Sec. 38a-478c. Managed care organization's report to the commissioner: Data, reports and information required.
Sec. 38a-478c. Managed care organization's report to the commissioner:
Data, reports and information required. (a) On or before May 1, 1998, and annually
thereafter, each managed care organization shall submit to the commissioner:
(1) A report on its quality assurance plan that includes, but is not limited to, information on complaints related to providers and quality of care, on decisions related to patient
requests for coverage and on prior authorization statistics. Statistical information shall
be submitted in a manner permitting comparison across plans and shall include, but not
be limited to: (A) The ratio of the number of complaints received to the number of
enrollees; (B) a summary of the complaints received related to providers and delivery
of care or services and the action taken on the complaint; (C) the ratio of the number
of prior authorizations denied to the number of prior authorizations requested; (D) the
number of utilization review determinations made by or on behalf of a managed care
organization not to certify an admission, service, procedure or extension of stay, and the
denials upheld and reversed on appeal within the managed care organization's utilization
review procedure; (E) the percentage of those employers or groups that renew their
contracts within the previous twelve months; and (F) notwithstanding the provisions of
this subsection, on or before July 1, 1998, and annually thereafter, all data required by
the National Committee for Quality Assurance (NCQA) for its Health Plan Employer
Data and Information Set (HEDIS). If an organization does not provide information for
the National Committee for Quality Assurance for its Health Plan Employer Data and
Information Set, then it shall provide such other equivalent data as the commissioner
may require by regulations adopted in accordance with the provisions of chapter 54.
The commissioner shall find that the requirements of this subdivision have been met if
the managed care plan has received a one-year or higher level of accreditation by the
National Committee for Quality Assurance and has submitted the Health Plan Employee
Data Information Set data required by subparagraph (F) of this subdivision.
(2) A model contract that contains the provisions currently in force in contracts
between the managed care organization and preferred provider networks in this state,
and the managed care organization and participating providers in this state and, upon
the commissioner's request, a copy of any individual contracts between such parties,
provided the contract may withhold or redact proprietary fee schedule information.
(3) A written statement of the types of financial arrangements or contractual provisions that the managed care organization has with hospitals, utilization review companies, physicians, preferred provider networks and any other health care providers including, but not limited to, compensation based on a fee-for-service arrangement, a risk-sharing arrangement or a capitated risk arrangement.
(4) Such information as the commissioner deems necessary to complete the consumer report card required pursuant to section 38a-478l. Such information may include,
but need not be limited to: (A) The organization's characteristics, including its model,
its profit or nonprofit status, its address and telephone number, the length of time it has
been licensed in this and any other state, its number of enrollees and whether it has
received any national or regional accreditation; (B) a summary of the information required by subdivision (3) of this section, including any change in a plan's rates over the
prior three years, its medical loss ratio or percentage of the total premium revenues
spent on medical care compared to administrative costs and plan marketing, how it
compensates health care providers and its premium level; (C) a description of services,
the number of primary care physicians and specialists, the number and nature of participating preferred provider networks and the distribution and number of hospitals, by
county; (D) utilization review information, including the name or source of any established medical protocols and the utilization review standards; (E) medical management
information, including the provider-to-patient ratio by primary care provider and speciality care provider, the percentage of primary and speciality care providers who are
board certified, and how the medical protocols incorporate input as required in section
38a-478e; (F) the quality assurance information required to be submitted under the
provisions of subdivision (1) of subsection (a) of this section; (G) the status of the
organization's compliance with the reporting requirements of this section; (H) whether
the organization markets to individuals and Medicare recipients; (I) the number of hospital days per thousand enrollees; and (J) the average length of hospital stays for specific
procedures, as may be requested by the commissioner.
(5) A summary of the procedures used by managed care organizations to credential
providers.
(b) The information required pursuant to subsection (a) of this section shall be consistent with the data required by the National Committee for Quality Assurance (NCQA)
for its Health Plan Employer Data and Information Set (HEDIS).
(c) The commissioner may accept electronic filing for any of the requirements under
this section.
(d) No managed care organization shall be liable for a claim arising out of the submission of any information concerning complaints concerning providers, provided the
managed care organization submitted the information in good faith.
(P.A. 97-99, S. 4; P.A. 98-27, S. 19; P.A. 03-169, S. 12.)
History: P.A. 98-27 amended Subpara. (a)(1)(F) to add "Notwithstanding the provisions of this subsection, on or before
July 1, 1998, and annually thereafter" re required data; P.A. 03-169 amended Subsec. (a) to reword Subdiv. (1)(D) re
utilization review determinations, to add in Subdivs. (2) and (3) reference to preferred provider networks, to substitute
"required" for "he is required to develop and distribute" in Subdiv. (4) and to add "the number and nature of participating
preferred provider networks" in Subpara. (C), and make conforming changes.