Bill Text: CA AB1558 | 2013-2014 | Regular Session | Amended
Bill Title: California Health Data Organization: all-payer claims database.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Engrossed - Dead) 2014-08-14 - In committee: Held under submission. [AB1558 Detail]
Download: California-2013-AB1558-Amended.html
BILL NUMBER: AB 1558 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 5, 2014
INTRODUCED BY Assembly Member Roger Hernández
JANUARY 28, 2014
An act to add Title 22.5 (commencing with Section 100800) to the
Government Code, to amend Sections 1375.7 and 1395.6 of the
Health and Safety Code, and to amend Sections 10178.3 and 10178.4 of
the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 1558, as amended, Roger Hernández. California Health Data
Organization. Organization: all-payer claims
database.
Existing law establishes the Office of Statewide Health Planning
and Development (OSHPD) to perform various functions and duties with
respect to health facilities, health professions development, and
health policy and planning, including, but not limited to, consulting
with the Insurance Commissioner, the Director of the Department of
Managed Health Care, and others to adopt a California uniform billing
form format for professional health care services and a California
uniform billing form format for institutional provider services.
Existing law requires organizations that operate or own a health
facility to file specified reports with OSHPD containing various
financial and patient data.
Existing law, the Knox-Keene Health Care Service Plan Act of
1975, provides for the licensure and regulation of health care
service plans and makes a willful violation of the act a
crime . Existing law also provides for the regulation of
health insurers by the Department of Insurance. Existing law requires
health care service plans and health insurers to provide an
explanation of benefits or explanation of review that identifies the
name of the network that has a written agreement signed by the
provider whereby the payor is entitled, directly or indirectly, to
pay a preferred rate for the services rendered.
This bill would request the University of California to establish
the California Health Data Organization and would require
health care service plans and health insurers to provide the
explanations of benefits or explanations of review to that
organization to the extent permitted by federal law
request the organization to collect data from payers, as
specified, and establish an all-payer claims database. The bill would
require certain private payers to submit claims data to the
organization on utilization, payment, and cost sharing for services
delivered to beneficiaries. The bill would request the organization
to establish working groups consisting of specified representatives
to coordinate with existing stakeholder processes related to federal
and state price transparency and payment reform and would request the
organization to consider the recommendations of those working
groups, as specified . The bill would require
request the organization to organize the data
provided in those documents collected
pursuant to the bill's provisions and to design and maintain an
Internet Web site that allows consumers to compare the prices paid
by carriers payers for procedures, as
specified. The bill would prohibit data made available to the
public from containing sufficient information to identify an
individual and would require the organization to keep confidential
any proprietary information it obtains. The bill would request
the University of California to seek available funding
from the federal government and other private sources to cover the
costs associated with these provisions and would authorize the
organization to charge a fee to each person or entity requesting
access to data stored in the database it creates.
Existing constitutional provisions require that a statute that
limits the right of access to the meetings of public bodies or the
writings of public officials and agencies be adopted with findings
demonstrating the interest protected by the limitation and the need
for protecting that interest.
This bill would make legislative findings to that effect.
Because a willful violation of the bill's requirement for a health
care service plan to provide an explanation of benefits or
explanation of review to the organization would be a crime, the bill
would impose a state-mandated local program.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes no .
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Title 22.5 (commencing with Section 100800) is added to
the Government Code, to read:
TITLE 22.5. California Health Data Organization
100800. For purposes of this title, the following definitions
shall apply:
(a) "All-payer claims database" or "database" means a database
that receives and stores claims data from payers.
(b) For purposes of this section, "beneficiary" means one of the
following:
(1) With respect to a health care service plan, a subscriber or
enrollee.
(2) With respect to a health insurer, a policyholder or insured.
(3) With respect to a self-insured employee welfare benefit plan,
an employee or dependent of an employee.
(c) "Claims data" means claim or encounter data representing
medical, dental, mental health, and substance use disorder services
financed by payers.
(d) "Claim" means a submitted claim that was processed and
adjudicated by a payer, representing the paid amount and any
adjustments that occurred after the original submission.
