(i) Improve health quality.
(ii) Increase the likelihood of desired health outcomes in ways that are capable of being objectively measured and of producing verifiable results and achievements.
(iii) Be directed toward individual enrollees or incurred for the benefit of specified segments of enrollees or provide health improvements to the population beyond those enrolled in coverage as long as no additional costs are incurred due to the non-enrollees.
(iv) Be grounded in evidence-based medicine, widely accepted best clinical practice, or criteria issued by recognized professional medical associations, accreditation bodies, government agencies or other nationally recognized health care quality organizations.
(2) The activity must be primarily designed to:(i) Improve health outcomes including increasing the likelihood of desired outcomes compared to a baseline and reduce health disparities among specified populations.
(A) Examples include the direct interaction of the issuer (including those services delegated by contract for which the issuer retains ultimate responsibility under the insurance policy), providers and the enrollee or the enrollee's representative (for example, face-to-face, telephonic, web-based interactions or other means of communication) to improve health outcomes, including activities such as:
(1) Effective case management, care coordination, chronic disease management, and medication and care compliance initiatives including through the use of the medical homes model as defined in section 3606 of the Affordable Care Act.
(2) Identifying and addressing ethnic, cultural or racial disparities in effectiveness of identified best clinical practices and evidence based medicine.
(3) Quality reporting and documentation of care in non-electronic format.
(4) Health information technology to support these activities.
(5) Accreditation fees directly related to quality of care activities.
(B) [Reserved]
(ii) Prevent hospital readmissions through a comprehensive program for hospital discharge. Examples include:
(A) Comprehensive discharge planning (for example, arranging and managing transitions from one setting to another, such as hospital discharge to home or to a rehabilitation center) in order to help assure appropriate care that will, in all likelihood, avoid readmission to the hospital;
(B) Patient-centered education and counseling.
(C) Personalized post-discharge reinforcement and counseling by an appropriate health care professional.
(D) Any quality reporting and related documentation in non-electronic form for activities to prevent hospital readmission.
(E) Health information technology to support these activities.
(iii) Improve patient safety, reduce medical errors, and lower infection and mortality rates.
(A) Examples of activities primarily designed to improve patient safety, reduce medical errors, and lower infection and mortality rates include:
(1) The appropriate identification and use of best clinical practices to avoid harm.
(2) Activities to identify and encourage evidence-based medicine in addressing independently identified and documented clinical errors or safety concerns.
(3) Activities to lower the risk of facility-acquired infections.
(4) Prospective prescription drug Utilization Review aimed at identifying potential adverse drug interactions.
(5) Any quality reporting and related documentation in non-electronic form for activities that improve patient safety and reduce medical errors.
(6) Health information technology to support these activities.
(B) [Reserved]
(iv) Implement, promote, and increase wellness and health activities:
(A) Examples of activities primarily designed to implement, promote, and increase wellness and health activities, include—
(1) Wellness assessments;
(2) Wellness/lifestyle coaching programs designed to achieve specific and measurable improvements;
(3) Coaching programs designed to educate individuals on clinically effective methods for dealing with a specific chronic disease or condition;
(4) Public health education campaigns that are performed in conjunction with State or local health departments;
(5) Actual rewards, incentives, bonuses, reductions in copayments (excluding administration of such programs), that are not already reflected in premiums or claims should be allowed as a quality improvement activity for the group market to the extent permitted by section 2705 of the PHS Act;
(6) Any quality reporting and related documentation in non-electronic form for wellness and health promotion activities;
(7) Coaching or education programs and health promotion activities designed to change member behavior and conditions (for example, smoking or obesity); and
(8) Health information technology to support these activities.
(B) [Reserved]
(v) Enhance the use of health care data to improve quality, transparency, and outcomes and support meaningful use of health information technology consistent with § 158.151 of this subpart.
