PROPOSAL
Maryland Register
Issue Date: November 13, 2017
Volume 44• Issue 23 • Pages 1101—1103
Title 10
MARYLAND DEPARTMENT OF HEALTH
Subtitle 09 MEDICAL CARE PROGRAMS
10.09.65 Maryland Medicaid Managed Care Program: Managed Care Organizations
Authority: Health-General Article, §2-104, 15-102.3, and 15-103; Insurance Article, §15-112, 15-605, and 15-1008, Annotated Code of Maryland
Notice of Proposed Action
[17-266-P]
The Secretary of Health proposes to amend Regulation .03 under COMAR 10.09.65 Maryland Medicaid Managed Care Program: Managed Care Organizations.
Statement of Purpose
The purpose of this action is to add federal managed care regulation requirements effective January 1, 2018 and to update the performance measures and methodology for Value Based Purchasing effective January 1, 2019.
Comparison to Federal Standards
There is no corresponding federal standard to this proposed action.
Estimate of Economic Impact
The proposed action has no economic impact.
Economic Impact on Small Businesses
The proposed action has minimal or no economic impact on small businesses.
Impact on Individuals with Disabilities
The proposed action has no impact on individuals with disabilities.
Opportunity for Public Comment
Comments may be sent to Michele Phinney, Director, Office of Regulation and Policy Coordination, Maryland Department of Health, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to mdh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through December 13, 2017. A public hearing has not been scheduled.
.03 Quality Assessment and Improvement.
A. An MCO shall have a continuous, systematic program designed to monitor, measure, evaluate, and improve the quality of health care services delivered to enrollees including individuals with special health care needs. At a minimum, the MCO shall:
(1)—(2) (text unchanged)
(3) Be able to provide the Department with timely accurate information in areas including but not limited to:
(a)—(c) (text unchanged)
B. An MCO shall participate in all quality assessment activities required by the Department in order to determine if the MCO is providing medically necessary enrollee health care. These activities include, but are not limited to:
(1) (text unchanged)
(2) The annual collection, validation, and evaluation of the latest approved version of the Healthcare Effectiveness Data and Information Set (HEDIS) in order to assess the access to and quality of services provided [as follows:
(a) The Department shall establish the number of HEDIS measures to be collected each year based on relevancy to the HealthChoice population;
(b) At a minimum, at least one measure shall be collected on each of the following:
(i) Prenatal, perinatal, and postnatal care;
(ii) Screening and preventive services for women and children; and
(iii) Children and adults with special health care needs; and
(c) At least 90 days before the audit process, the Department shall identify all measures to be collected;], in addition to any additional performance measures specified by the Department or CMS;
(3) The annual collection and evaluation of a set of performance measures with targets as determined by the Department as follows:
(a) The composition of the core performance measures is listed in [§B(3)(d) and (e)] §B(3)(d)—(f) of this regulation;
(b)—(c) (text unchanged)
(d) Effective January 1, 2014, the core performance measures are:
(i)—(xii) (text unchanged)
(xiii) Well child visits 3—6 years old[.];
(e) (text unchanged)
(f) Effective January 1, 2019, the core performance measures are:
(i) Adolescent well care visits;
(ii) Ambulatory care for SSI adults;
(iii) Ambulatory care for SSI children;
(iv) Asthma medication ratio;
(v) Breast cancer screening;
(vi) Comprehensive diabetes care – HbA1c control (<8.0%);
(vii) Controlling high blood pressure;
(viii) Postpartum care;
(ix) Lead screening for children 12 through 23 months old; and
(x) Well child visits in the first 15 months of life;
[(f)] (g) Starting with the 2014 performance measures, the Department shall implement the following methodology for imposing penalties and incentives:
(i)—(iii) (text unchanged)
(iv) The total amount of the penalties as described in [§B(3)(e)(iii)] §B(3)(g)(iii) of this regulation may not exceed 1 percent of the total capitation amount paid to the MCO during the same measurement year;
(v) (text unchanged)
(vi) The total amount of the incentive payments as described in [§B(3)(e)(v)] §B(3)(g)(v) of this regulation paid to the MCOs each year may not exceed the total amount of the penalties as described in [§B(3)(e)(iii)] §B(3)(g)(iii) of this regulation collected from the MCOs in that same year, plus any additional funds allocated to the Department for a quality initiative; and
(vii) Any funds remaining after the payment of the incentives due under [§B(3)(e)(v)] §B(3)(g)(v) of this regulation shall be distributed to the MCOs receiving the four highest normalized scores for Value Based Purchasing for all thirteen performance measures at a rate calculated by multiplying each MCO’s adjusted enrollment as of December 31 of the measurement year by a per enrollee amount;
(h) Starting with the 2019 performance measures, the Department shall implement the following methodology for imposing penalties and incentives:
(i) There shall be three levels of performance;
(ii) Performance shall be evaluated separately for each measure, and each measure shall have equal weight;
(iii) On any of the measures in §B(3)(f)(i)—(x) of this regulation for which the MCO does not meet the minimum target, as determined by the Department, a penalty of 1/10 of 1 percent of the total capitation amount paid to the MCO during the measurement year shall be collected;
(iv) The total amount of the penalties as described in §B(3)(h)(iii) of this regulation may not exceed 1 percent of the total capitation amount paid to the MCO during the same measurement year;
(v) On any of the measures in §B(3)(f) of this regulation for which the MCO meets or exceeds the incentive target, as determined by the Department, the MCO shall be paid an incentive payment of up to 1/10 of 1 percent of the total capitation paid to the MCO during that measurement year;
(vi) The total amount of the incentive payments as described in §B(3)(h)(v) of this regulation paid to the MCOs each year may not exceed the total amount of the penalties as described in §B(3)(g)(iii) of this regulation collected from the MCOs in that same year, plus any additional funds allocated to the Department for a quality initiative; and
(vii) Any funds remaining after the payment of the incentives due under §B(3)(h)(v) of this regulation shall be distributed to the MCOs receiving the four highest normalized scores for Value Based Purchasing for all ten performance measures at a rate calculated by multiplying each MCO’s adjusted enrollment as of December 31 of the measurement year by a per enrollee amount;
[(g)] (i) The adjusted enrollment amount in [§B(3)(e)(vii)] §B(3)(g)(vii) and §B(3)(h)(vii) of this regulation shall be calculated by:
(i)—(iv) (text unchanged)
[(h)] (j) The per enrollee amount in [§B(3)(e)(vii)] §B(3)(g)(vii) and §B(3)(h)(vii) of this regulation shall be calculated by dividing the sum of the calculations in [§B(3)(f)(i)—(iv)] §B(3)(g)(i)—(iv) and §B(3)(h)(i)—(iv) of this regulation into the funds remaining as described in [§B(3)(e)(vii)] §B(3)(g)(vii) and §B(3)(h)(vii) of this regulation;
(4) An annual enrollee satisfaction survey using the latest version of the [Consumer Assessment of Health Plans Survey] Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey tool, conducted by an NCQA-certified CAHPS vendor;
(5) (text unchanged)
(6) Performance improvement projects to be conducted by the MCOs that focus on clinical or nonclinical areas as determined by the Department or CMS and include the following:
(a)—(d) (text unchanged)
(e) Reporting of results to the Department or CMS.
C. (text unchanged)
D. An MCO shall provide the Department a copy of its most recent NCQA accreditation, including:
(1) Accreditation status, survey type, and level;
(2) Accreditation results, including:
(a) Recommended actions or improvements,
(b) Corrective action plans, and
(c) Summaries of findings; and
(3) Expiration date of the accreditation.
DENNIS SCHRADER
Secretary of Health
