By: Walle H.B. No. 1907
A BILL TO BE ENTITLED
AN ACT
relating to the establishment of a statewide all payor claims
database to increase public transparency of health care data and
improve quality of health care in this state.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 38, Insurance Code, is amended by adding
Subchapter I to read as follows:
SUBCHAPTER I. TEXAS ALL PAYOR CLAIMS DATABASE
Sec. 38.401. PURPOSE OF SUBCHAPTER. The purpose of this
subchapter is to authorize the department to establish an all payor
claims database in this state to increase public transparency of
health care information and improve the quality of health care in
this state.
Sec. 38.402. DEFINITIONS. In this subchapter:
(1) "Allowed amount" means the amount of a billed
charge that a health benefit plan issuer determines to be covered
for services provided by a non-network provider. The allowed amount
includes both the insurer's payment and any applicable deductible,
copayment, or coinsurance amounts for which the insured is
responsible.
(2) "Center" means the Center for Healthcare Data at
The University of Texas Health Science Center at Houston.
(3) "Contracted rate" means the fee or reimbursement
amount for a network provider's services, treatments, or supplies
as established by agreement between the provider and health benefit
plan issuer.
(4) "Data" means the specific claims and encounters,
enrollment, and benefit information submitted to the center under
this subchapter.
(5) "Database" means the Texas All Payor Claims
Database established under this subchapter.
(6) "Geozip" means an area that includes all zip codes
with identical first three digits.
(7) "Payor" means any of the following entities that
pay, reimburse, or otherwise contract with a health care provider
for the provision of health care services, supplies, or devices to a
patient:
(A) an insurance company providing health or
dental insurance;
(B) the sponsor or administrator of a health or
dental plan;
(C) a health maintenance organization operating
under Chapter 843;
(D) the state Medicaid program, including the
Medicaid managed care program operating under Chapter 533,
Government Code;
(E) a health benefit plan offered or administered
by or on behalf of this state or a political subdivision of this
state or an agency or instrumentality of the state or a political
subdivision of this state, including:
(i) a basic coverage plan under Chapter
1551;
(ii) a basic plan under Chapter 1575; and
(iii) a primary care coverage plan under
Chapter 1579; or
(F) any other entity providing a health insurance
or health benefit plan subject to regulation by the department.
(8) "Protected health information" has the meaning
assigned by 45 C.F.R. Section 160.103.
(9) "Qualified research entity" means:
(A) an organization engaging in public interest
research for the purpose of analyzing the delivery of health care in
this state that is exempt from federal income tax under Section
501(a), Internal Revenue Code of 1986, by being listed as an exempt
organization in Section 501(c)(3) of that code;
(B) an institution of higher education engaged in
public interest research related to the delivery of health care in
this state; or
(C) a health care provider in this state engaging
in efforts to improve the quality and cost of health care.
(10) "Stakeholder advisory group" means the
stakeholder advisory group established under Section 38.403.
Sec. 38.403. STAKEHOLDER ADVISORY GROUP. (a) The center
shall establish a stakeholder advisory group to assist the center
as provided by this subchapter, including assistance in:
(1) establishing and updating the standards,
requirements, policies, and procedures relating to the collection
and use of data contained in the database required by Sections
38.404(e) and (f);
(2) evaluating and prioritizing the types of reports
the center should publish under Section 38.404(e);
(3) evaluating data requests from qualified research
entities under Section 38.404(e)(2); and
(4) assisting the center in developing the center's
recommendations under Section 38.408(3).
(b) The advisory group created under this section must be
composed of:
(1) the state Medicaid director or the director's
designee;
(2) a member designated by the Teacher Retirement
System of Texas;
(3) a member designated by the Employees Retirement
System of Texas; and
(4) 12 members designated by the center, including:
(A) two members representing the business
community, with at least one of those members representing small
businesses that purchase health benefits but are not involved in
the provision of health care services, supplies, or devices or
health benefit plans;
(B) two members who represent consumers and who
are not professionally involved in the purchase, provision,
administration, or review of health care services, supplies, or
devices or health benefit plans, with at least one member
representing the behavioral health community;
(C) two members representing hospitals that are
licensed in this state;
(D) two members representing health benefit plan
issuers that are regulated by the department;
(E) two members who are physicians licensed to
practice medicine in this state, one of whom is a primary care
physician; and
(F) two members who are not professionally
involved in the purchase, provision, administration, or review of
health care services, supplies, or devices or health benefit plans
and who have expertise in:
(i) health planning;
(ii) health economics;
(iii) provider quality assurance;
(iv) statistics or health data management;
or
(v) medical privacy laws.
