# COMAR Title 10 — Maryland Department of Health

## Subtitle 25 — Maryland Health Care Commission

### Chapter 08 — Evaluation of Quality and Performance of Health Benefit Plans

**Authority:** Health-General Article, §§19-109(a)(1) and (7), 19-132, and 19-134(c), Annotated Code of Maryland

**Administrative History:** Effective date: October 17, 2011 (38:21 Md. R. 1278)

#### Regulation .01 Scope.

*COMAR 10.25.08.01*

A. This chapter applies to each carrier that participates in the health benefit plan quality and performance evaluation system.

B. This chapter requires participation in the health benefit plan quality and performance evaluation system by each carrier that:

  (1) Holds a certificate of authority in the State;

  (2) Has a premium volume in Maryland for each category of health benefit plan that exceeds $1,000,000; and

  (3) Has no more than 65 percent of its Maryland enrollees covered through the Medicaid and Medicare Programs (for each category of health benefit plan), as reported in an annual statement submitted by a carrier to the Commission that includes premium volume and enrollment percentages for the calendar year preceding the reporting period.

C. The evaluation system described in this chapter is designed to address the information needs of consumers and purchasers by providing an assessment of the quality and performance of health benefit plans based on measures endorsed or implemented by nationally recognized organizations involved in quality of care and performance measurement.

#### Regulation .02 Definitions.

*COMAR 10.25.08.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Carrier” means an insurer or nonprofit health service plan that holds a certificate of authority and provides health insurance policies or contracts in the State in accordance with Insurance Article, Annotated Code of Maryland, or a health maintenance organization that holds a certificate of authority in the State.

  (2) “Commission” means the Maryland Health Care Commission.

  (3) Health Benefit Plan.

    (a) “Health benefit plan” means a hospital or medical policy, contract, or certificate issued by a carrier.

    (b) “Health benefit plan” does not include:

      (i) Coverage for accident or disability income insurance;

      (ii) Coverage issued as a supplement to liability insurance;

      (iii) Liability insurance, including general liability insurance and automobile liability insurance;

      (iv) Workers’ compensation or similar insurance;

      (v) Automobile or property medical payment insurance;

      (vi) Credit-only insurance;

      (vii) Coverage for on–site medical clinics;

      (viii) Dental or vision insurance;

      (ix) Long-term care insurance or benefits for nursing home care, home health care, community-based care, or any combination of these;

      (x) Coverage only for a specified disease or illness;

      (xi) Hospital indemnity or other fixed indemnity insurance or a hospital or medical policy, contract, or certificate issued by a carrier; or

      (xii) If offered as a separate insurance policy, Medicare supplemental health insurance, as defined in §1882(g)(1) of the Social Security Act, coverage supplemental to the coverage provided under Chapter 55 of Title 10 of the United States Code, or similar supplemental coverage provided under an employer sponsored plan.

  (4) “HEDIS” means the Healthcare Effectiveness Data and Information Set published by the National Committee for Quality Assurance.

  (5) “Measurement year” means the calendar year in which services take place and that precedes the reporting period in which the quality and performance measures report is submitted to the Commission or its contractor.

  (6) “Performance measures report” means the report that a carrier submits to the Commission or its contractor that includes the performance measures calculated in accordance with the HEDIS and other applicable performance measure specifications.

  (7) “Proprietary information” means information that would put a carrier at a competitive disadvantage if such information were disclosed.

  (8) “Quality and performance evaluation system” means the process by which the Commission carries out its responsibilities related to the evaluation and reporting of quality and performance of health benefit plans.

  (9) “Reporting period” means the year in which a carrier submits HEDIS and other performance measures to the Commission or its contractor and which follows the measurement year.

#### Regulation .03 Health Benefit Plan Quality and Performance Evaluation System — Implementation.

*COMAR 10.25.08.03*

A. Carrier Participation.

  (1) Each carrier may participate in the health benefit plan quality and performance evaluation system.

  (2) Each carrier that meets the criteria of Regulation .01B of this chapter is required to participate.

  (3) A carrier that chooses not to participate in the health benefit plan quality and performance evaluation system must present clear evidence to the Commission that shows that the carrier has no more than $1,000,000 in annual premium volume by category of health benefit plan and no more than 65 percent of its Maryland enrollees covered through the Medicaid and Medicare programs.

B. Performance Measures. The Commission shall choose performance measures that are important, feasible, scientifically sound, and actionable, including performance measures that:

  (1) Are related to the quality and performance of medical services provided by a health benefit plan;

  (2) Allow for comparisons among health benefit plans;

  (3) Can be of interest to purchasers, consumers, providers, carriers, or health officials;

  (4) Can be used to affect changes in performance; and

  (5) Can be validated through an audit conducted by an independent party for validity, reliability, and comparability.

