Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 421 - HEALTH CARE INFORMATION › Subchapter B - COLLECTION AND REPORTING OF HEALTH PLAN EMPLOYER DATA AND INFORMATION SET (HEDIS) FROM HEALTH MAINTENANCE ORGANIZATIONS (HMOS) › Section 421.23 - Collection and Reporting of Health Plan Employer Data and Information Set (HEDIS) Data by Health Maintenance Organizations (HMOs)

Current through Reg. 49, No. 28; July 12, 2024
(a) Any health maintenance organization (HMO) operating in the State of
											  Texas on December 1, 1996, and on that date each year thereafter, shall have a system in place to collect the
											  full HEDIS data set, and shall be required to report HEDIS data, collected during the next calendar year.
											  Single service HMOs which contract as secondary providers with other HMOs to provide services to covered
											  lives which are the same lives covered by the primary HMO, shall report data as necessary to fulfill data
											  reporting requirements under this rule to the primary HMO, which will report HEDIS data to the Council.
											  Single service HMOs, which contract directly with employers to provide specific services, shall report HEDIS
											  data directly to the Council. Basic HMOs which contract as secondary providers with other basic HMOs to
											  provide a range of health care services normally considered to be full health coverage on a specified group
											  of covered lives, e.g., ages 0 to 18 year olds, shall report complete HEDIS data to primary HMOs, with which
											  the secondary HMOs have contracted to provide services, which, in turn, shall report directly to the
											  Council.
(b) HMOs shall report HEDIS data, by Service area
											  division. Data to be reported shall be a subset of the "Reporting Set Measures" (i.e., this excludes data
											  specified as "Testing Set Measures"), as specified by the Council by November 15th of the year for which the
											  data are collected. Reporting by any specific subpopulation (e.g., Medicare, Medicaid) will be specified by
											  the Council by November 15th of the year for which the data are collected.
(c) The HMO shall report HEDIS data to the Council by the reporting
											  deadline as specified by NCQA or as specified by the executive director (should the date be incompatible with
											  the Council's goals) in the current year.
(d) HEDIS data shall be
											  reported to the Council or its agents at physical or telephonic addresses specified by the executive
											  director. The executive director shall notify all HMOs in writing and by publication in the Texas Register at
											  least 30 days before any change in the address.
(e) Any HMO which
											  judges that it cannot meet required performance measure specifications due to either low enrollment (such
											  that sample size requirements are not met) or short time of existence (such that length of time requirements
											  are not met) shall provide the Council with a narrative that documents the reason for not reporting the data
											  for that performance measure. Single service HMOs shall notify the Council to address which measures are
											  applicable to the services they provide. All requests for exemptions from reporting data for any performance
											  area(s) required by this chapter shall be submitted by the HMO on an annual basis, prior to November 15th of
											  the year for which the data are collected, and processed by the executive director using the following
											  procedures.
(1) An HMO requesting an exemption from reporting any required
											  performance measure prescribed by this chapter shall submit to the executive director a letter requesting the
											  exemption and provide all information necessary to establish the HMO's entitlement to the exemption. The
											  exemption request shall be signed by the chief executive officer of the HMO who shall certify that all
											  information contained in the request is true and correct.
(2) The
											  executive director shall review the request for exemption. The executive director may request additional
											  information from the HMO relevant to the exemption request. Within 30 days of receipt of a request for
											  exemption, the executive director shall issue a letter granting or denying the exemption. If denied, the
											  letter shall state in detail the reasons for the denial. The executive director shall notify Council members
											  of exemptions requested and the disposition of these requests for information purposes only.
(3) If the executive director denies an exemption request, the HMO may
											  resubmit the request along with any additional information or analysis the HMO deems relevant to the
											  executive director. The resubmission shall be considered in the same manner as the initial
											  submission.
(4) If the executive director denies the resubmitted
											  exemption request, the HMO may appeal the executive director's decision to the Council. In making its
											  determination, the Council will consider only those facts and issues which have been previously presented to
											  the executive director. The Council will decide exemption appeals by majority vote of members
											  present.