| (a) Purpose. In accordance with the Insurance Code §1460.005, this section specifies the standards and guidelines that are necessary to ensure that a health benefit plan issuer, including a subsidiary or affiliate, that utilizes rankings, tiers, ratings or other comparisons of a physician's performance against standards, measures, or other physicians, uses a nationally recognized physician ranking system that emphasizes quality of health care. (b) Applicability. (1) This section applies to a health benefit plan issuer as defined in the Insurance Code §1460.001. (2) This section does not apply to: (A) a plan specified in the Insurance Code §1460.002; or (B) a Medicare plan offered pursuant to Title XVIII, Part C and D of the Social Security Act. (c) General Prohibition. A health benefit plan issuer may not rank, tier or publish physician-specific information unless the standards used by the health benefit plan issuer meet the requirements of this section. (d) National Quality Forum (NQF) or AQA Alliance. A health benefit plan issuer that uses a physician ranking system is required to follow the endorsed measures, guidelines, and standards of the NQF or the endorsed measures, guidelines, and standards of the AQA Alliance. (e) National Committee on Quality Assurance (NCQA) and Other Similar National Organizations. If neither the NQF nor the AQA Alliance has an endorsed measure, guideline, and standard regarding an issue, the health benefit plan issuer is required to follow the endorsed measures, guidelines, and standards of the NCQA and other similar national organizations. (f) Other Guidelines, Quality Standards, and Clinical Evidence. If the NQF, AQA Alliance, or other national organizations have not established standards or guidelines regarding an issue, the health benefit plan issuer is required to follow measures, guidelines, and standards based on other bona fide nationally recognized guidelines, expert-based physician consensus quality standards, or leading objective clinical evidence and scholarship standards adopted by the Commissioner. (g) Duties of Health Benefit Plan Issuer. In accordance with the Insurance Code §1460.006, a health benefit plan issuer using a comparison program as described in the Insurance Code §1460.003 shall ensure that: (1) physicians currently in clinical practice are actively involved in the development of the standards used in the health benefit plan issuer's comparison program; and (2) the measures and methodology used in the health benefit plan issuer's comparison program are transparent and valid. |
