1-1     By:  Kitchen (Senate Sponsor - Madla)                 H.B. No. 1591
 1-2           (In the Senate - Received from the House May 1, 2001;
 1-3     May 2, 2001, read first time and referred to Committee on Health
 1-4     and Human Services; May 8, 2001, reported favorably by the
 1-5     following vote:  Yeas 7, Nays 0; May 8, 2001, sent to printer.)
 1-6                            A BILL TO BE ENTITLED
 1-7                                   AN ACT
 1-8     relating to reporting and certification of Medicaid managed care
 1-9     encounter data.
1-10           BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-11           SECTION 1. Subchapter A, Chapter 533, Government Code, is
1-12     amended by adding Sections 533.0131, 533.016, 533.017, and 533.018
1-13     to read as follows:
1-14           Sec. 533.0131.  USE OF ENCOUNTER DATA IN DETERMINING PREMIUM
1-15     PAYMENT RATES. (a)  In determining premium payment rates and other
1-16     amounts paid to managed care organizations under a managed care
1-17     plan, the commission may not base or derive the rates or amounts on
1-18     or from encounter data, or incorporate in the determination an
1-19     analysis of encounter data, unless a certifier of encounter data
1-20     certifies that:
1-21                 (1)  the encounter data for the most recent state
1-22     fiscal year is complete, accurate, and reliable; and
1-23                 (2)  there is no statistically significant variability
1-24     in the encounter data attributable to incompleteness, inaccuracy,
1-25     or another deficiency as compared to equivalent data for similar
1-26     populations and when evaluated against professionally accepted
1-27     standards.
1-28           (b)  For purposes of determining whether data is equivalent
1-29     data for similar populations under Subsection (a)(2), a certifier
1-30     of encounter data shall, at a minimum, consider:
1-31                 (1)  the regional variation in utilization patterns of
1-32     recipients and costs of health care services;
1-33                 (2)  the range and type of health care services to be
1-34     covered by premium payment rates;
1-35                 (3)  the number of managed care plans in the region;
1-36     and
1-37                 (4)  the current number of recipients in each region,
1-38     including the number for each category of recipient.
1-39           Sec. 533.016.  PROVIDER REPORTING OF ENCOUNTER DATA.  The
1-40     commission shall collaborate with managed care organizations that
1-41     contract with the commission and health care providers under the
1-42     organizations' provider networks to develop incentives and
1-43     mechanisms to encourage providers to report complete and accurate
1-44     encounter data to managed care organizations in a timely manner.
1-45           Sec. 533.017.  QUALIFICATIONS OF CERTIFIER OF ENCOUNTER DATA.
1-46     (a)  The person acting as the state Medicaid director shall appoint
1-47     a person as the certifier of encounter data.
1-48           (b)  The certifier of encounter data must have:
1-49                 (1)  demonstrated expertise in estimating premium
1-50     payment rates paid to a managed care organization under a managed
1-51     care plan; and
1-52                 (2)  access to actuarial expertise, including expertise
1-53     in estimating premium payment rates paid to a managed care
1-54     organization under a managed care plan.
1-55           (c)  A person may not be appointed under this section as the
1-56     certifier of encounter data if the person participated with the
1-57     commission in developing premium payment rates for managed care
1-58     organizations under managed care plans in this state during the
1-59     three-year period before the date the certifier is appointed.
1-60           Sec. 533.018.  CERTIFICATION OF ENCOUNTER DATA. (a)  The
1-61     certifier of encounter data shall certify the completeness,
1-62     accuracy, and reliability of encounter data for each state fiscal
1-63     year.
1-64           (b)  The commission shall make available to the certifier all
 2-1     records and data the certifier considers appropriate for evaluating
 2-2     whether to certify the encounter data.  The commission shall
 2-3     provide to the certifier selected resources and assistance in
 2-4     obtaining, compiling, and interpreting the records and data.
 2-5           SECTION 2. Not later than January 1, 2002, the person acting
 2-6     as the state Medicaid director shall appoint the certifier of
 2-7     Medicaid managed care encounter data required by Section 533.017,
 2-8     Government Code, as added by this Act.
 2-9           SECTION 3. If before implementing any provision of this Act a
2-10     state agency determines that a waiver or authorization from a
2-11     federal agency is necessary for implementation of that provision,
2-12     the agency affected by the provision shall request the waiver or
2-13     authorization and may delay implementing that provision until the
2-14     waiver or authorization is granted.
2-15           SECTION 4. This Act takes effect September 1, 2001.
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