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(a) Please see
Attachment 3 of Carrier Letter 2013-22 for the process and information required for OPM review of CAPs.
(b) We are encouraged by the improvement in HEDIS results and look forward to additional performance gains in the coming year. Please note that progress toward HEDIS goals will be reflected in OPM's overall health plan evaluation. Contract specialists will pay particular attention to any health plan that declines in overall evaluation score, and any health plan remaining below OPM's minimum performance threshold despite two or more Corrective Action Plans for the same metric(s).
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OPM permits the use of either hybrid or administrative data collection, where applicable per measure specifications, for metrics reported to NCQA. For HEDIS 2013, we asked carriers to refrain from switching data collection methodologies while we implemented a new OPM scoring system. For HEDIS 2014, all carriers are encouraged to utilize hybrid data collection for all measures where NCQA provides this option and it is applicable to the reported product.
While we will continue to accept the use of only administrative data collection, we believe the hybrid data collection method will allow more complete data capture. If expenses associated with hybrid data collection cannot be accommodated within a plan’s projected expense limit for HEDIS 2015, an explanation and cost justification should be submitted along with the administrative expense limit proposal.
Metrics collected via the administrative methodology only include: Breast Cancer Screening (BCS), Follow-up After Hospitalization for Mental Illness (FUH), Plan-All Cause Readmissions (PCR), Ambulatory Care Emergency Department Visits (AMB-B), Medication Management for People with Asthma (MMA), Use of Imaging Studies for Low Back Pain (LBP), Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB), and Well-Child Visits in the First 15 Months of Life (W15).
Metrics collected via the administrative or hybrid methodologies include: Cholesterol Management for Patients with Cardiovascular Conditions LDL-C Screening (CMC), Comprehensive Diabetes Care Hemoglobin A1c Testing (CDC), Comprehensive Diabetes Care LDL-C Screening (CDC), Prenatal and Postpartum Care - Timeliness of Prenatal Care (PPC), and Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC).
Metrics collected via the hybrid methodology only include: Controlling High Blood Pressure (CBP).
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As noted in previous carrier letters, OPM evaluates FEHB health plan HEDIS metrics against relevant national commercial benchmarks. When filing HEDIS 2014 results with the National Committee for Quality Assurance (NCQA), please designate your reporting product (HMO, PPO, HMO/POS) according to your relationship with NCQA. Changes in reporting product with NCQA will not assist in the attainment of Exemplary and/or Most Improved awards in the year the change is made.
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All FEHB health plan quality performance deserves recognition; therefore, we are removing the following language from the HEDIS 2015 carrier letter:
"Each Federal Employees Health Benefits (FEHB) Carrier must submit audited Healthcare Effectiveness Data and Information Set (HEDIS) metrics unless the plan has 500 or fewer FEHB enrollees as of the reporting period (calculated in March, annually)."
Although Carriers with fewer than 500 FEHB enrollees are exempt from HEDIS 2014 reporting, we encourage those health plans to submit OPM's selected HEDIS metrics (
Attachment 1 of Carrier Letter 2013-22) to NCQA, and to prepare for the requirement beginning in HEDIS 2015. Voluntary reporting will not prompt any consequences, but will serve to open the lines of communication. FEHB health plans that have not previously reported HEDIS data to NCQA for FEHB or other purposes should inform OPM and contact NCQA for instructional information.
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All Federal health systems are focused on accountability for quality, safety, and value. Health plan accreditation provides OPM with an external assessment of plans and aligns FEHB with HHS requirements for Qualified Health Plans.
Our recent review of health plan accreditation indicated that OPM's 2001 Carrier Letter was outdated and not all FEHB plans hold an appropriate level of accreditation.
Carrier Letter 2014-10 includes options for plans to meet OPM's requirements through comprehensive or modular accreditation.
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Plans delegating any of the modules listed in Carrier Letter 2014-10 are required to submit documentation of the vendor’s accreditation, including the name of the entity, the expiration date of the accreditation, and a link to the searchable site of the accrediting entity’s records for verification. OPM may ask for additional information on a case-by-case basis.
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Plans can begin the accreditation process directly, or may wish to make an inquiry or seek formal consultation from their intended accreditor to help match their unique organizational structure to available accreditation pathways/products. Such a consultation would also assess accreditation readiness. OPM has received information from both URAC and AAAHC indicating they are able to scope a consultation upon request.
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OPM requires that each FEHB carrier has appropriate and verifiable oversight, but takes no position on whether Medical Direction should be an in-house or contracted function. The accreditation survey will examine how the Medical Director function is fulfilled and will also evaluate how the carrier ensures that continuity of care/services is provided to members, how quality is assessed and progress is monitored, how handoffs are facilitated, and how the carrier assures that any delegated function is competently performed.
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To our knowledge, NCQA Credentialing and Recredentialing is offered with the Utilization Management Certification, and as such does not address full scope of the "accreditation of provider network(s), including review of the credentialing process" listed in Carrier Letter 2014-10.
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By requiring all plans to comply no later than April 2017, OPM has allowed ample time for plans to obtain preliminary consultation if appropriate and complete all the steps necessary to attain accreditation. If unexpected delays are encountered, plans should submit accreditor documentation of "in progress" or "pending" status to OPM, along with any outstanding items that must be addressed.
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Plans attaining a comprehensive health plan accreditation from AAAHC, NCQA, or URAC will have their provider and network oversight assessed as part of that process. No further action is needed.
FEHB carriers satisfying OPM’s accreditation through a modular approach must provide evidence that all networks are accredited. This is best accomplished by means of a separate network accreditation. As an alternative, plans able to demonstrate that their entire network is part of a fully accredited health plan that serves as a subcontractor to the FEHB carrier may provide OPM with detailed documentation for consideration.
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No. Modular accreditation of a specific function only examines how the core standards apply to that function and does not evaluate plan "oversight of all delegated responsibilities, subcontractor functions, and customer service."
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Plans seeking accreditation from an entity other than URAC, NCQA, or AAAHC should submit detailed documentation about the intended accreditor and applicable standards, along with a written analysis of how your proposed approach meets the intent of OPM’s requirements. We’ll provide you with a timely review and response.
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Yes, URAC Health Network Accreditation would meet this requirement.
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OPM strongly encourages all plans eligible for a comprehensive health plan accreditation to pursue and maintain that certification. As noted in Carrier Letter 2014-10, "plans that are ineligible (emphasis added) for comprehensive health plan accreditation can still attain modular accreditation for key functions." OPM’s plan management accreditation requirement can be met through either comprehensive health plan accreditation, or a modular accreditation that evaluates core functions along with oversight of delegated/subcontracted responsibilities.
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Yes, OPM will accept products from different accrediting organizations. For example, a plan could utilize NCQA Case Management and URAC Pharmacy Benefit Management as two of their required accreditation modules.
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Yes, comprehensive health plan accreditation from AAAHC using either their Accreditation Handbook for Health Plans or using their Accreditation Handbook for FEHB Health Plans fulfills OPM’s requirement. AAAHC uses the same standards in both handbooks; the Accreditation Handbook for FEHB Health Plans clarifies how existing standards would be applied to plans that delegate functions.
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Certification is not automatically a permissible substitute for accreditation. Plans may submit specific requests to OPM with appropriate documentation.
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Yes, URAC Core would meet OPM’s requirement.
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