C. Notice by the Commission.

  (1) Beginning in November 2011, and each November thereafter, the Commission shall provide a dated notice posted on the Commission’s website and a written notice to each carrier required to report under Regulation .01A. of this chapter regarding the following:

    (a) The required categories of health benefit plans for which HEDIS and other performance measures must be submitted for the upcoming measurement year;

    (b) The selected HEDIS and other performance measures for each category of health benefit plan to be included in the reporting period; and

    (c) Quality and performance measures that will be subject to audit.

  (2) Beginning in December 2011, and each December thereafter, the Commission shall provide a dated notice posted on the Commission’s website and a written notice to each carrier required to report under Regulation .01A of this chapter regarding the following:

    (a) The required categories of health benefit plans for which HEDIS and other performance measures must be submitted for the upcoming measurement year;

    (b) The selected HEDIS and other performance measures for each category of health benefit plan to be included in the reporting period;

    (c) Quality and performance measures that will be subject to audit; and

    (d) The HEDIS and other performance measures anticipated to be required in the measurement year occurring after the current measurement year.

D. Performance Measures Collection.

  (1) Beginning in January of each reporting period, a carrier that is required to participate or elects to participate in the health benefit plan quality and performance evaluation system shall collect all required performance measures as follows:

    (a) Collecting HEDIS measures, a carrier shall follow the specifications contained in the latest version or technical update of HEDIS applicable to the measurement year;

    (b) Collecting other performance measures, a carrier shall follow specifications published by a nationally recognized organization involved in quality and performance measurement, and in accordance with the notice provided by the Commission in November for the measurement year; and

    (c) A carrier shall use the specifications, templates, and other documents provided by the Commission, which shall be consistent with those published by the National Committee for Quality Assurance for HEDIS measures and, for non-HEDIS performance measures, required by the Commission, consistent with specifications, templates, or documents published by nationally recognized organizations involved in quality of care and performance measurement.

  (2) A carrier is not required to submit HEDIS or other performance measures regarding proprietary information contained in descriptive information on health plan management and activities.

  (3) The Commission shall provide technical assistance and auditing services to a carrier required to report the HEDIS and other performance measures.

E. Commission Publication of Health Benefit Plan Quality and Performance Evaluation Reports. On or before November 1 of each year, the Commission shall publish on its website one or more reports for use by consumers and purchasers who make health benefit plan enrollment and contracting decisions. The reports shall:

  (1) Compare quality and performance evaluation results of each health benefit plan on the various HEDIS and other performance measures required by the Commission; and

  (2) Include information on valid and reliable HEDIS and other performance measures that are comparable on a health benefit plan level, as determined by the Commission.

#### Regulation .04 Audits.

*COMAR 10.25.08.04*

A. In order to verify the validity, reliability, and comparability of HEDIS and other performance measures required by the Commission, a carrier shall participate in certified audits as specified by the Commission, which may include:

  (1) A process audit;

  (2) One or more site visits;

  (3) Specification and source code review and verification; and

  (4) Medical records review.

B. Each carrier that is required to participate or elects to participate in the health benefit plan quality and performance evaluation system shall submit audited HEDIS and other performance measures for each designated health benefit plan for the reporting period to the Commission or its contractor by June 1 of the reporting period.

C. Within the time period specified by the Commission, a carrier shall correct inaccurate or incomplete data contained in its performance measures report that become apparent during the audit or other process.

#### Regulation .05 Extension of Time.

*COMAR 10.25.08.05*

A. A carrier may request an extension of not more than 30 days for submission of the performance measures report.

B. A request for an extension of time shall:

  (1) Be submitted to the Executive Director of the Commission not later than 30 days before the carrier’s performance measures report is due;

  (2) Explain the good cause for the requested extension; and

  (3) Propose a reasonable date certain, not to exceed 30 days after the original due date, for submission of the performance measures report.

C. A carrier may seek Commission review of the Executive Director’s denial of a requested extension of time by filing a written petition for review within 7 days of receipt of the denial.

D. The Commission shall provide the carrier with an opportunity to present its position to the Commission, and may affirm, reverse, or modify the decision of the Executive Director.

#### Regulation .06 Penalty for Failure to File Reports.

*COMAR 10.25.08.06*

A carrier that is required to participate under Regulation .01B of this chapter and that does not timely file a performance measures report may be subject to the penalties provided in COMAR 10.25.12.