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 (Repealed.)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 October 8, 2003; repealed, Virginia Register Volume 32, Issue 8, eff.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 (Repealed.)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 October 8, 2003; repealed, Virginia Register Volume 32, Issue 8, eff.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.