The Department shall conduct a periodic examination of the HMO as often as the Commissioner deems necessary for the protection of the interests of the people of the State, but not less frequently than once every three years. The periodic examination shall include a desk audit and onsite review. No notice requirements pertaining to a scheduled examination shall be interpreted to preclude the Department from conducting an onsite examination without notice to the HMO. The Department shall not conduct a scheduled periodic examination of an HMO before three years following the date of the issuance of the HMO's first license.
As provided in this section, a periodic examination may be coordinated with an accreditation survey by a DHS approved national accrediting organization. An HMO accredited by, or seeking accreditation by, a nationally recognized accrediting organization may apply for Department approval of the accrediting organization. An application must include a copy of the accrediting organization's standards for the Department's consideration along with a statement identifying with specificity any differences between those standards and the requirements of this rule. Should the Department approve the HMO's application the periodic examination review process will be coordinated with the Department approved nationally recognized accrediting organization as described in this Section. In the event an HMO does not seek approval of a nationally recognized accrediting organization and the HMO is accredited by or seeking accreditation by NCQA, NCQA shall be considered the Department approved national accrediting organization.
1.05-1 Coordination with the Department Approved National Accrediting Organization If an HMO is subject to review by a Department approved national accrediting organization, the Department shall coordinate its periodic examination of the HMO with the Department approved national accrediting organization's accreditation review process. In order for the Department to coordinate the review process, the following provisions shall apply:
A. Within ten (10) working days after receiving its Department approved accrediting organization accreditation survey report, the HMO shall submit to the Department the following documentation: 1. the documentation required under Section 1.05-7, or such portion of that documentation as the Department may require; and2. the final accreditation survey report of the Department approved accrediting organization, as required under Section 1.05-2. B. The Department shall schedule an onsite review of the HMO for a date six weeks from one of the following dates: 1. One hundred (100) calendar days following the last day of NCQA's onsite accreditation review;2. the HMO's receipt of the NCQA accreditation survey report if receipt is later than one hundred (100) calendar days from the conclusion of NCQA's onsite survey; or3. such other date to be determined by the Department, if the HMO or the Department can show good cause for delay. The onsite review will be limited to only that portion of the periodic examination for which the Department did not deem the HMO in compliance with an equivalent State standard, based on the results of the Department approved national accrediting organization's review and as allowed under Section 1.05-3.
1.05-2 Review Process and Report If an HMO submits to an accreditation review by a Department approved, nationally recognized accrediting organization, the HMO shall:
A. Notify the Department of the dates scheduled for the Department approved accrediting organization's onsite survey;B. Contemporaneously with its submittal to the Department approved accrediting organization, furnish the Department with a duplicate copy of all documentation submitted to the accrediting organization unless otherwise directed by the Department;C. Cooperate with the Department's participation as an observer on the Department approved accrediting organization's onsite survey; andD. Submit its full accrediting organization accreditation survey report to the Department as required in Section 1.05-1. The accrediting organization accreditation survey report shall be held confidential by the Department except to the extent that portions of the accreditation survey report are incorporated into the final review findings report or are made available to the general public by the accrediting organization or by the HMO. 1.05-3 Deeming In conducting a periodic examination or any other function related to quality oversight, the Department shall consider the HMO's national accrediting organization accreditation survey report to determine whether the HMO's compliance with the national accrediting organization's standards applicable to the same subject matter are equivalent to compliance with certain of the standards imposed by this regulation or Title 24-A, M.R.S.A Chapter 56. Nothing herein shall be interpreted to require the Department to "deem" (i.e., treat compliance with an accrediting organization standard as compliance with any State standard). When the Department does not "deem" the Department will explain how the State standard is different from the national accrediting organization's standard and how the difference is necessary to meet the requirements of Title 24-A M.R.S.A. Chapter 56, Sections 4204 and 4215. In addition, nothing herein shall be interpreted to preclude the Department from considering other information, other than the accreditation survey report, in determining compliance with the requirements of this regulation or Title 24-A, M.R.S.A. Chapter 56.
