By Kitchen                                            H.B. No. 1591
         77R4648 KLA-F                           
                                A BILL TO BE ENTITLED
 1-1                                   AN ACT
 1-2     relating to reporting and certification of Medicaid managed care
 1-3     encounter data.
 1-4           BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
 1-5           SECTION 1. Subchapter A, Chapter 533, Government Code, is
 1-6     amended by adding Sections 533.0131, 533.016, 533.017, and 533.018
 1-7     to read as follows:
 1-8           Sec. 533.0131.  USE OF ENCOUNTER DATA IN DETERMINING PREMIUM
 1-9     PAYMENT RATES. (a)  In determining premium payment rates and other
1-10     amounts paid to managed care organizations under a managed care
1-11     plan, the commission may not base or derive the rates or amounts on
1-12     or from encounter data, or incorporate in the determination an
1-13     analysis of encounter data, unless a certifier of encounter data
1-14     certifies that:
1-15                 (1)  the encounter data for the most recent state
1-16     fiscal year is complete, accurate, and reliable; and
1-17                 (2)  there is no statistically significant variability
1-18     in the encounter data attributable to incompleteness, inaccuracy,
1-19     or another deficiency as compared to equivalent data for similar
1-20     populations and when evaluated against professionally accepted
1-21     standards.
1-22           (b)  For purposes of determining whether data is equivalent
1-23     data for similar populations under Subsection (a)(2), a certifier
1-24     of encounter data shall, at a minimum, consider:
 2-1                 (1)  the regional variation in utilization patterns of
 2-2     recipients and costs of health care services;
 2-3                 (2)  the range and type of health care services to be
 2-4     covered by premium payment rates;
 2-5                 (3)  the number of managed care plans in the region;
 2-6     and
 2-7                 (4)  the current number of recipients in each region,
 2-8     including the number for each category of recipient.
 2-9           Sec. 533.016.  PROVIDER REPORTING OF ENCOUNTER DATA.  The
2-10     commission shall collaborate with managed care organizations that
2-11     contract with the commission and health care providers under the
2-12     organizations' provider networks to develop incentives and
2-13     mechanisms to encourage providers to report complete and accurate
2-14     encounter data to managed care organizations in a timely manner.
2-15           Sec. 533.017.  QUALIFICATIONS OF CERTIFIER OF ENCOUNTER DATA.
2-16     (a)  The person acting as the state Medicaid director shall appoint
2-17     a person as the certifier of encounter data.
2-18           (b)  The certifier of encounter data must have:
2-19                 (1)  demonstrated expertise in estimating premium
2-20     payment rates paid to a managed care organization under a managed
2-21     care plan; and
2-22                 (2)  access to actuarial expertise, including expertise
2-23     in estimating premium payment rates paid to a managed care
2-24     organization under a managed care plan.
2-25           (c)  A person may not be appointed under this section as the
2-26     certifier of encounter data if the person participated with the
2-27     commission in developing premium payment rates for managed care
 3-1     organizations under managed care plans in this state during the
 3-2     three-year period before the date the certifier is appointed.
 3-3           Sec. 533.018.  CERTIFICATION OF ENCOUNTER DATA. (a)  The
 3-4     certifier of encounter data shall certify the completeness,
 3-5     accuracy, and reliability of encounter data for each state fiscal
 3-6     year.
 3-7           (b)  The commission shall make available to the certifier all
 3-8     records and data the certifier considers appropriate for evaluating
 3-9     whether to certify the encounter data.  The commission shall
3-10     provide to the certifier selected resources and assistance in
3-11     obtaining, compiling, and interpreting the records and data.
3-12           SECTION 2. Not later than January 1, 2002, the person acting
3-13     as the state Medicaid director shall appoint the certifier of
3-14     Medicaid managed care encounter data required by Section 533.017,
3-15     Government Code, as added by this Act.
3-16           SECTION 3. If before implementing any provision of this Act a
3-17     state agency determines that a waiver or authorization from a
3-18     federal agency is necessary for implementation of that provision,
3-19     the agency affected by the provision shall request the waiver or
3-20     authorization and may delay implementing that provision until the
3-21     waiver or authorization is granted.
3-22           SECTION 4. This Act takes effect September 1, 2001.