Issue Date: September 20, 2013
Volume 40 • Issue 19 • Page 1560
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Subtitle 09 MEDICAL CARE PROGRAMS
10.09.65 Maryland Medicaid Managed Care Program: Managed Care Organizations
Authority: Insurance Article, §§15-112, 15-605, and 15-1008; Health-General Article, §§2-104, 15-102.3, and 15-103; Annotated Code of Maryland
Notice of Proposed Action
The Secretary of Health and Mental Hygiene proposes to amend Regulation .03 under COMAR 10.09.65 Maryland Medicaid Managed Care Program: Managed Care Organizations.
Statement of Purpose
The purpose of this action is to update the core performance measures and the incentive and penalty calculation methodology for CY 2014.
Comparison to Federal Standards
There is no corresponding federal standard to this proposed action.
Estimate of Economic Impact
The proposed action has no economic impact.
Economic Impact on Small Businesses
The proposed action has minimal or no economic impact on small businesses.
Impact on Individuals with Disabilities
The proposed action has no impact on individuals with disabilities.
Opportunity for Public Comment
Comments may be sent to Michele A. Phinney, Director, Office of Regulation and Policy Coordination, Department of Health and Mental Hygiene, 201 W. Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499; TTY:800-735-2258, or email to firstname.lastname@example.org, or fax to 410-767-6483. Comments will be accepted through October 21, 2013. A public hearing has not been scheduled.
.03 Quality Assessment and Improvement.
A. (text unchanged)
B. An MCO shall participate in all quality assessment activities required by the Department in order to determine if the MCO is providing medically necessary enrollee health care. These activities include, but are not limited to:
(1)—(2) (text unchanged)
(3) The annual collection and evaluation of a set of performance measures with targets as determined by the Department as follows:
(a) The composition of the core performance measures [is] are listed in [§B(3)(g)] §B(3)(d) and (e) of this regulation;
(b)—(d) (text unchanged)
(e) Effective January 1, 2014, the core performance measures are:
(i) Adolescent well care visits;
(ii) Adult Body Mass Index (BMI) assessment;
(iii) Ambulatory care for Supplemental Security Income (SSI) adults;
(iv) Ambulatory care for Supplemental Security Income (SSI) children;
(v) Breast cancer screening;
(vi) Childhood immunizations—Combo 3;
(vii) Comprehensive diabetes care—HbA1c testing;
(viii) Controlling high blood pressure;
(ix) Immunization for adolescents;
(x) Lead screening for children 12—23 months old;
(xi) Medication management for people with asthma—75 percent grouping;
(xii) Postpartum care; and
(xiii) Well child visits, 3—6 years old.
[(e)] (f)—[(i)] (j) (text unchanged)
(k) Starting with the 2014 performance measures, the Department shall implement the following methodology for imposing penalties and incentives:
(i) There shall be three levels of performance;
(ii) Performance shall be evaluated separately for each measure, and each measure shall have equal weight;
(iii) On any of the measures in §B(3)(e)(i)—(xiii) of this regulation for which the MCO does not meet the minimum target, as determined by the Department, a penalty of 1/13 of 1 percent of the total capitation amount paid to the MCO during the measurement year shall be collected;
(iv) The total amount of the penalties as described in §B(3)(k)(iii) of this regulation may not exceed 1 percent of the total capitation amount paid to the MCO during the same measurement year;
(v) On any of the measures in §B(3)(e) of this regulation for which the MCO meets or exceeds the incentive target, as determined by the Department, the MCO shall be paid an incentive payment of up to 1/13 of 1 percent of the total capitation paid to the MCO during that measurement year;
(vi) The total amount of the incentive payments as described in §B(3)(k)(v) of this regulation paid to the MCOs each year may not exceed the total amount of the penalties as described in §B(3)(k)(iii) of this regulation collected from the MCOs in that same year, plus any additional funds allocated to the Department for a quality initiative; and
(vii) Any funds remaining after the payment of the incentives due under §B(3)(k)(v) of this regulation shall be distributed to the MCOs receiving the four highest normalized scores for Value Based Purchasing for all thirteen performance measures at a rate calculated by multiplying each MCO’s adjusted enrollment as of December 31 of the measurement year by a per enrollee amount;
(l) The adjusted enrollment amount in §B(3)(k)(vii) of this regulation shall be calculated by:
(i) Multiplying four times the enrollment of the MCO with the highest normalized score;
(ii) Multiplying three times the enrollment of the MCO with the second highest normalized score;
(iii) Multiplying two times the enrollment of the MCO with the third highest normalized score; and
(iv) Using the actual enrollment of the MCO with the fourth highest normalized score;
(m) The per enrollee amount in §B(3)(k)(vii) of this regulation shall be calculated by dividing the sum of the calculations in §B(3)(l)(i)—(iv) of this regulation into the funds remaining as described in §B(3)(k)(vii) of this regulation;
[(i)] (n) text unchanged
(4)—(6) text unchanged)
C. (text unchanged)
JOSHUA M. SHARFSTEIN, M.D.
Secretary of Health and Mental Hygiene