making available HEDIS or any other quality of care or performance information set and the appropriateness of the fee structure. This evaluation shall be completed by January 15.

B. As part of the biennial evaluation, the board may consult with the HMOs and the nonprofit organization to determine whether changes should be made to the HEDIS or any other quality of care or performance information set requirements.

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.

12VAC5-407-120. (Repealed.)

Historical Notes

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

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