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



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



(2)  Standards shall result in measurement and
reporting that is purposeful, valid, and scientifically based, applied in a
consistent and comparable manner, efficient and cost effective, and designed to
minimize redundancy and duplication of effort.



(b)  All managed care plans, no less than
annually, shall report to the commissioner comparable information on
performance, including measures of quality, outcomes, access, satisfaction, and
utilization of services; provided that:



(1)  Reporting shall be based upon a core data and
information set that builds upon nationally recognized performance measurement
systems.  The core data and information set shall include standardized measures
of:



(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 first
trimester of pregnancy, and diabetic retinal examinations);



(B)  Access and availability of care (the
extent to which plan enrollees have access to the health care providers they
need 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 standardized
survey design and methods);



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



(E)  Use of services (rates of service use per
one thousand enrollees as well as percentages of enrollees who receive
specified services);



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



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



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



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



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



(5)  A managed care plan shall ensure confidentiality
of records and shall not disclose individually identifiable data or information
pertaining to the diagnosis, treatment, or health of any enrollee, except as
provided under law; and



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