§432E-10  Managed care plan performancemeasurement and data reporting standards.  (a)  It is the policy of thisState that all managed care plans shall adopt and comply with nationallydeveloped and promulgated standards for measuring quality, outcomes, access,satisfaction, and utilization of services.  Every contract between a managedcare plan and a participating provider of health care services shall requirethe participating provider to comply with the managed care plan's requests forany information necessary for the managed care plan to comply with therequirements of this chapter.  The State shall require that:

(1)  Consumers, providers, managed care plans,purchasers, and regulators shall be equitably represented in the development ofstandards; and

(2)  Standards shall result in measurement andreporting that is purposeful, valid, and scientifically based, applied in aconsistent and comparable manner, efficient and cost effective, and designed tominimize redundancy and duplication of effort.

(b)  All managed care plans, no less thanannually, shall report to the commissioner comparable information onperformance, including measures of quality, outcomes, access, satisfaction, andutilization of services; provided that:

(1)  Reporting shall be based upon a core data andinformation set that builds upon nationally recognized performance measurementsystems.  The core data and information set shall include standardized measuresof:

(A)  Effectiveness and appropriateness of care(the impact of care delivered to managed care plan enrollees, for example,results of the plan for childhood immunizations, cholesterol screening,mammography screening, cervical cancer screening, prenatal visits in the firsttrimester of pregnancy, and diabetic retinal examinations);

(B)  Access and availability of care (theextent to which plan enrollees have access to the health care providers theyneed or desire to see, and receive appropriate services in a timely manner,without inappropriate barriers or inconvenience);

(C)  Satisfaction with the experience of care(the results of the most recent enrollee satisfaction survey using standardizedsurvey design and methods);

(D)  Managed care plan stability (attributes ofa managed care plan which affect its ability to deliver high-quality care andservice on a sustained basis);

(E)  Use of services (rates of service use perone thousand enrollees as well as percentages of enrollees who receivespecified services);

(F)  Cost of care (expenditures per enrolleeper month, premium rates for selected membership categories, and rates ofincreases); and

(G)  Managed care plan descriptive information(the plan name, location of headquarters, and number of years the plan has beenin business; the model type of the plan; the counties in which the planoperates; the total number of participating physicians per one thousandenrollees and the number of primary care physicians per one thousand enrollees;the number of participating hospitals per ten thousand enrollees; thepercentage of participating physicians who are board certified; and a list ofwellness and health care education programs offered by the plan);

(2)  Information shall be uniformly reported bymanaged care plans in a standardized format, as determined by rule;

(3)  Information supplied by managed care plans shallbe subject to independent audit by the appropriate regulatory agency or itsdesignee to verify accuracy and protect against misrepresentation;

(4)  Information reported by managed care plans shallbe adjusted, based on standardized methods, to control for the effects ofdifferences in health risk, severity of illness, or mix of services;

(5)  A managed care plan shall ensure confidentialityof records and shall not disclose individually identifiable data or informationpertaining to the diagnosis, treatment, or health of any enrollee, except asprovided under law; and

(6)  A managed care plan shall disclose to itsenrollees the quality and satisfaction assessments used, including the currentresults of the assessments. [L 1998, c 178, pt of §2; am L 1999, c 137, §8]