Montana Administrative Register Notice 37-786 No. 6   03/24/2017    
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In the matter of the amendment of ARM 37.108.507 pertaining to healthcare effectiveness data and information set (HEDIS) measures








TO: All Concerned Persons


1. The Department of Public Health and Human Services proposes to amend the above-stated rule.


2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require an accommodation, contact the Department of Public Health and Human Services no later than 5:00 p.m. on April 19, 2017, to advise us of the nature of the accommodation that you need. Please contact Kenneth Mordan, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena MT 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail dphhslegal@mt.gov.


3. The rule proposed to be amended provides as follows, new matter underlined, deleted matter interlined:



          (1) Annually, the health carrier shall evaluate its quality assessment activities by using the following HEDIS 2014 2017 measures:

          (a) through (3) remain the same.

          (4) The department adopts and incorporates by reference the HEDIS 2014 2017 measures for the categories listed in (1)(a) through (e). The HEDIS 2014 2017 measures are developed by the National Committee for Quality Assurance and provide a standardized mechanism for measuring and comparing the quality of services offered by managed care health plans. Copies of HEDIS 2014 2017 measures are available from the National Committee for Quality Assurance, 1100 13th St. NW, Suite 1000, Washington, D.C. 20005 or on the Internet at www.ncqa.org.


AUTH: 33-36-105, MCA

IMP:     33-36-105, 33-36-302, MCA




The Managed Care Plan Network Adequacy and Quality Assurance Act (Title 33, chapter 36, MCA) establishes standards for health carriers offering managed care plans and for the implementation of quality assurance standards in administrative rules. ARM 37.108.501 through 37.108.521 were adopted in 2001 to establish mechanisms for the department to evaluate quality assurance activities of health carriers providing managed care plans in Montana. ARM 37.108.507 requires health carriers to report their quality assessment activities to the department using healthcare effectiveness data and information set (HEDIS) measures, nationally utilized measures that are updated annually. Since the HEDIS standards change somewhat every year, the rule must also be updated annually to reflect the current year's measures and ensure that national comparisons are possible, since the other states will also be using the same updated measures.


The option of not updating the HEDIS measure was considered and rejected because these are national quality measures which allow comparison among health plans. If the measures are not kept current, this function is lost.


The changes from adopted 2014 measures to the proposed measures are quoted below:


Changes to HEDIS 2017, Volume 2


(1) Childhood Immunization Status:

(a)  added CVX codes to the measure;

(b) added HIV Type 2 Value Set to the optional exclusions; and

(c) added optional exclusions for the rotavirus vaccine.

(2) Breast Cancer Screening:

(a) clarified that diagnostic screenings are not included in the measure.

(3) Cervical Cancer Screening:

(a) clarified that reflex testing does not meet criteria in step 2 of the hybrid specification.

(4) Comprehensive Diabetes Care:

(a) added an administrative method and new value set to identify negative eye exams in the year prior to the measurement year;

(b) added glycohemoglobin, glycated hemoglobin and glycosylated hemoglobin as acceptable HbA1c tests;

(c) clarified documentation requirements for a negative eye exam; and

(d) replaced "Each of the 7 rates" with a "checkmark" for the "Measurement year" row in Table CDC-1/2/3.

(5) HEDIS/Consumer Assessment of Health Plan Survey (CAHPS) for Adults:

(a) This measure is collected using survey methodology.  Detailed specifications and summary of changes are contained in HEDIS 2017, Volume 3: Specifications for Survey Measures.


Corrections, policy changes, and clarifications to HEDIS 2017, Volume 2, Technical Specifications


(1) Breast Cancer Screening Exclusion (optional)

(a) Replaced the second bullet with the following text:

Unilateral mastectomy (Unilateral Mastectomy Value Set) with a bilateral modifier (Bilateral Modifier Value Set). Codes must be on the same claim;

(b) in the first row of bullets in the table, replace both references to "(same date of service)" with "(same claim)."

(c) replace the Note with the following text:

"This measure evaluates primary screening.  Do not count biopsies, breast ultrasounds, MRIs, or tomosynthesis (3D mammography), because they are not appropriate methods for primary breast cancer screening."

(2) Comprehensive Diabetes Care Hybrid Specification - Denominator

(a) Add the following text as the second sentence in the third paragraph:

(i)  "Members from the oversample should be added to the denominator for all measure indicators."


5. The department intends the proposed rule amendments to be applied retroactively to January 1, 2017. There is no negative impact to the affected health insurance company by applying the rule amendment retroactively.


6. Concerned persons may submit their data, views, or arguments concerning the proposed action in writing to: Kenneth Mordan, Office of Legal Affairs, Department of Public Health and Human Services, P.O. Box 4210, Helena MT 59604-4210, no later than 5:00 p.m. on April 21, 2017. Comments may also be faxed to (406) 444-9744 or e-mailed to dphhslegal@mt.gov.


7. If persons who are directly affected by the proposed action wish to express their data, views, or arguments orally or in writing at a public hearing, they must make written request for a hearing and submit this request along with any written comments to Kenneth Mordan at the above address no later than 5:00 p.m., April 21, 2017.


8. If the agency receives requests for a public hearing on the proposed action from either 10% or 25, whichever is less, of the persons directly affected by the proposed action; from the appropriate administrative rule review committee of the Legislature; from a governmental subdivision or agency; or from an association having not less than 25 members who will be directly affected, a hearing will be held at a later date. Notice of the hearing will be published in the Montana Administrative Register. Ten percent of those directly affected has been determined to be 1 person based on there being only one health insurance provider affected by this proposed rule amendment.


9. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 6 above or may be made by completing a request form at any rules hearing held by the department.


10. An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of this notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.


11. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.


12. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment of the above-referenced rule will not significantly and directly impact small businesses.




/s/ Flint Murfitt                                       /s/ Sheila Hogan                                   

Flint Murfitt, Attorney                             Sheila Hogan, Director                

Rule Reviewer                                       Public Health and Human Services


Certified to the Secretary of State March 13, 2017.


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