(e) "Encounter" means a submitted record of a visit, a service
delivered, a procedure, or other activity, reported by a provider to
a payer when payment is not issued on a fee-for-service basis.
(f) "Exchange" means the California Health Benefit Exchange
established by Section 100500 of the Government Code.
(a) "Organization" means the California Health Data Organization
established pursuant to Section 100801.
(b) "Carrier claims database" or "database" means a database that
receives and stores data from carriers reported to the organization
pursuant to Section 1395.6 of the Health and Safety Code and Section
10178.3 of the Insurance Code.
(c) "Carrier" means either a private health insurer holding a
valid outstanding certificate of authority from the Insurance
Commissioner or a health care service plan licensed by the Department
of Managed Health Care.
(d)
(g) "Health care service plan" has the same meaning as
that term is defined in subdivision (f) of Section 1345 of the Health
and Safety Code.
(e)
(h) "Health insurer" means an insurer admitted to
transact health insurance business in this state. For purposes of
this subdivision, "health insurance" has the meaning used in Section
106 of the Insurance Code.
(f)
(i) "Individually identifiable information" means
information that includes or contains any element of personal
identifying information sufficient to allow identification of the
individual, including the person's name, address, electronic mail
address, telephone number, or social security number, or other
information that, alone or in combination with other publicly
available information, reveals the individual's identity.
(j) "Organization" means the California Health Data Organization
established pursuant to Section 100801.
(k) "Payer" means a private payer, the Medi-Cal program, or the
Medicare program.
(l) "Private payer" means any of the following:
(1) A health care service plan.
(2) A health insurer.
(3) A third-party administrator processing claims on behalf of a
self-insured employee welfare benefit plan that provides coverage for
health care expenses to at least 200 beneficiaries.
(m) "Proprietary information" includes, but is not limited to, any
information that supports or provides any of the clinical rationale
used for the purposes of supporting claims processing decisions.
100801. (a) The Legislature hereby requests the University of
California to establish the California Health Data Organization.
(b) The organization shall Legislature
requests that the organization be staffed by persons with
demonstrated experience in all of the following:
(1) Performing statewide individual-level data collection.
(2) Managing and analyzing complex patient-level data.
(3) Complying with HIPAA requirements.
(4) Communicating information to the public via a user-friendly
web interface.
(c) In order to avoid potential conflicts of interest within the
University of California between providers of health care services
and individuals working within the organization, the Legislature
hereby requests that the organization not be based in a school of
medicine or a University of California medical center.
(c)
(d) The Legislature hereby requests the University of
California to seek available funding from the federal
government and other private sources to cover
defray the costs associated with the planning, implementation,
and administration of this title.
100803. The organization shall
Legislature requests the organization to do all of the
following:
(a) Establish a carrier an all-payer
claims database using the data collected and organized as described
in this title.
(b) Collect data from carriers reported pursuant to
Section 1395.6 of the Health and Safety Code and Section 10178.3 of
the Insurance Code private payers submitted pursuant
to Section 100804 .
(c) Until data is collected as described in subdivision (b),
collect claims data for private payers from publicly available data
sources.
(d) Request and collect available claims data from the Medi-Cal
program and the Medicare program, including claims data reported to
those programs by a health care service plan or health insurer
participating in those programs.
(e) Request and collect data from the Exchange that is related to
the quality of care provided by health plans through the Exchange.
(c)
(f) Organize data reported by carriers
pursuant to Section 1395.6 of the Health and Safety Code and Section
10178.3 of the Insurance Code the data collected
pursuant to this section into the following categories:
(1) Charges billed and total amounts paid by
carriers payers and patients, including, but not
limited to, charge amount, paid amount, prepaid amount, copayment,
coinsurance, deductible, and allowed amount.
(2) Type of health care service, including, but not limited to,
ambulatory care procedures and services and inpatient physician
services reported by Common Procedural Terminology (CPT) codes, and
inpatient hospital services reported by Diagnosis-Related Group (DRG)
codes.
