Or. Admin. Code § 836-053-1170

Current through Register Vol. 63, No. 12, December 1, 2024

Section 836-053-1170 - Annual Summary, Quality Assessment Activities

(1) To comply with the requirements of ORS 743.814(2) and (3), an insurer offering a managed health benefit plan shall electronically submit on or before June 30 of each calendar year an annual quality assessment program summary for the previous calendar year to the Division of Financial Regulation in the format required by the director of the Department of Consumer and Business Services as set forth on the website of the Division of Financial Regulation of the Department of Consumer and Business Services. Filing and reporting requirements in this rule apply to:

(a) A domestic insurer; and

(b) A foreign insurer transacting $2 million or more in health benefit plan premium in Oregon during the calendar year immediately preceding the due date of a required report.

(2) For calendar year 2014 and each subsequent calendar year the annual summary required under section (1) of this rule must:

(a) Identify current quality assessment program accreditations, accrediting organization, accreditation level and date. If the quality assessment program is not accredited, describe plans and timelines, if any, to gain accreditation.

(b) Describe the insurer's quality assessment program that enables the insurer to evaluate, maintain and improve the quality of health services provided to enrollees.

(c) Identify the frequency of internal quality assessment program review, evaluation, and update.

(d) List quality improvement goals the insurer has identified, measures of success towards meeting those goals and outcomes demonstrated by selected measures.

(e) Provide a summary of policies and monitoring activities established for each of the following program areas:

(A) Internal program monitoring and oversight;

(B) Credentialing of providers;

(C) Provider program participation procedures;

(D) Clinical practice guidelines;

(E) Identification of priorities;

(F) Assessment of enrollee satisfaction; and

(G) Enrollee and provider communication processes

(3) For calendar year 2014 and each subsequent calendar year the annual summary required under section (1) of this rule must provide:

(a) The results of all publicly available federal Health Care Financing Administration reports and accreditation surveys by national accreditation organizations; and

(b) The reporting of the insurer's health promotion and disease prevention activities, if any, as defined in the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance, including:

(A) The following preventive measures:

(i) Childhood immunizations, including the percentage of children in the insurer's managed care health plans who have received appropriate immunizations by their second birthdays; and

(ii) Tobacco use cessation, including the percentage of adult smokers and the percentage of those who have ceased tobacco use after receiving advice to quit smoking from a health professional in health plans of the insurer.

(B) The chronic condition of diabetes as specified in the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance.

(C) The acute condition of pregnancy care. The information must include the percentage of pregnant women in the insurer's health plans that began prenatal care during the first 13 weeks of pregnancy.

(4) To minimize duplicative reporting requirements, the insurer may satisfy the reporting requirements of sections (2) and (3) of this rule by submitting either of the following:

(a) Information prepared by the insurer for another purpose if the information contains the information required by sections (2) and (3) of this rule and the insurer highlights the relevant information to satisfy the reporting requirement; or

(b) An addendum to an annual filing of the immediately preceding year:

(A) Stating, if applicable, that no information has changed since the previous annual filing; or

(B) Identifying, if applicable, only the information that has changed since the previous annual filing.

(5) Summary information described in sections (2) and (3) of this rule may include information prepared by the insurer for the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance and may be submitted on the basis of any sampling method recognized by the Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance. A multi-state or regional Healthcare Effectiveness Data Information Set maintained by the National Committee for Quality Assurance report may be used for reporting under this subsection if the insurer furnishes with the report the number or an estimate of the number of regional members and Oregon members to whom the report applies.

(6) An insurer may not submit addenda described in sections (2) and (3) of this rule in two consecutive years.

(7) Nothing in this rule prohibits an insurer from submitting additional information that is significant in relation to its quality assessment and improvement activities.

Or. Admin. Code § 836-053-1170

ID 1-1998, f. & cert. ef. 1-15-98; ID 17-1998, f. & cert. ef. 11-16-98; ID 12-2013, f. 12-31-13, cert. ef. 1-1-14; ID 24-2024, minor correction filed 08/12/2024, effective 8/12/2024

Publications: Publications referenced are available from the agency.

Statutory/Other Authority: ORS 731.244, 743.814 & 743.819

Statutes/Other Implemented: ORS 743.804 & 743.814