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 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, commercial 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 questions, sample size and sampling method. Separate satisfaction surveys shall be conducted on regular HMO and HMO point-of-service plans for commercial enrollees;
   2. (B) The data provided to the department shall be in electronic form and meet the specifications of Table A;
   3. (C) In 1998 the data shall be submitted by September 1. In subsequent years the data shall be submitted by June 15 or the date required by NCQA if other than June 15; and
   4. (D) Medicare and Medicaid health care plans shall participate in a member satisfaction survey conducted by the Division of Medical Services and the Health Care Financing Administration respectively. The department will obtain the data from the agencies conducting the surveys.

3. (3) Starting in 1998, health care plans shall provide annually to the department, audited quality indicator rates and the numerators and denominators of the rates— 19 CSR 10-5

   1. (A) Quality indicator rates 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) The quality indicators data shall conform to specifications listed in Table B; and
   4. (D) In 1998 the data shall be submitted by September 1. In subsequent years the data shall be submitted by June 15 or the date required by NCQA if other than June 15.

4. (4) Starting in 1998, all commercial health care plans shall submit annually to the department enrollee data for linkage with department data to produce quality indicators—

   1. (A) The enrollee data shall be submitted to the department by September 1, 1998, and by April 1 of each year thereafter, on persons enrolled in a health care plan as of December 31 of the previous year;
   2. (B) The enrollee data shall include the data elements and conform to the specifications listed in Table C of this rule and shall be submitted on magnetic media.
5. (5) 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.

6. (6) 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. 1997.* 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.

*Original authority 1997.