Section 1
General Provisions
Purpose. The five largest health insurance companies doing
business in Vermont, as measured by covered lives, are required to file with
the Commissioner (1) an annual report card on the health insurance plan's
performance in relation to quality measures for the care, treatment, and
treatment options of mental health and substance abuse conditions covered under
the plan, and (2) the health insurance plan's revenue loss and expense ratio
relating to the care and treatment of mental health conditions covered under
the health insurance plan. This regulation sets out the minimum reporting
requirements.
Section 2
Authority
This regulation is issued pursuant to the authority of the
Commissioner of the Department of Banking, Insurance, Securities and Health
Care Administration to promulgate regulations.
8
V.S.A. §
4089b(f) and
(g) and 8 V.S.A. § 75.
Section 3 Scope
This rule applies to the five largest health insurance
companies licensed in Vermont, as measured by covered Vermont lives, which
shall be measured annually by the Vermont Department of Banking, Insurance,
Securities and Health Care Administration as of December 31 of the year
immediately preceding the report.
Section
4 Definitions
(A) "Commissioner"
means the commissioner of the Vermont Department of Banking, Insurance,
Securities and Health Care Administration.
(B) "Discharge rate" means the number of
insureds who were discharged from an inpatient facility divided by the number
of covered lives in the calendar year ending December 31 immediately preceding
the report.
(C) "Division" means
the Division of Health Care Administration of the Department of Banking,
Insurance, Securities and Health Care Administration.
(D) "Insured" means the certificate holder
and any dependents.
(E) "Insurer"
means each of the five largest health insurance companies doing business in
Vermont as measured by covered Vermont lives, as determined annually by the
Division.
Section 5
Responsibilities of Insurers
A. Report Cards.
On or before March 1 of each year or at such other time as specified in
8
V.S.A. §
4089b, insurers must file with
the Division a report card on the health plan's performance in relation to
quality measures for the care, treatment, and treatment options of mental
health and substance abuse conditions covered under the plan. The measures
presented in the report card will be based on data from the previous calendar
year, unless otherwise indicated by the Division.
The measures that must be filed include:
(1) the discharge rates from inpatient mental
health and substance abuse care and treatment of insureds;
(2) the average length of stay for insureds
receiving inpatient mental health and substance abuse care and
treatment;
(3) the average number
of treatment sessions for insureds receiving outpatient mental health and
substance abuse care and treatment;
(4) the percentage of insureds receiving
inpatient mental health and substance abuse care and treatment;
(5) the percentage of insureds receiving
outpatient mental health and substance abuse care and treatment;
(6) the number of insureds denied
authorization (prior and concurrent) for mental health and substance abuse
services, per 1000 members using average membership;
(7) number of insureds denied authorization
(prior and concurrent) for mental health and substance abuse services with X
denials in a calendar year per 1000 members using average membership (where X
is defined in the Act 129 Reporting Manual);
(8) the number of denials appealed internally
by insureds reported separately from the number of denials appealed internally
by providers;
(9) the rates of
readmission to inpatient mental health and substance abuse care
facilities;
(10) the level of
patient satisfaction with the quality of the mental health and substance abuse
care and treatment provided to insureds under the health insurance plan. The
Commissioner shall approve the form content of the survey or mechanism used to
determine patient satisfaction; and
(11) any other quality measure established by
the commissioner.
B. Loss
Ratios. On or before March 1 of each year or at such other time as specified in
8
V.S.A. §
4089b, insurers must file with
the Division the health insurance plan's revenue loss and expense ratio
relating to the care and treatment of mental health conditions covered under
the health insurance plan. The expense ratio report shall list amounts paid in
claims for services and administrative costs separately.
Section 6 Responsibilities of the Department
Reporting Specifications. The Division will produce an annual
reporting manual with specifications for submitting each of the required report
card and loss ratio elements. Where applicable, these specifications will be
based on nationally accepted reporting standards such as the Health Plan
Employers Data and Information Set (HEDIS).
Coordination with Rule 10. The Division will ensure that
compliance with this regulation does not duplicate a reporting requirement for
those insurers that are also subject to reporting requirements under the
Division's Rule 10. 000, Quality Assurance Standards and Consumer Protections
for Managed Care. In cases where a reporting measure is required under this
regulation and under Rule 10, the reporting manual specification will be the
same as in the most recent edition of the Rule 10 Implementation
Manual.
Section 7
Severability
If any provision of this regulation or the application
thereof to any person or circumstance is for any reason held to be invalid, the
remainder of the regulation and the application of such provisions to other
persons or circumstances shall not be affected thereby.
Section 8 Effective Date
This regulation shall be effective on April 2, 2001. However,
the requirements of section
5(B)
above shall sunset July 1, 2003.