(c) A person serving on the stakeholder advisory group must
disclose any conflict of interest.
(d) Members of the stakeholder advisory group serve fixed
terms as prescribed by commissioner rules adopted under this
subchapter.
Sec. 38.404. ESTABLISHMENT AND ADMINISTRATION OF DATABASE.
(a) The department shall collaborate with the center under this
subchapter to aid in the center's establishment of the database.
The center shall leverage the existing resources and infrastructure
of the center to establish the database to collect, process,
analyze, and store data relating to medical, dental,
pharmaceutical, and other relevant health care claims and
encounters, enrollment, and benefit information for the purposes of
increasing transparency of health care costs, utilization, and
access and improving the affordability, availability, and quality
of health care in this state, including by improving population
health in this state.
(b) The center shall serve as the administrator of the
database, design, build, and secure the database infrastructure,
and determine the accuracy of the data submitted for inclusion in
the database.
(c) In determining the information a payor is required to
submit to the center under this subchapter, the center must
consider requiring inclusion of information useful to health policy
makers, employers, and consumers for purposes of improving health
care quality and outcomes, improving population health, and
controlling health care costs. The required information at a
minimum must include the following information as it relates to all
health care services, supplies, and devices paid or otherwise
adjudicated by the payor:
(1) the name and National Provider Identifier, as
described in 45 C.F.R. Section 162.410, of each health care
provider paid by the payor;
(2) the claim line detail that documents the health
care services, supplies, or devices provided by the health care
provider;
(3) the amount of charges billed by the health care
provider and the payor's:
(A) allowed amount or contracted rate for the
health care services, supplies, or devices; and
(B) adjudicated claim amount for the health care
services, supplies, or devices;
(4) the name of the payor, the name of the health
benefit plan, and the type of health benefit plan, including
whether health care services, supplies, or devices were provided to
an individual through:
(A) a Medicaid or Medicare program;
(B) workers' compensation insurance;
(C) a health maintenance organization operating
under Chapter 843;
(D) a preferred provider benefit plan offered by
an insurer under Chapter 1301;
(E) a basic coverage plan under Chapter 1551;
(F) a basic plan under Chapter 1575;
(G) a primary care coverage plan under Chapter
1579; or
(H) a health benefit plan that is subject to the
Employee Retirement Income Security Act of 1974 (29 U.S.C. Section
1001 et seq.); and
(5) claim level information that allows the center to
identify the geozip where the health care services, supplies, or
devices were provided.
(d) Each payor shall submit the required data under
Subsection (c) at a schedule and frequency determined by the center
and adopted by the commissioner by rule.
(e) In the manner and subject to the standards,
requirements, policies, and procedures relating to the use of data
contained in the database established by the center in consultation
with the stakeholder advisory group, the center may use the data
contained in the database for a noncommercial purpose:
(1) to produce statewide, regional, and geozip
consumer reports available through the public access portal
described in Section 38.405 that address:
(A) health care costs, quality, utilization,
outcomes, and disparities;
(B) population health; or
(C) the availability of health care services; and
(2) for research and other analysis conducted by the
center or a qualified research entity to the extent that such use is
consistent with all applicable federal and state law, including the
data privacy and security requirements of Section 38.406 and the
purposes of this subchapter.
(f) The center shall establish data collection procedures
and evaluate and update data collection procedures established
under this section. The center shall test the quality of data
collected by and reported to the center under this section to ensure
that the data is accurate, reliable, and complete.
Sec. 38.405. PUBLIC ACCESS PORTAL. (a) Except as provided
by this section and Sections 38.404 and 38.406 and in a manner
consistent with all applicable federal and state law, the center
shall collect, compile, and analyze data submitted to or stored in
the database and disseminate the information described in Section
38.404(e)(1) in a format that allows the public to easily access and
navigate the information. The information must be accessible
through an open access Internet portal that may be accessed by the
public through an Internet website.
(b) The portal created under this section must allow the
public to easily search and retrieve the information disseminated
under Subsection (a), subject to data privacy and security
restrictions described in this subchapter and consistent with all
applicable federal and state law.
(c) Any information or data that is accessible through the
portal created under this section:
(1) must be segmented by type of insurance or health
benefit plan in a manner that does not combine payment rates
relating to different types of insurance or health benefit plans;
(2) must be aggregated by like Current Procedural
Terminology codes and health care services in a statewide,
regional, or geozip area; and
(3) may not identify a specific patient, health care
provider, health benefit plan, health benefit plan issuer, or other
payor.
(d) Before making information or data accessible through
the portal, the center shall remove any data or information that may
identify a specific patient in accordance with the
de-identification standards described in 45 C.F.R. Section
164.514.
