Section 9.40. Required quality assurance and remedial action plans.

 

(1)  In this section:

(a) "HEDIS data" means the elements of the Health Plan Employer Data and Information Set as defined by the National Committee on Quality Assurance.

(b) "Quality assurance" means the measurement and evaluation of the quality and outcomes of medical care provided.

(2)  

(a) By April 1, 2000, an insurer, with respect to a defined network plan that is not a preferred provider plan shall submit a quality assurance plan consistent with the requirements of s. 609.32 , Stats., to the commissioner, except as provided in par. (b) . The insurers shall submit a quality assurance plan that is consistent with the requirements of s. 609.32 , Stats., by April 1 of each subsequent year. The quality assurance plan shall be designed to reasonably assure that health care services provided to enrollees of the defined network plan meet the quality of care standards consistent with prevailing standards of medical practice in the community. The quality assurance plan shall document the procedures used to train employees of the defined network plan in the content of the quality assurance plan.

(b) Insurers offering a defined network plan that is not also a preferred provider plan or health maintenance organization plan shall submit a quality assurance plan consistent with the requirements of par. (a) and s. 609.32 , Stats., to the commissioner by April 1, 2007, and April 1 of each subsequent year.

(3)  Insurers offering a preferred provider plan shall develop procedures for taking effective and timely remedial action to address issues arising from quality problems including access to, and continuity of care from, participating primary care providers. The remedial action plan shall at least contain all of the following:

(a) Designation of a senior-level staff person responsible for the oversight of the insurer's remedial action plan.

(b) A written plan for the oversight of any functions delegated to other contracted entities.

(c) A procedure for the periodic review of services related to clinical protocols and utilization management performed by the insurer offering a preferred provider plan or by another contracted entity.

(d) Periodic and regular review of grievances, complaints and OCI complaints.

(e) A written plan for maintaining the confidentiality of protected information.

(f) Documentation of timely correction of access to and continuity of care issues identified in the plan. Documentation shall include all of the following:

1. The date of awareness that an issue exists for which a remedial action plan shall be initiated.

2. The type of issue that is the focus of the remedial action plan.

3. The person or persons responsible for developing and managing the remedial action plan.

4. The remedial action plan utilized in each situation.

5. The outcome of the remedial action plan.

6. The established time frame for re-evaluation of the issue to ensure resolution and compliance with the remedial action plan.

(4)  All insurers offering a defined network plan, other than a preferred provider plan, shall establish and maintain a quality assurance committee and a written policy governing the activities of the quality assurance committee that assigns to the committee responsibility and authority for the quality assurance program. All complaints, OCI complaints, appeals and grievances relating to quality of care shall be reviewed by the quality assurance committee.

(5)  Beginning June 1, 2002, every health maintenance organization shall submit the HEDIS data, or other standardized data set appropriate for health maintenance organizations designated by the commissioner, for the previous calendar year to the commissioner no later than June 15 or the HEDIS submission deadline established by the national committee for quality assurance of each year.

(6)  Beginning June 1, 2008, every insurer offering a defined network plan other than a health maintenance organization or preferred provider plan, shall submit the standardized data set designated by the commissioner and appropriate to the specific plan type for the previous calendar year to the commissioner no later than June 15 of each year.

(7)  No later than April 1, 2001, with respect to an insurer offering a defined network plan that is a health maintenance organization plan, and by April 1, 2008, for insurers offering a defined network plan that is not also a preferred provider plan or health maintenance organization plan, shall do all of the following:

(a) Include a summary of its quality assurance plan in its marketing materials.

(b) Include a brief summary of its quality assurance plan and a statement of patient rights and responsibilities with respect to the plan in its certificate of coverage or enrollment materials.

(8)  Beginning April 1, 2000, an insurer offering any defined network plan shall submit an annual certification for each plan with the commissioner no later than April 1 of each year. The certification shall assert the type of plan and be signed by an officer of the company. OCI shall maintain for public review a current list of health benefit plans, categorized by type.

History: Cr. Register, February, 2000, No. 530 , eff. 3-1-00; CR 05-059 : am. (2), (3), (4), (6), (7) and (8), r. (1) (c) Register February 2006 No. 602 , eff. 3-1-06; reprinted to restore dropped copy in (3), Register September 2006 No. 609 .