1.05-4 Coordination of Standards The Department shall revise, where appropriate, its data collection tool to reflect the most recent revisions to the standards of the Department approved accrediting organization. Currently, the Department uses NCQA standards and procedures as its model for HMO quality oversight.
1.05-5 Not Coordinated with the Department Approved National Accreditation Organization If the Department's periodic examination is not coordinated with a national accreditation review, (i.e., when an HMO has not submitted to or is not scheduled to submit to review by a Department approved national accrediting organization within the three-year time period imposed by 24-A M.R.S.A. Chapter 56, Section 4215.), the Department shall give the HMO twenty weeks notice that an onsite review has been scheduled. Six weeks prior to the scheduled onsite review, the HMO shall submit the documentation required under Section 1.05-7.
1.05-6 Review Process The periodic examination, when the examination is not coordinated with the review by a Department approved national accrediting organization, shall be conducted as follows:
A. The Department will review the documentation submitted by the HMO;B. The Department will conduct an onsite examination of the HMO to determine the HMO's compliance with the regulatory and statutory requirements;C. Based on the Department's review of the documentation and its onsite examination the Department will produce preliminary review findings that evaluate the HMO's compliance with the regulatory requirements;D. The Department's preliminary review findings will not be final until: 1. the HMO has had twenty days, or such additional reasonable period as the Commissioner may allow, to review and comment on the findings; and2. final approval by the Commissioner or Superintendent, as applicable.E. The Department's final review findings are public documents. All other working papers, survey instruments, and preliminary findings are confidential except to the degree that they are incorporated into the final review findings or are made available to the general public by the HMO or as otherwise provided by law. 1.05-7 Document Submittal The HMO shall submit, in a format acceptable to the Department, the following documentation:
A. Information relating to the structure and process of the QMP, including: 1. A written description of the QMP for current year (and previous year if substantially different);2. An organization chart for the QMP;3. An annual workplan for the current year;4. An annual workplan for the previous year;6. Reports on QMP activities;7. List of HMO full-time equivalent staff and consultants dedicated to quality management;8. Brief description of data available to and used in quality management; and9. Brief description of personnel, including credentials, (HMO staff and consultants) providing analytical expertise to the quality management function.B. Information relating to the operations of the QMP, including at least one template of the following contracts, representative of a typical contract of that type: 1. a primary care practitioner contract;2. a specialty care physician contract;3. a hospital contract; and4. another facility contract.C. Information relating to the HMO's clinical guidelines, including: 1. date of first dissemination;3. whether it is related to preventive health;4. whether it is related to any issues studied by the HMO.D. For each of two of the HMO's most comprehensive clinical guidelines, information including: 1. its relevance to the enrolled members residing in Maine;3. mechanisms for practitioner involvement;4. evidence and date of review;5. mechanisms for dissemination to practitioners;6. a description of the last two performance assessments;7. a description of the HMO's method for ensuring consistency between guidelines and the utilization review function and member and physician education.E. Completed forms, as provided by the Department, describing the HMO's studies meeting the number and specifications of Section 1.03-4;F. Copies of the following communications with members and providers, evidencing communication of guidelines, QM activities, medical record standards, or any other communication required with members or providers under this rule: G. Copies of the HMO's policies, procedures, or standards for peer review and credentialing;H. A description of credentialing committee activities related to the HMO's peer review function;I. A copy of the HMO's credentialing application;J. A description of the HMO's study of overutilization and underutilization, including: 1. methods used to identify problems and dates HMO began using method;2. frequency of analysis;3. the HMO's standards or thresholds for underutilization;4. whether the HMO identified problems; and5. the methods the HMO used to correct or monitor the problem.K. A description of the HMO's study of continuity or coordination of care, including: 1. mechanisms for monitoring the continuity or coordination of care;2. methods used for analyzing the data;3. conclusions the HMO drew as a result of its study; and4. the methods the HMO used to correct or monitor problems.L. Any other documentation that may be reasonably required by the Department in order to properly conduct its examination.10-144 C.M.R. ch. 109, § 1.05