Sec. 38.406. DATA PRIVACY AND SECURITY. (a) Any
information that may identify a patient, health care provider,
health benefit plan, health benefit plan issuer, or other payor is
confidential and subject to applicable state and federal law
relating to records privacy and protected health information,
including Chapter 181, Health and Safety Code, and is not subject to
disclosure under Chapter 552, Government Code.
(b) A qualified research entity with access to data or
information that is contained in the database but not accessible
through the portal described in Section 38.405:
(1) may use information contained in the database only
for purposes consistent with the purposes of this subchapter and
must use the information in accordance with standards,
requirements, policies, and procedures established by the center in
consultation with the stakeholder advisory group;
(2) may not sell or share any information contained in
the database; and
(3) may not use the information contained in the
database for a commercial purpose.
(c) A qualified research entity with access to information
that is contained in the database but not accessible through the
portal must execute an agreement with the center relating to the
qualified research entity's compliance with the requirements of
Subsections (a) and (b), including the confidentiality of
information contained in the database but not accessible through
the portal.
(d) Notwithstanding any provision of this subchapter, the
department and the center may not disclose an individual's
protected health information in violation of any state or federal
law.
(e) The center shall include in the database only the
minimum amount of protected health information identifiers
necessary to link public and private data sources and the
geographic and services data to undertake studies.
(f) The center shall maintain protected health information
identifiers collected under this subchapter but excluded from the
database under Subsection (e) in a separate database. The separate
database may not be aggregated with any other information and must
use a proxy or encrypted record identifier for analysis.
Sec. 38.407. CERTAIN ENTITIES NOT REQUIRED TO SUBMIT DATA.
Any sponsor or administrator of a health benefit plan subject to the
Employee Retirement Income Security Act of 1974 (29 U.S.C. Section
1001 et seq.) may elect or decline to participate in or submit data
to the center for inclusion in the database as consistent with
federal law.
Sec. 38.408. REPORT TO LEGISLATURE. Not later than
September 1 of each even-numbered year, the center shall submit to
the legislature a written report containing:
(1) an analysis of the data submitted to the center for
use in the database;
(2) information regarding the submission of data to
the center for use in the database and the maintenance, analysis,
and use of the data;
(3) recommendations from the center, in consultation
with the stakeholder advisory group, to further improve the
transparency, cost-effectiveness, accessibility, and quality of
health care in this state; and
(4) an analysis of the trends of health care
affordability, availability, quality, and utilization.
Sec. 38.409. RULES. (a) The commissioner, in consultation
with the center, shall adopt rules:
(1) specifying the types of data a payor is required to
provide to the center under Section 38.404 to determine health
benefits costs and other reporting metrics, including, if
necessary, types of data not expressly identified in that section;
(2) specifying the schedule, frequency, and manner in
which a payor must provide data to the center under Section 38.404,
which must:
(A) require the payor to provide data to the
center not less frequently than quarterly; and
(B) include provisions relating to data layout,
data governance, historical data, data submission, use and sharing,
information security, and privacy protection in data submissions;
and
(3) establishing oversight and enforcement mechanisms
to ensure that payors submit data to the database in accordance with
this subchapter.
(b) In adopting rules governing methods for data
submission, the commissioner shall to the maximum extent
practicable use methods that are reasonable and cost-effective for
payors.
SECTION 2. (a) Not later than January 1, 2022, the Center
for Healthcare Data at The University of Texas Health Science
Center at Houston shall establish the stakeholder advisory group in
accordance with Section 38.403, Insurance Code, as added by this
Act.
(b) Not later than June 1, 2022, the Texas Department of
Insurance shall adopt rules, and the Center for Healthcare Data at
The University of Texas Health Science Center at Houston shall
adopt, in consultation with the stakeholder advisory group,
standards, requirements, policies, and procedures, necessary to
implement Subchapter I, Chapter 38, Insurance Code, as added by
this Act.
SECTION 3. As soon as practicable after the effective date
of this Act, the Center for Healthcare Data at The University of
Texas Health Science Center at Houston shall actively seek
financial support from the federal grant program for development of
state all payer claims databases established under the Consolidated
Appropriations Act, 2021 (Pub. L. No. 116-260) and from any other
available source of financial support provided by the federal
government for purposes of implementing Subchapter I, Chapter 38,
Insurance Code, as added by this Act.
SECTION 4. If before implementing any provision of
Subchapter I, Chapter 38, Insurance Code, as added by this Act, the
commissioner of insurance determines that a waiver or authorization
from a federal agency is necessary for implementation of that
provision, the commissioner shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 5. This Act takes effect September 1, 2021.