Md. Code Regs. 10.67.04.03

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.04.03 - 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) Comply with all applicable federal and State laws and regulations;

(2) Comply with all access and quality standards and levels of performance established by the Department including all standards for individuals with special health care needs in Regulations .04-.10 of this chapter; and

(3) Be able to provide the Department with timely accurate information in areas including but not limited to:

(a) Provider networks;

(b) Utilization of services; and

(c) Identification and management of individuals with special health care needs, including but not limited to:

(i) Enrollees with HIV;

(ii) Pregnant women;

(iii) Enrollees with disabilities;

(iv) Adult enrollees with diabetes;

(v) Pediatric enrollees with asthma; and

(vi) Children with special health care needs.

B. An MCO shall participate in all quality assessment activities required by the Department to determine if the MCO is providing medically necessary enrollee health care. These activities include but are not limited to:

(1) A Systems Performance Review (SPR) performed by an external quality review organization hired by the Department to assess an MCO's structure and operations in order to determine its ability to provide health care to its enrollees as follows:

(a) The SPR shall include, but not be limited to:

(i) MCO's Quality Assessment and Improvement program;

(ii) Enrollee rights;

(iii) Access and availability of services;

(iv) Care management;

(v) Enrollee outreach;

(vi) Utilization management and review; and

(vii) MCO organization, operations, and financial management;

(b) The results of the SPR shall be reported in draft to the MCOs for comment;

(c) MCO shall submit all comments and any required corrective action within 45 days of receipt of draft report; and

(d) The Department shall issue a final report of the SPR results;

(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, 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)-(f) of this regulation;

(b) Each year before the audit period begins, the Department shall identify and obtain public input on all measures to be collected as well as the target for each;

(c) In accordance with COMAR 10.67.73, MCOs may receive financial or other types of incentives or disincentives based on performance measure results;

(d) Effective January 1, 2017, the core performance measures are:

(i) Adolescent well care visits;

(ii) Adult Body Mass Index (BMI) assessment;

(iii) Ambulatory care for Supplemental Security Income (SSI) adults;

(iv) Ambulatory care for Supplemental Security Income (SSI) children;

(v) Breast cancer screening;

(vi) Childhood immunizations - Combo 3;

(vii) Comprehensive diabetes care - HbA1c testing;

(viii) Controlling high blood pressure;

(ix) Immunization for adolescents;

(x) Lead screening for children 12-23 months old;

(xi) Asthma medication ratio;

(xii) Postpartum care; and

(xiii) Well child visits, 3-6 years old;

(e) 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) Lead screening for children 12 through 23 months old; and

(ix) Well child visits in the first 15 months of life;

(f) Effective January 1, 2021, 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) Lead screening for children 12 through 23 months old;

(ix) Postpartum care; and

(x) Well child visits in the first 15 months of life;

(g) 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)-(ix) of this regulation for which the MCO does not meet the minimum target, as determined by the Department, a penalty of 1/9 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 1/9 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;

(h) Starting with the 2021 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) 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 if the conditions in §B(3)(h)(iv) of this regulation do not apply;

(iv) If the Department's actuary determines that the MCO's total capitation amount for the measurement year does not meet the actuarial soundness definition described in 42 CFR § 438.4 after collection of the total penalty amount described in §B(3)(h)(iii) of this regulation, the Department's actuary shall calculate the maximum penalty the Department shall apply that results in the MCO's total capitation for the measurement year remaining actuarially sound;

(v) If the MCO's penalty amount is reduced as described in §B(3)(h)(iv) of this regulation, the Department may impose any of the additional sanctions described in COMAR 10.67.10;

(vi) 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;

(vii) 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;

(viii) The total amount of the incentive payments as described in §B(3)(h)(vii) of this regulation shall be paid to the MCOs with total amount of the penalties as described in §B(3)(h)(iii) of this regulation collected from the MCOs in that same year, plus additional reserves in the Health Choice Performance Incentive Fund if the total amount of the penalties collected is insufficient to pay the total amount of the incentive payments;

(ix) 40 percent of any funds remaining after the payment of the incentives due under §B(3)(h)(vii) of this regulation shall be distributed to the MCOs earning net incentives with the four highest normalized scores, at a rate calculated by multiplying each MCO's adjusted enrollment as of December 31 of the measurement year by a per-enrollee amount;

(x) MCOs earning net disincentives are ineligible to receive the funds described in §B(3)(h)(ix) of this regulation;

(xi) 25 percent of any funds remaining after the payment of the incentives due under §B(3)(h)(vii) of this regulation shall be distributed to the MCOs that the Department determines have demonstrated performance improvement in the measurement year, provided that the MCOs use the funding to target performance improvement in areas defined by the Department;

(xii) 25 percent of any funds remaining after the payment of the incentives due under §B(3)(h)(vii) of this regulation shall be retained for health improvement programs under the Maryland Medicaid Managed Care Program;

(xiii) 10 percent of any funds remaining after the payment of the incentives due under §B(3)(h)(vii) of this regulation shall be used to establish a reserve in the Health Choice Performance Incentive Fund, to be used in any calendar year when the amount of penalties collected is insufficient to pay incentives earned by MCOs; and

(xiv) If the amount in the Health Choice Performance Incentive Fund exceeds $5,000,000, the Department shall equally allocate the remaining 10 percent of funds for use in items B(3)(h)(ix)-(xii);

(i) The adjusted enrollment amount in §§B(3)(g)(vii) and B(3)(h)(ix) of this regulation shall be calculated by:

(i) Multiplying four times the enrollment of the MCO with the highest normalized score;

(ii) Multiplying three times the enrollment of the MCO with the second highest normalized score;

(iii) Multiplying two times the enrollment of the MCO with the third highest normalized score; and

(iv) Using the actual enrollment of the MCO with the fourth highest normalized score;

(j) The per enrollee amount in §§B(3)(g)(vii) and B(3)(h)(ix) of this regulation shall be calculated by dividing the sum of the calculations in §B(3)(i)(i)-(iv) of this regulation into the funds remaining as described in §§B(3)(g)(vii) and B(3)(h)(ix) of this regulation; and

(k) The methodology described in §B(3)(a)-(j) of this regulation shall remain in effect through December 31, 2021;

(4) An annual enrollee satisfaction survey using the latest version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey tool, conducted by an NCQA-certified CAHPS vendor;

(5) An annual Maryland Healthy Kids audit in order to determine the quality of the clinical care provided to all children younger than 21 years old enrolled in the HealthChoice Program as follows:

(a) The audit shall include a review of a sample of medical records from each provider reviewed during the calendar year to assess clinical care;

(b) The results of the audit that are below minimum EPSDT standards may result in corrective action required by both the provider and the MCO; and

(c) The Department shall issue a final report of the audit results;

(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) Measurement of performance using objective quality indicators;

(b) Implementation of system interventions to achieve improvement in quality;

(c) Evaluation of effectiveness of interventions;

(d) Planning and initiation of activities to sustain improvement; and

(e) Reporting of results to the Department or CMS; and

(7) Validation and evaluation of MCO provider networks to ensure compliance with the network adequacy and access standards set forth in COMAR 10.67.66.

C. If an MCO is assessed as deficient in accordance with federal and State standards, the MCO shall submit a plan of corrective action to the Department.

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.

Md. Code Regs. 10.67.04.03

Regulations .03 recodified from 10.09.65.03 effective 46:22 Md. R. 976, eff. 11/1/2019; amended effective 48:8 Md. R. 309, eff. 4/19/2021; amended effective 48:21 Md. R. 889, eff. 10/18/2021