BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.108.507 pertaining to components of quality assessment activities

) ) ) ) )

NOTICE OF PROPOSED AMENDMENT   NO PUBLIC HEARING CONTEMPLATED

 

TO: All Interested Persons

 

1. On March 28, 2008 the Department of Public Health and Human Services proposes to amend the above-stated rule.

 

2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or who need an alternative accessible format of this notice. If you need an accommodation, contact the department no later than 5:00 p.m. on March 3, 2008. Please contact Gwen Knight, Office of Legal Affairs, Department of Public Health and Human Services, P.O. Box 202951, Helena MT 59620-2951; telephone (406)444-9503; fax (406)444-9744; e-mail dphhslegal@mt.gov.

 

3. The rule as proposed to be amended provides as follows. New matter is underlined. Matter to be deleted is interlined.

 

37.108.507 COMPONENTS OF QUALITY ASSESSMENT ACTIVITIES

(1) Annually, the health carrier shall evaluate its quality assessment activities by using the following HEDIS year 2007 2008 measures:

(a) childhood immunization;

(b) breast cancer screening;

(c) cervical cancer screening;

(d) comprehensive diabetes care; and

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

(2) through (3) remain the same.

(4) The department adopts and incorporates by reference the HEDIS year 2007 2008 measures for the categories listed in (1)(a) through (e). The HEDIS year 2007 2008 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 2007 2008 measures are available from the National Committee for Quality Assurance, 2000 L Street NW, Suite 500, Washington, DC 20036 or on the internet at www.ncqa.org.

 

AUTH: 33-36-105, MCA

IMP: 33-36-105, 33-36-302, MCA

 

4. The Managed Care Plan Network Adequacy and Quality Assurance Act (Title 33, chapter 36, MCA) established standards for health carriers offering managed care plans and for the implementation of quality assurance standards in administrative rules. ARM 37.105.501 et seq. were adopted in 2001 to establish mechanisms for the department to evaluate quality assurance activities of health carriers providing managed care plans in Montana. ARM 37.108.507 requires health carriers to report their quality assessment activities to the department using health plan employer data and information set (HEDIS) measures, nationally-utilized measures that are updated annually. Since the HEDIS standards change somewhat every year, the rule must also be updated annually to reflect the current year's measures and ensure that national comparisons are possible, since the other states will also be using the same updated measures. The changes from adopted 2007 measures to the proposed 2008 measures are quoted below:

 

"Changes to HEDIS 2008

 

Childhood Immunization Status

 

• Deleted "documented history of illness" and "seropositive test result" as numerator evidence for DTaP, IPV, HiB and pneumococcal conjugate.

 

• Require four acellular pertussis vaccines for the DTaP antigen.

 

• Deleted CPT code 90709 from Table CIS-A.

 

• Deleted HCPCS codes Q3021, Q3023 from Table CIS-A.

 

• Deleted ICD-9-CM Diagnosis codes 032, 033, 037, 038.41, 041.5, 045, 138, 320.0, 482.2, V02.4, V12.02 from Table CIS-A.

 

• Replaced ICD-9-CM Diagnosis code 323.5 with 323.51 in Table CIS-B.

 

Breast Cancer Screening

 

• Added CPT codes 77055-77057 to Table BCS-A.

 

• Added CPT codes 19303-19307 to Tables BCB-B.

 

Cervical Cancer Screening

 

• Deleted CPT codes 88144, 88145 from Table CCS-A.

 

Comprehensive Diabetes Care

 

• Added glimepiride-pioglitazone and metformin-sitagliptin to Table CDC-A.

 

• Added CPT Category II codes 3044F, 304SF to Tables CDC-D and CDC-E.

 

• Added Table CDC-F: Codes to Identify HbAlc Levels <7%.

 

• Added CPT codes 67030, 67031, 67036, 67121, 67220, 67221 to Table CDC-G.

 

• Added HCPCS codes G0392, G0393 to Table CDC-K.

 

• Expanded ICD-9-CM Diagnosis codes in Table CDC-K (evidence of treatment for nephropathy description) to include the entire range of 580-588.

 

• Added eprosartan-hydrochiorothiazide and hydrochlorothiazide-olmesartan to Table CDC-L.

 

• Added Table CDC-M: Codes to Identify Systolic and Diastolic BP Levels <130/80.

 

• Added CPT Category II codes 3074F, 307SF to Table CDC-N.

 

• Clarified how to identify the medical record from which to abstract the BP level.

 

• Clarified that organizations should not use a BP from an acute inpatient stay.