(3) Information relating to risk adjustment, including
other diagnoses, length of stay, and discharge.
diagnosis codes, dates of service, monthly enrollment, age, gender,
length of stay, modifiers, and discharge disposition.
(g) Seek to combine existing quality, outcomes, and patient
experience and satisfaction data with the other data collected
pursuant to this section in order to facilitate value-based
purchasing of health care coverage in the state.
(h) Pursue the calculation of quality measures based on claims
data submitted by payers to allow for comparisons among facilities
and provider groups.
(d)
(i) Ensure that patient privacy is protected in
compliance with state and federal laws. Patient
In collecting, managing, and analyzing claims data, patient
privacy shall be protected using encryption and storage of
the confidential information on secure
servers. Data that is made available to the public by the
organization, including, but not limited to, data made available
pursuant to a request for access described in paragraph (3) of
subdivision (a) of Section 100805, shall not contain sufficient
information to identify an individual, including, but not limited to,
an individual health care provider.
(j) Keep confidential any proprietary information the organization
obtains pursuant to this title. Proprietary information obtained by
the organization shall not be made available to the public, shall not
be subject to subpoena or discovery, and shall not be subject to the
California Open Records Act (Chapter 3.5 (commencing with Section
6250) of Division 7 of Title 1 of the Government Code).
100804. (a) Commencing on the date that the organization is
established, a private payer shall regularly submit claims data to
the organization on utilization, payment, and cost sharing for
services delivered to beneficiaries. The data submitted shall, at a
minimum, include the following for each claim or encounter:
(1) A linkable patient identifier that can be mapped across all
claims or encounters.
(2) Date of service.
(3) Date of payment.
(4) Adjustment flag.
(5) Claim identification number.
(6) At least two diagnosis codes related to the claim or encounter
based on current coding standards.
(7) Any procedure codes associated with the claim or encounter
based on current coding standards.
(8) National Drug Code for prescription drugs.
(9) Revenue codes.
(10) Allowed amount.
(11) Patient billed share of cost, including amounts billed prior
to the patient satisfying any applicable deductible requirements.
(12) Total charge.
(13) Patient demographics, including, but not limited to, age,
gender, race, ethnicity, and language, if available.
(14) Product type (HMO, PPO, POS, EPO, or FFS).
(15) Whether the claim or encounter is billed or reported under a
health plan covering a single individual or a family and whether that
plan is an individual market plan, a group market plan, or a
self-insured employee welfare benefit plan.
(16) Type of payment to which claim or encounter is related
(capitated, diagnosis related group, bundled, per diem, or other
negotiated rate).
(17) Procedure modifiers based on current coding standards.
(18) Setting of service, including, but not limited to, hospital,
outpatient primary care, outpatient specialty care, freestanding
clinic, freestanding federally qualified health center, or ambulatory
surgery center.
(19) National provider identification information for the provider
billing for the service, including name, federal tax identification
number, and address.
(20) National provider identification information for the provider
rendering the service, including name, federal tax identification
number, and address.
(21) Monthly enrollment flags for the time period of the claims or
encounter file indicating if the individual was covered by the payer
for any given month in the year.
(b) A private payer may, with approval of the organization, modify
the information required to be submitted under this section as
necessary to comply with applicable federal and state privacy laws.
(c) A private payer shall not be required to report to the
organization the data required under this section with respect to
beneficiaries enrolled in the Medi-Cal or Medicare program.
100804.5. (a) The Legislature requests the organization to
establish working groups consisting of representatives of private
payers, physicians and surgeons, provider groups, state and federal
regulators, academia, and consumer stakeholders.
(b) The Legislature requests the working groups established by the
organization to coordinate, to the extent possible, with existing
stakeholder processes related to federal and state price transparency
and payment reform. The organization is requested to consider the
recommendations made by the working groups in providing updates to
the desired data fields for claims data reporting, collecting and
displaying price, quality, and value information for consumers,
making comparisons by geographic region, provider type, and
individual health care facilities, and conducting additional analyses
to inform consumer decisions on price, quality, and value.
