PURPOSE: This rule establishes the procedures for health maintenance organizations to collect and submit data to the Department of Health pursuant to section 192.068, RSMo.

1. (1) The following definitions shall be used in the interpretation and enforcement of this rule:

   1. (A) Department means Missouri Department of Health;
   2. (B) Director means the director of the Missouri Department of Health;
   3. (C) Health care plan means any separately licensed entity subject to the provisions of sections 354.400 to 354.636, RSMo which had enrollees in the plan for at least six (6) months of the year for which data are to be reported and for at least six (6) months of the following year;
   4. (D) NCQA means the National Committee on Quality Assurance; and
   5. (E) HEDIS© means the current Health Plan Employer Data and Information Set.

2. (2) Starting in 1998, health care plans shall submit annually to the department, member satisfaction survey data—

   1. (A) The member satisfaction survey shall be conducted according to HEDIS© technical specifications, including survey instrument, sample size, sampling method, and collection protocols;
   2. (B) The commercial and Medicaid member satisfaction data shall be submitted to the department in electronic form, through a certified survey vendor, and meet the specifications of Table A. Table A is incorporated herein by reference. An exception to this requirement shall be made for those Medicaid health care plans that are required to participate in a member satisfaction survey conducted by the Division of Medical Services. For these plans, the department will obtain the member satisfaction data from the Division of Medical Services;
   3. (C) In 1998 the data shall be submitted by September 1. In subsequent years a final member-level data file shall be submitted by June 15 or the date required by NCQA if other than June 15; and
   4. (D) Medicare health care plans shall participate in a member satisfaction survey con- 19 CSR 10-5

ducted by the Health Care Financing Amended: Filed Sept. 15, 2000, effective Administration. The department will obtain April 30, 2001. the data from the Health Care Financing *Original authority: 192.068, RSMo 1997. Administration.

1. (3) Starting in 1998, health care plans shall provide annually to the department, audited quality indicator data—

   1. (A) Quality indicator data shall be in accordance to all HEDIS© specifications;
   2. (B) All health care plans shall submit to the department documentation from a NCQA licensed organization that the quality indicator data submitted to the department have been audited through a partial or complete audit according to HEDIS© specifications;
   3. (C) Each licensed health care plan shall submit separate quality indicator data files for their commercial, Medicaid and Medicare enrollees. Health care plans that contract with the Division of Medical Services to provide coverage in more than one Medicaid region, shall submit separate quality indicator data for the enrollees in each region. The quality indicator data shall be submitted to the department in electronic form and conform to the specifications listed in Table B. Table B is incorporated herein by reference; and
   4. (D) In 1998 the data shall be submitted by September 1. In subsequent years a final data file shall be submitted by June 15 or the date file required by NCQA if other than June 15.
2. (4) In 1998 access to care data shall be submitted by September 1. In subsequent years the data shall be submitted by June 15. Access to care data shall include the data elements and conform to the specifications listed in Table D. Table D is incorporated herein by reference.

3. (5) A health care plan demonstrates continual or substantial failure to comply with the provisions of this rule when the health care plan has been notified by the department that it fails to comply with the provisions of section 192.068, RSMo and this rule and the health care plan—

   1. (A) Fails to provide required data;
   2. (B) Fails to submit data that meet the data standards detailed in this rule; or
   3. (C) Fails to submit data within the time frames established in this rule. AUTHORITY: section 192.068, RSMo Supp. 1999.* Emergency rule filed Jan. 16, 1998, effective Jan. 26, 1998, terminated April 15, 1998. Original rule filed Jan. 16, 1998, effective Aug. 30, 1998. Amended: Filed Oct. 30, 1998, effective May 30, 1999. Amended: Filed Dec. 20, 1999, effective May 30, 2000. of Data to Monitor Health Maintenance Organizations 19 CSR 10-5 of Data to Monitor Health Maintenance Organizations 19 CSR 10-5 of Data to Monitor Health Maintenance Organizations 19 CSR 10-5 of Data to Monitor Health Maintenance Organizations 19 CSR 10-5 of Data to Monitor Health Maintenance Organizations 19 CSR 10-5