 

HEDIS/Consumer Assessment of Health Plan Survey (CAHPS) for Adults

 

• This measure is collected using survey methodology. Detailed specifications and summary of changes are contained in HEDIS 2008. Volume 3: Specifications for Survey Measures.

 

Corrections, policy changes and clarifications to HEDIS 2008

 

Updated Random Number Table for Measures Using the Hybrid Method

 

Childhood lmmunization Status

 

• Table CIS-B

 

Add an asterisk after ICD-9-CM Diagnosis code 323.51 in the

DTaP row, and add the following below the table.

 

*Use ICD-9-CM Diagnosis code 323.5 (with no fifth digit) to

identify DTaP prior to October 1, 2006; the date of service

must be before October 1, 2006.

 

Cervical Cancer Screening

 

• Table CCS-A

 

Add LOINC code 47527-7.

 

Comprehensive Diabetes Care

 

• Administrative Specification¡ªHbAlc good control (<7%)

 

Replace the last sentence (in first paragraph) with the

following. The member is not numerator compliant if the

automated result for the most recent HbAlc test is ¡İ7% or is

missing a result, or if an HbAlc test was not done during the

measurement year.

 

• Table CDC-H

 

Add LOINC code 49132-4.

 

• Table CDC-J

 

Add LOINC codes 1757-4, 34535-5, 40486-3, 40662-9,

40663-7, 43605-5, 43606-3, 43607-1, 44292-1.

 

• Blood pressure control¡ªIdentifying the medical record

 

Replace the test with the following.

 

The organization should use the medical record from which it

abstracts data for the other CDC indicators. If the

organization does not abstract for other indicators, it should

use the medical record of the provider that manages the

member's diabetes. If that medical record does not contain a

BP, the organization may use the medical record of another

PCP or specialist from which the member receives care.

 

Addendum: MS-DRG Crosswalk

 

• Comprehensive Diabetes Care

 

Page 128

 

Table Name CDC-B: Codes to Identify Diabetes

 

Description Diabetes

 

CMS-DRG 294, 295

 

MS-DRG 637, 638, 639

 

• Comprehensive Diabetes Care

 

Page 132

 

Table Name CDC-K: Codes to Identify Evidence of

Nephropathy

 

Description Evidence of treatment for nephropathy

 

CMS-DRG 316, 317

 

MS-DRG 682-685".

 

The option of not updating the HEDIS measure was considered and rejected because these are national quality measures which allow comparison among health plans. If the measures are not kept current, this function is lost.

 

5. This rule amendment will be applied retroactively to January 1, 2008. There is no negative impact to the affected health insurance companies by applying the rule amendment retroactively.

 

6. Interested persons may submit their data, views, or arguments concerning the proposed action in writing to Gwen Knight, Office of Legal Affairs, Department of Public Health and Human Services, P.O. Box 202951, Helena MT 59620-2951, no later than 5:00 p.m. on March 13, 2008. Comments may also be faxed to (406)444-9744 or e-mailed to dphhslegal@mt.gov. The department maintains lists of persons interested in receiving notice of administrative rule changes. These lists are compiled according to subjects or programs of interest. To be included on such a list, please notify this same person.

 

7. If a person who is directly affected by the proposed action wishes to comment orally or in writing at a public hearing, the person must make a written request for a public hearing and submit such request, with any written comments to Gwen Knight, Office of Legal Affairs, Department of Public Health and Human Services, P.O. Box 202951, Helena MT 59620-2951; by fax (406)444-9744; or by e-mail to dphhslegal@mt.gov no later than 5:00 p.m. on March 13, 2008.

 

8. If the agency receives requests for a public hearing on the proposed action from either 10% or 25, whichever is less, of the persons who are directly affected by the proposed action; from the appropriate administrative rule review committee; from a governmental subdivision or agency; or from an association having no less than 25 members who will be directly affected, a hearing will be held at a later date. Notice of the hearing will be published in the Montana Administrative Register. Ten percent of those directly affected has been determined to be one, based on the two health insurance providers affected by this rule change.

 

9. An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of this notice conform to the official version of the notice as printed in the Montana Administrative Register, but advises all concerned persons that, in the event of a discrepancy between the official printed text of the Notice and the electronic version of the notice, only the official printed text will be considered. The web site may be unavailable at times, due to system maintenance or technical problems.

 

10. The bill sponsor notice requirements of 2-4-302, MCA, do not apply.

 

 

 

/s/ Lisa A. Swanson            /s/ John Chappuis for

Rule Reviewer                    Director, Public Health and Human Services

 

 

Certified to the Secretary of State February 4, 2008.