SRC-MKV H.B. 1591 77(R)   BILL ANALYSIS


Senate Research Center   H.B. 1591
77R4648 KLA-FBy: Kitchen (Madla)
Health & Human Services
5/4/2001
Engrossed


DIGEST AND PURPOSE 

Managed care organizations (organization) are asked to submit information
to the Texas Department of Health about the encounters or services
delivered under their contracts. Encounter data include information
regarding the patient's medical history, diagnosis, and treatment, and are
used to measure utilization, immunization rates, health care quality, and
outcomes and to assess contract performance, the value of services to
patients, and the appropriate use of state funds. Furthermore, states use
encounter data to assess managed care fraud and abuse. If health care
providers do not report complete and accurate encounter data to the
organization, the state cannot effectively evaluate Medicaid managed care.
H.B. 1591 provides for reporting and certifying the validity of encounter
data.  

RULEMAKING AUTHORITY

This bill does not expressly grant any additional rulemaking authority to a
state officer, institution, or agency. 

SECTION BY SECTION ANALYSIS

SECTION 1. Amends Chapter 533A, Government Code, by adding Sections
533.0131, 533.016, 533.017, and 533.018, as follows: 

Sec. 533.0131.  USE OF ENCOUNTER DATA IN DETERMINING PREMIUM PAYMENT RATES.
(a)  Prohibits the Health and Human Services Commission or an agency
operating part of the state Medicaid managed care program, as appropriate
(commission), in determining premium payment rates and other amounts paid
to managed care organizations under a managed care plan, from basing or
deriving the rates or amounts on or from encounter data, or incorporating
in the determination an analysis of encounter data, unless a certifier of
encounter data certifies certain information. 
  
 (b)  Requires that for purposes of determining whether data is equivalent
data for similar populations under Subsection (a)(2), a certifier of
encounter data, at a minimum, consider certain information. 
 
Sec. 533.016.  PROVIDER REPORTING OF ENCOUNTER DATA.  Requires the
commission to collaborate with managed care organizations that contract
with the commission and health care providers under the organizations'
provider networks to develop incentives and mechanisms to encourage
providers to report complete and accurate encounter data to managed care
organizations in a timely manner. 

Sec. 533.017.  QUALIFICATIONS OF CERTIFIER OF ENCOUNTER DATA. (a) Requires
the person acting as the state Medicaid director to appoint a person as the
certifier of encounter data. 

  (b)  Requires the certifier of encounter data to meet certain
requirements. 
  
 (c)  Prohibits a person from being appointed under this section as the
certifier of encounter data if the person participated with the commission
in developing premium payment rates for managed care organizations under
managed care plans in this state during the three-year period before the
date the certifier is appointed. 

Sec. 533.018.  CERTIFICATION OF ENCOUNTER DATA. (a)  Requires the certifier
of encounter data to certify the completeness, accuracy, and reliability of
encounter data for each state fiscal year. 

 (b)  Requires the commission to make available to the certifier all
records and data the certifier considers appropriate for evaluating whether
to certify the encounter data. Requires the commission to provide to the
certifier selected resources and assistance in obtaining, compiling, and
interpreting the records and data. 

SECTION 2. Requires that not later than January 1, 2002, the person acting
as the state Medicaid director appoint the certifier of Medicaid managed
care encounter data required by Section 533.017, Government Code, as added
by this Act. 
 
SECTION 3. Requires a state agency affected by a provision of this Act to
request a waiver or authorization and authorizes the agency to delay
implementing that provision until the waiver or authorization is granted,
if the agency determines before implementing any provision of this Act that
a waiver or authorization from a federal agency is necessary. 
 
SECTION 4. Effective date: September 1, 2001.