37.108.507 COMPONENTS OF QUALITY ASSESSMENT ACTIVITIES

(1) Annually, the health carrier shall evaluate its quality assessment activities by using the following HEDIS 2020 measures:

(a) childhood immunization;

(b) breast cancer screening;

(d) comprehensive diabetes care; and

(e) HEDIS/Consumer Assessment of Health Plan Survey (CAHPS) for adults.

(2) The health carrier shall record organizational components that affect accessibility, availability, comprehensiveness, and continuity of care, including:

(a) referrals;

(b) case management;

(d) appointment scheduling and waiting periods for all types of health care services;

(e) second opinions, as applicable;

(f) prior authorizations, as applicable;

(g) provider reimbursement arrangements that contain financial incentives that may affect the care provided; and

(h) other systems, procedures, or administrative requirements used by the health carrier that affect the delivery of care.

(3) The health carrier may meet the requirements in (2) by submitting information to the department regarding network adequacy as specified in ARM 37.108.201, et seq., as long as the information is consistent with what is required in (2).

(4) The department adopts and incorporates by reference the HEDIS 2020 measures for the categories listed in (1)(a) through (e). The HEDIS 2020 measures are developed by the National Committee for Quality Assurance and provide a standardized mechanism for measuring and comparing the quality of services offered by managed care health plans. Copies of HEDIS 2020 measures are available from the National Committee for Quality Assurance, 1100 13th St. NW, Suite 1000, Washington, D.C. 20005 or at www.ncqa.org.

History: 33-36-105, MCA; IMP, 33-36-105, 33-36-302, MCA; NEW, 2001 MAR p. 1342, Eff. 7/20/01; AMD, 2002 MAR p. 954, Eff. 3/29/02; AMD, 2003 MAR p. 1662, Eff. 8/1/03; AMD, 2004 MAR p. 1406, Eff. 6/18/04; AMD, 2005 MAR p. 1296, Eff. 7/15/05; AMD, 2006 MAR p. 1642, Eff. 6/23/06; AMD, 2007 MAR p. 303, Eff. 3/9/07; AMD, 2008 MAR p. 958, Eff. 5/9/08; AMD, 2009 MAR p. 1019, Eff. 6/26/09; AMD, 2010 MAR p. 437, Eff. 2/12/10; AMD, 2011 MAR p. 333, Eff. 3/11/11; AMD, 2012 MAR p. 1264, Eff. 6/22/12; AMD, 2013 MAR p. 336, Eff. 3/15/13; AMD, 2014 MAR p. 327, Eff. 2/14/14; AMD, 2017 MAR p. 610, Eff. 5/13/17; AMD, 2018 MAR p. 1167, Eff. 6/23/18; AMD, 2019 MAR p. 397, Eff. 4/13/19; AMD, 2020 MAR p. 331, Eff. 2/15/20.