(c) The Legislature requests that the working groups established
by the organization provide guidance on additional data that would be
important for consumers and stakeholders in making price, quality,
and value comparisons and the appropriate information to be displayed
by variables, including, but not limited to, geographic region,
provider type, facility, and provider group.
100805. (a) The organization may do all of the following:
(1) Receive and accept gifts, grants, or donations of moneys from
any agency of the United States, any agency of the state, any
municipality, county, or other political subdivision of the state.
(2) Receive and accept gifts, grants, or donations from
individuals, associations, private foundations, or corporations, in
compliance with the existing conflict-of-interest
provisions to be adopted by the board at
a public meeting University of California .
(3) Charge a reasonable fee to each person or entity requesting
access to data stored in the database, not to exceed the actual costs
of providing that access.
(4) Explore alternative sources of funding, to the extent
permitted by law, to ensure the sustainabilty
sustainability of the organization.
(b) The organization shall not accept
Legislature requests that the organization refuse gifts or
grants from an entity that may have a vested interest in the
decisions of the organization.
100809. (a) The organization shall
Legislature requests the organization to disseminate the
information collected pursuant to this title to the public in a
meaningful and comprehensive manner.
(b) For purposes of this section, the organization shall
is requested to do all of the following:
(1) Design and maintain an interactive searchable Internet Web
site that is accessible to the public and in which both of the
following requirements are satisfied:
(A) Information on payments for services is easily searchable by
the average consumer.
(B) The format used allows for the comparison of prices paid by
carriers payers per procedure
without identifying the particular price paid by a particular private
payer .
(2) Investigate how to combine price information with quality
information, either within the database or by linkage to other
searchable databases.
(3) Investigate the most efficient way of presenting information
to the public, including, but not limited to, reporting on price
information for the average severity of the condition or for
different tiers of severity.
(4) Coordinate efforts with the health care coverage market and
provide information to the public using the geographic areas used by
carriers payers in order to do both of
the following:
(A) Make price transparency readily available to all purchasers of
health care coverage.
(B) Help guide consumers in their choice between different health
plans available through the California Health Benefit
Exchange established by Section 100500 .
(5) Aggregate at a high level of detail the information collected
pursuant to this title and made available to the public so as not to
disclose any propriety information.
(c) Information disclosed pursuant to this section shall
not contain any individually identifiable information
comply with subdivision (g) of Section 100803 .
(d) To allow for the development of the Internet Web site
described in this section without delay, the organization may
contract with a qualified, nongovernmental, independent third party
for the delivery of a commercially available claims dataset with the
appropriate level of detail in term of payments, geocoding, and
provider information. This information shall
The Legislature requests that this information be replaced
or supplemented with information directly collected by the
organization once the first set of data directly collected from
carriers payers has been cleaned and
analyzed.
(e) In order to ensure the confidentiality, security, and
affordability of maintaining the organization, the Legislature
requests that the organization expand its data storage and processing
capacity internally to house the Internet Web site described in this
section and the large data sets gathered from payers under this
title.
100811. The organization shall
Legislature requests the organization to use the data collected
pursuant to this title and produce annual reports on the cost of
specific ambulatory care procedures and services and inpatient
physician services aggregated within geographic market areas in this
state, as determined by the organization, so as not to identify
individual physicians.
SEC. 2. The Legislature finds and declares that
Section 1 of this act, which adds Section 100803 to the Government
Code, imposes a limitation on the public's right of access to the
meetings of public bodies or the writings of public officials and
agencies within the meaning of Section 3 of Article I of the
California Constitution. Pursuant to that constitutional provision,
the Legislature makes the following findings to demonstrate the
interest protected by this limitation and the need for protecting
that interest:
In order to protect the confidentiality of proprietary information
collected pursuant to this act, it is necessary that this act limit
the public's right of access to that information. matter
omitted in this version of the bill appears in the bill as introduced
in the Assembly, January 28, 2014. (JR11)
