59B-13.001. Health Plan Quality Indicators  

Effective on Thursday, July 25, 2019
  • 1(1) 2Reporting Instructions.

    4(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 44this rule and specified in the Healthcare Effectiveness Data and Information Set 56(HEDIS) Volume 2: Technical Specifications for Health Plans 64developed by the National Committee for Quality Assurance (NCQA), 1100 13th St. NW, Third Floor, Washington , DC 2000582.

    83(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.

    112(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.

    192(d) Each health maintenance organization must submit 199the HEDIS measures from the NCQA Interactive Data Submission System (IDSS) file as an Excel file215.

    216(e) Each health maintenance organization shall send indicator data by electronic mail to 229HMOguide@ahca.myflorida.com and shall include in the electronic mailing the following information:

    2401. “HMO Indicator Data”;

    2442. Health maintenance organization identification number assigned by the Agency;

    2543. Health maintenance organization name; and

    2604. File name in the format 266HMOyyyy.xls 267where yyyy is the year of the indicator data.

    276(2) Definitions – 279“HEDIS” means the Healthcare Effectiveness Data and Information Set 2882019 Volume 2: Technical Specifications for Health Plans 296developed 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 323includes technical specifications for the calculation of indicators of access and quality of care.

    337(3) Measures Required to be Reported.

    343Each 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 41232308 413and the Department of State, R.A. Gray building 500 South Bronough Street, Tallahassee, FL 32399. A copy may also be obtained from the 436National Committee for Quality Assurance (NCQA), 4421100 13th St. NW, Third Floor, Washington, DC 20005.

    451(a) Adult BMI Assessment (ABA) Medicaid;

    457(b) Childhood Immunization Status (CIS) Medicaid;

    463(c) Immunizations for Adolescents (IMA) Medicaid;

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

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

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

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

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

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

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

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

    546(4) 547Certification.

    548A 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.

    573(5) Penalties for Report Deficiencies.

    578(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.

    646(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 679408.061, F.S., 681other Florida law, or rules adopted thereunder, shall be subject to administrative penalties pursuant to section 697408.08(5), F.S.

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

    719(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.

    782(6) Uniform Publication Format.

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

    8051. Health maintenance organization name;

    8102. Calendar year of data;

    8153. Type of product line;

    8204. Rate; and,

    8235. Notation that the health plan is new or small (not measurable) if applicable.

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

    857Rulemaking Authority 859408.15(8) FS. 861Law Implemented 863408.061, 864408.063(2), 865408.08(5), 866641.51(9) FS. 868History–New 6-27-00, Amended 10-22-02, 7-25-19.