Chapter Ins 9, Wis. Adm. Code, contains a requirement for health maintenance organizations (HMOs) to annually submit to the Office of the Commissioner of Insurance (OCI), data elements specified by the Commissioner. On November 10, 2000, the office issued a bulletin that outlines the data collection requirements for calendar year 2001, which must be submitted to OCI no later than June 17, 2002. The current bulletin responds to insurers' requests for clarification on the data requirements.
As stated in the November 10, 2000, bulletin, the HEDIS data should be collected according to HEDIS guidelines, although an independent audit of the HEDIS data is not required. The HMO should either follow NCQA guidelines for the CAHPS survey, or report any variations in its survey process.
The data must be submitted on form OCI 26-903 (see HMO Data Collection page on this Web site). However, this form may be modified only as necessary to provide complete information and to clarify the HMO's data.
Clarifications on HEDIS Data Requirements
- HMOs are required to submit administrative data only, but may submit hybrid data if it is clearly identified as such. We suggest that the HMO indicate whether data is administrative or hybrid by including an "A" or an "H" in the "score" column in the HEDIS Data Elements section of the form. The cover letter should also explain whether any hybrid data was included.
- The HMO may submit rotated data if it is allowed to use the rotated data according to NCQA standards and if it is clearly identified as rotated data in the report to OCI.
- Although the form requests the number of diabetics with an eye exam "during the past year," the HMO should follow the HEDIS guidelines, which also includes members who meet at least two of the three criteria presented in the specifications.
- The form requests HEDIS data regarding the number of members age 6 and over who were hospitalized for a mental illness and had an ambulatory visit within 7 days or within 30 days of discharge. These are two separate measures; the form should be modified to report both measures.
Clarifications of CAHPS Data Requirements
- The form requests the total number of usable answers (valid responses) and the response rate. HMOs should provide this information for the overall survey and also for each of the two CAHPS questions.
- The two questions from the CAHPS questionnaire are question number 32 (In the last 12 months, how often did doctors or other health providers spend enough time with you?) and question number 47 (How would you rate your health plan now?).
- Report the number of respondents who chose each response option for the CAHPS survey questions. Do not report the percentage.
- We understand that HMOs that report HEDIS data to NCQA are required to use an NCQA-approved survey vendor that submits the survey results directly to NCQA. We have been told that these HMOs may not have received the results of their CAHPS surveys by the OCI submission deadline. If this is the case, the HMO should submit the required form to OCI with the HEDIS data included by the submission deadline and provide a revised form with all required data as soon as reasonably possible.
All insurers offering HMOs are required to submit a form by June 17, 2002. Those insurers that cannot submit the CAHPS survey results by that date should provide a form that includes the HEDIS data by June 17th, and a revised form that include all required data no later than July 19, 2002.
If you have questions concerning this bulletin, please put them in writing and address them to the contact person listed below:
Barbara Belling firstname.lastname@example.org