§ 131E-287. PSO Reporting.
§ 131E‑287. PSOReporting.
(a) The PSO shall file with the Division financial informationrelating to PSO solvency standards described in this Article, according to thefollowing schedule:
(1) On a quarterly basis until breakeven; and
(2) On an annual basis after breakeven, if the PSO has a netoperating surplus; or
(3) On a quarterly or monthly basis, as specified by theDivision, after breakeven, if the PSO does not have a net operating surplus.
(b) To the extent not preempted by federal law or otherwisemandated by the Medicare program, the PSO shall annually, on or before thefirst day of March of each year, file with the Division the followinginformation for the previous calendar year:
(1) The number of and reasons for grievances and complaintsreceived from Medicare beneficiaries enrolled with the PSO under the PSO'sMedicare contract regarding medical treatment. The report shall include thenumber of covered lives, total number of grievances categorized by reason forthe grievance, the number of grievances referred to the second level grievancereview, the number of grievances resolved at each level and their resolution,and a description of the actions that are being taken to correct the problemsthat have been identified through grievances received. Every PSO shall filewith the Division, as part of its annual grievance report, a certificate ofcompliance stating that the PSO has established and follows, for its Medicarecontract, grievance procedures that comply with this Article.
(2) The number of Medicare beneficiaries enrolled with the PSOunder the PSO's Medicare contract who terminated their enrollment with the PSOfor any reason.
(3) The number of provider contracts between the PSO and networkproviders for the provision of covered services to Medicare beneficiaries thatwere terminated and reasons for termination. This information shall include thenumber of providers leaving the PSO network and the number of new providers inthe network. The report shall show voluntary and involuntary terminationsseparately.
(4) Data relating to the utilization, quality, availability, andaccessibility of service. The report shall include the following:
a. Information on the PSO's program to determine the level ofnetwork availability, as measured by the numbers and types of networkproviders, required to provide covered services to covered persons. Thisinformation shall include the PSO's methodology under its Medicare+Choiceprogram for:
1. Establishingperformance targets for the numbers and types of providers by specialty, areaof practice, or facility type, for each of the following categories: primarycare physicians, specialty care physicians, nonphysician health care providers,hospitals, and nonhospital health care facilities.
2. Determiningwhen changes in PSO Medicare+Choice program enrollees will necessitate changesin the provider network.
The report shall also include: the availabilityperformance targets for the previous and current years; the numbers and typesof providers currently participating in the PSO's provider network; and anevaluation of actual plan performance against performance targets.
b. The PSO's method for arranging or providing health careservices from nonnetwork providers, both within and outside of its servicearea, when network providers are not available to provide covered services.
c. Information on the PSO's program under its Medicare+Choiceprogram to determine the level of provider network accessibility necessary toserve its Medicare enrollees. This information shall include the PSO'smethodology for establishing performance targets for member access to coveredservices from primary care physicians, specialty care physicians, nonphysicianhealth care providers, hospitals, and nonhospital health care facilities. Themethodology shall establish targets for:
1. Theproximity of network providers to members, as measured by member drivingdistance, to access primary care, specialty care, hospital‑basedservices, and services of nonhospital facilities.
2. Expectedwaiting time for appointments for urgent care, acute care, specialty care, androutine services for prevention and wellness.
The report shall also include: the accessibilityperformance targets for the previous and current years; data on actual overallaccessibility as measured by driving distance and average appointment waitingtime; and an evaluation of actual Medicare+Choice plan performance againstperformance targets. Measures of actual accessibility may be developed usingscientifically valid random sample techniques.
d. A statement of the PSO's methods and standards fordetermining whether in‑network services are reasonably available andaccessible to a Medicare enrollee for the purpose of determining whether suchenrollee should receive the in‑network level of coverage for servicesreceived from a nonnetwork provider.
e. A description of the PSO's program to monitor the adequacyof its network availability and accessibility methodologies and performancetargets, Medicare+Choice plan performance, and network provider performance.
f. A summary of the PSO's utilization review programactivities for the previous calendar year under its Medicare+Choice program.The report shall include the number of: each type of utilization reviewperformed, noncertifications for each type of review, each type of reviewappealed, and appeals settled in favor of Medicare enrollees. The report shallbe accompanied by a certification from the carrier that it has established andfollows procedures that comply with this Article.
(5) Aggregate financial compensation data, including thepercentage of providers paid under a capitation arrangement, discounted fee‑for‑serviceor salary, the services included in the capitation payment, and the range ofcompensation paid by withhold or incentive payments. This information shall besubmitted on a form prescribed by the Division.
The name, or group or institutional name, of an individual provider maynot be disclosed pursuant to this subsection. No civil liability shall arisefrom compliance with the provisions of this subsection, provided that the actsor omissions are made in good faith and do not constitute gross negligence,willful or wanton misconduct, or intentional wrongdoing.
(c) Disclosure Requirements. To the extent not otherwiseprohibited by federal law or under the terms of the PSO's Medicare contract,each PSO shall provide the following applicable information to Medicarebeneficiaries enrolled with the PSO under the PSO's Medicare contract and bonafide prospective enrollees upon request:
(1) The evidence of coverage under the Medicare+Choice planprovided by the PSO to Medicare beneficiaries under the terms of the PSO'sMedicare contract;
(2) An explanation of the utilization review criteria andtreatment protocol under which treatments are provided for conditions specifiedby the prospective enrollee. This explanation shall be in writing if sorequested;
(3) If denied a recommended treatment, written reasons for thedenial and an explanation of the utilization review criteria or treatment protocolupon which the denial was based;
(4) The plan's restrictive formularies or prior approvalrequirements for obtaining prescription drugs, whether a particular drug ortherapeutic class of drugs is excluded from its formulary, and thecircumstances under which a nonformulary drug may be covered; and
(5) The procedures and medically based criteria under the PSO'sMedicare contract for determining whether a specified procedure, test, ortreatment is experimental.
(d) Effective January 1, 1999, PSOs shall make the reports thatare required under subsection (b) of this section and that have been filed withthe Division available on their business premises and shall provide anyMedicare beneficiary enrolled with the PSO access to them upon request, unless otherwiseprohibited by federal law or under the terms of the PSO's Medicare contract.
(e) Every PSO licensed under this Article shall annually on orbefore the first day of March of each year, file with the Division a swornstatement verified by at least two of the principal officers of the PSO showingits condition on the thirty‑first day of December, then next preceding;which shall be in such form as the Division shall prescribe. In case the PSOfails to file the annual statement as herein required, the Division isauthorized to suspend the license issued to the PSO until the statement shallbe properly filed.
(f) A PSO shall report to the Division the efforts it hasundertaken to foster measurable improvements in the health status of thecommunity's Medicare population, increase access to health care for noncoveredbenefits, and address critical health care needs of the community's Medicarepopulation. (1998‑227, s.1.)