59B-13.001. Health Plan Quality Indicators

(1) Reporting Instructions.

(a) Any health maintenance organization authorized to transact business in the state under chapter 641, F.S., as of January 1 of the report year shall report access and quality indicator data for Florida members to the Agency as identified in this rule and specified in the Healthcare Effectiveness Data and Information Set (HEDIS) Volume 2: Technical Specifications for Health Plans developed by the National Committee for Quality Assurance (NCQA), 1100 13th St. NW, Third Floor, Washington , DC 20005.

(b) Beginning with calendar year 2018 data, each health maintenance organization shall submit indicator data for each calendar year period no later than October 1 of the following year.

(c) Extensions to the indicator data due date will be granted by the Agency for a maximum of 30 days from the due date in response to a written request signed by the chief executive officer of the health maintenance organization or his/her designee. The request must be received prior to the due date and the delay must be due to unforeseen and unforeseeable factors beyond the control of the reporting health maintenance organization. Extensions shall not be granted verbally.

(d) Each health maintenance organization must submit the HEDIS measures from the NCQA Interactive Data Submission System (IDSS) file as an Excel file.

(e) Each health maintenance organization shall send indicator data by electronic mail to [e-mail] and shall include in the electronic mailing the following information:

1. “HMO Indicator Data”;

2. Health maintenance organization identification number assigned by the Agency;

3. Health maintenance organization name; and

4. File name in the format HMOyyyy.xls where yyyy is the year of the indicator data.

(2) Definitions – “HEDIS” means the Healthcare Effectiveness Data and Information Set 2019 Volume 2: Technical Specifications for Health Plans developed and published by the National Committee for Quality Assurance, 1100 13th St. NW, Third Floor, Washington, DC 20005. HEDIS Volume 2: Technical Specifications for Health Plans includes technical specifications for the calculation of indicators of access and quality of care.

(3) Measures Required to be Reported.

Each health maintenance organization shall submit Florida member aggregate data for each HEDIS measure listed in paragraphs (a) through (k) for each line of business included for that measure. For each measure, the applicable guideline is HEDIS 2019 Volume 2: Technical Specifications for Health Plans which is hereby incorporated by reference and effective at adoption. The copyrighted material can be viewed at the Agency 2727 Mahan Drive, Tallahassee, FL 32308 and the Department of State, R.A. Gray building 500 South Bronough Street, Tallahassee, FL 32399. A copy may also be obtained from the National Committee for Quality Assurance (NCQA), 1100 13th St. NW, Third Floor, Washington, DC 20005.

(a) Adult BMI Assessment (ABA) Medicaid;

(b) Childhood Immunization Status (CIS) Medicaid;

(c) Immunizations for Adolescents (IMA) Medicaid;

(d) Breast Cancer Screening (BCS) Medicaid, Commercial, Medicare;

(e) Cervical Cancer Screening (CCS) Medicaid, Commercial;

(f) Chlamydia Screening in Women (CHL) Medicaid, Commercial;

(g) Controlling High Blood Pressure (CBP) Medicaid, Commercial, Medicare;

(h) Comprehensive Diabetes Care (CDC) Medicaid, Commercial, Medicare;

(i) Prenatal and Postpartum Care (PPC) Medicaid, Commercial;

(j) Well-Child Visits in the First 15 Months of Life (W15) Medicaid, Commercial;

(k) Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) Medicaid, Commercial.

(4) Certification.

A copy of the statement of certification from the HEDIS auditor that includes report designations for each performance measure must accompany the plan’s report submission.

(5) Penalties for Report Deficiencies.

(a) For purposes of this rule, a report, certification, or other information is incomplete when it does not contain all data required by the Agency in this rule or when it contains inaccurate data. A report or certification is “false” if done or made with the knowledge of the preparer or a superior of the preparer that it contains information or data which is not true or accurate.

(b) A health maintenance organization that refuses to file, fails to timely file, or files a false or incomplete report, certification or other information required to be filed under the provisions of section 408.061, F.S., other Florida law, or rules adopted thereunder, shall be subject to administrative penalties pursuant to section 408.08(5), F.S.

(c) The penalty period will begin on the first work day following the due date for purposes of penalty assessments.

(d) The penalty for filing a false report or refusal to file a report is $1,000 per day for each day until the report is corrected. The penalty for filing an incomplete report is $50 per day for each day until the complete report is filed. The penalty for failing to file timely is $50 per day until the report is filed.

(6) Uniform Publication Format.

(a) The Agency shall publish the following indicator data for each indicator no less frequently than every two years:

1. Health maintenance organization name;

2. Calendar year of data;

3. Type of product line;

4. Rate; and,

5. Notation that the health plan is new or small (not measurable) if applicable.

(b) In each publication of indicator data, the Agency shall include a title and a summary description of the indicator.

Rulemaking Authority 408.15(8) FS. Law Implemented 408.061, 408.063(2), 408.08(5), 641.51(9) FS. History–New 6-27-00, Amended 10-22-02, 7-25-19.