Or. Admin. R. 836-053-1170

Current through Register Vol. 63, No. 8, August 1, 2024

Section 836-053-1170 - Annual Summary, Quality Assessment Activities

(1) The annual summary required by ORS 743.814(2) shall:

(a) Describe the insurer's quality assessment program that enables the insurer to evaluate, maintain and improve the quality of health services provided to enrollees;

(b) Identify the specific quality-improvement goals chosen by the insurer and report any progress on those goals as measured by the insurer's data gathering;

(c) Describe the insurer's quality assessment activities, to the extent the insurer engages in relevant activities, in the following areas:

(A) Corporate oversight;

(B) Credentialing of providers;

(C) Provider participation;

(D) Use of clinical practice guidelines;

(E) Identification of priorities;

(F) Assessment of enrollee satisfaction;

(G) Communication with enrollees and providers;

(H) Program evaluation.

(2) An insurer shall include the following in the annual information required by ORS 743.814(3):

(a) The results of all publicly available federal Health Care Financing Administration reports and accreditation surveys by national accreditation organizations; and

(b) The reporting of the insurer's health promotion and disease prevention activities, if any, specified in section (3) of this rule.

(3) The activities to be reported as required by section (2)(b) of this rule are all contained in the National Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS), and are selected for their standardized definitions and data collection protocols in order to facilitate collection of comparable data from all plans. The activities are as follows:

(a) The following preventive measures:

(A) Childhood immunizations, including the percentage of children in the insurer's managed care health plans who have received appropriate immunizations by their second birthdays; and

(B) Tobacco use, including the percentage of adult smokers and recent quitters who received advice to quit smoking from a health professional in health plans of the insurer.

(b) Chronic conditions, as follows:

(A) For calendar year 1999 only, the chronic condition of breast cancer including the percentage of the insurer's health plans' female members between the ages of 52 and 69 who had at least one mammogram during the past two years; and

(B) For calendar year 2000 and each calendar year thereafter, the chronic condition of diabetes as specified in the HEDIS.

(c) The acute condition of pregnancy care. The information shall include the percentage of pregnant women in the insurer's health plans that began prenatal care during the first 13 weeks of pregnancy.

(4) In order to minimize duplicative reporting requirements, the insurer may submit the summary required in section (1) of this rule and the information required in section (2)(b) of this rule in the format of the insurer's choosing. For purposes of this section:

(a) The insurer may submit a summary prepared by the insurer for another purpose. If the insurer submits such a summary, the insurer shall comply with OAR 836-053-1000(3) and (5). The insurer may include in the summary any additional information that the insurer deems significant in describing its quality assessment and improvement activities;

(b) The summary may include information prepared by the insurer for HEDIS and may be submitted on the basis of any sampling method recognized by HEDIS. A multi-state or regional HEDIS report may be used for reporting under this subsection if the insurer furnishes with the report the number or an estimate of the number of regional members and Oregon members to whom the report applies.

Or. Admin. R. 836-053-1170

ID 1-1998, f. & cert. ef. 1-15-98; ID 17-1998, f. & cert. ef. 11-16-98

Publications: The publication(s) referred to or incorporated by reference in this rule are available from the agency.

Stat. Auth.: ORS 731.244, ORS 743.814 & ORS 743.819

Stats. Implemented: ORS 743.804 & ORS 743.814