Bill Text: AZ HB2603 | 2019 | Fifty-fourth Legislature 1st Regular | Introduced
Bill Title: Health plans; providers; payment reporting
Spectrum: Partisan Bill (Republican 1-0)
Status: (Failed) 2019-02-25 - House APPROP Committee action: Discussed and Held, voting: (0-0-0-0-0-0) [HB2603 Detail]
Download: Arizona-2019-HB2603-Introduced.html
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REFERENCE TITLE: health plans; providers; payment reporting |
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State of Arizona House of Representatives Fifty-fourth Legislature First Regular Session 2019
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HB 2603 |
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Introduced by Representative Kern
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AN ACT
Amending Title 36, chapter 1, article 1.1, Arizona Revised Statutes, by adding section 36‑125.08; relating to uniform reporting.
(TEXT OF BILL BEGINS ON NEXT PAGE)
Be it enacted by the Legislature of the State of Arizona:
Section 1. Title 36, chapter 1, article 1.1, Arizona Revised Statutes, is amended by adding section 36-125.08, to read:
36-125.08. Health plans; health care providers; reporting requirements; relative prices; definitions
A. Each health plan shall report the information required by this section and rules adopted by the department to enable the department to calculate the weighted average payor rate for each hospital, outpatient facility and physician group. Each health plan shall report:
1. The relative price paid to each health care provider by type of provider, with hospital inpatient and outpatient prices listed separately, and health plan product type.
2. The annual rate of growth stated as a percentage of the average relative price by provider type and product type for the health plan's participating health care providers, and whether that rate exceeds the rate of growth of the applicable producer price index as reported by the United States department of labor, bureau of labor statistics.
3. A comparison of relative prices for the health plan's participating health care providers by provider type that shows the average relative price and the extent of variation in price stated as a percentage and that identifies providers who are paid more than ten percent, fifteen percent and twenty percent above the average relative price and more than ten percent, fifteen percent and twenty percent below the average relative price.
B. Each health plan that uses an alternative payment contract to pay health care providers shall disclose to the department all of the following:
1. The negotiated monthly or yearly budget for each alternative payment contract in the current contract year.
2. Any applicable measures of provider performance in the alternative payment contract.
3. If applicable, the average negotiated monthly or yearly budget weighted by member months for each geographic region of this state as further defined in rules adopted by the department.
C. For the purposes of subsection B of this section:
1. Health plans shall report the negotiated budget assuming a neutral health status score of 1.0 using an industry accepted health status adjustment tool and, if applicable, shall separately report the budget allowances for:
(a) All medical and behavioral health care, substance use disorders and mental health care provided by both in‑network and out‑of‑network providers.
(b) Pharmacy coverage allowances.
(c) Administrative expenses such as data analytics, health information technology, clinical program development and other program management fees.
(d) The purchase of reinsurance or stop‑loss coverage.
(e) Quality bonus monies, unit cost adjustments or other special allowances as may be required in rules adopted by the department.
2. If out‑of‑network care, behavioral health care, substance use disorders and mental health care, stop‑loss insurance or any other clinical services are carved out of any global budget, bundled payments or other alternative payment method such that there is no allowance included in the budget for those services, health plans shall report actual claims costs of these items on a per member, per month basis for the year immediately preceding the current contract year.
D. The department shall issue an annual report on relative prices paid by health plans and received by health care providers and the weighted average payor rate paid to each acute care hospital, outpatient facility and physician group. The department shall present the report in a manner that does not disclose actual prices paid and shall identify price variation among health care providers, by health plan and by provider type. The department's report shall include all of the following:
1. Baseline information about price variation among health care providers by each health plan, including identifying health care providers that are paid more than ten percent above or more than ten percent below the average relative price and identifying health plans that have entered into alternative payment contracts that vary by more than ten percent.
2. The annual change in price variation by health plan among the health plan's participating providers.
3. Factors that contribute to price variation in the health care system.
4. The impact of price variations on disproportionate share hospitals and other safety net providers.
5. The impact of health reform efforts on price variation, including the impact of increased price transparency and the use of alternative payment contracts.
E. Data collected by the department under this section is not a public record and shall be held in confidence by the department.
F. The department may adopt rules necessary to implement this section.
G. For the purposes of this section:
1. "Alternative payment contract" means any contract between a health care provider or provider organization and a public health plan or a private health plan that uses alternative payment methods.
2. "Alternative payment methods":
(a) Means methods of payment that are not based solely on fee‑for‑service reimbursements.
(b) Includes:
(i) Shared savings arrangements.
(ii) Bundled payments.
(iii) Global payments.
(iv) Fee‑for‑service payments that are settled or reconciled with a bundled or global payment.
3. "Fee-for-service" means a payment mechanism in which all reimbursable health care activity is described and categorized into discrete and separate units of service and a health care provider is separately reimbursed for each discrete service rendered to a patient.
4. "Health care", "health care provider" and "health plan" have the same meanings prescribed in 45 Code of Federal Regulations section 160.103.
5. "Medicaid program" means the medical assistance program administered by the Arizona health care cost containment system pursuant to chapter 29 of this title.
6. "Public health plan" means the medicaid program or any other health plan operated by this state or a political subdivision of this state that pays claims submitted by health care providers.
7. "Relative price" means the contractually negotiated amount paid to a health care provider by each private and public health plan for health care, including both fee‑for‑service payments and nonclaims-related payments, and expressed in the aggregate relative to the health plan's network‑wide average amount paid to providers, as calculated under subsection A or B of this section and rules adopted by the department.
8. "Weighted average payor rate" means a measure by which a sum of the inpatient revenue per discharge and outpatient revenue per visit is separately calculated for commercial, medicare and medicaid program payors, and a weighted average of the three resulting values is derived with the net patient service revenue‑based payor mix of the three payors serving as weights.
