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.
_______________________________ _______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 1591 was passed by the House on
April 30, 2001, by a non-record vote.
_______________________________
Chief Clerk of the House
I certify that H.B. No. 1591 was passed by the Senate on
May 17, 2001, by the following vote: Yeas 30, Nays 0, 1 present,
not voting.
_______________________________
Secretary of the Senate
APPROVED: __________________________
Date
__________________________
Governor