WEST virginia legislature
2017 regular session
Introduced
House Bill 2827
By Ellington and Summers
[Introduced March 8, 2017;
Referred
to the Committee on Health and Human Resources.]
A BILL to amend and reenact §33-4A-1, §33-4A-2, §33-4A-3, §33-4A-4, §33-4A-5, §33-4A-6, §33-4A-7 and §33-4A-8 of the Code of West Virginia, 1931, as amended, all relating to the updating the all payor claims database.
Be it enacted by the Legislature of West Virginia:
That §33-4A-1, §33-4A-2, §33-4A-3, §33-4A-4, §33-4A-5, §33-4A-6, §33-4A-7 and §33-4A-8 of the Code of West Virginia, 1931, as amended, be amended and reenacted, all to read as follows:
ARTICLE 4A. ALL-PAYER CLAIMS DATABASE.
§33-4A-1. Definitions.
The following terms are defined:
(a) (1) "All-payer claims database" or
"APCD" means the program authorized by this article that collects,
retains, uses and discloses information concerning the claims and
administrative expenses of health care payers.
(b) "Chair"
means the chairperson of the West Virginia Health Care Authority.
(c)
"Commissioner" means the West Virginia Insurance Commissioner
(d) (2) "Data" means the data elements
from enrollment and eligibility files, specified types of claims, and reference
files for data elements not maintained in formats consistent with national
coding standards.
(e) (3) "Health care payer" means any
entity that pays or administers the payment of health insurance claims or
medical claims under workers' compensation insurance to providers in this state,
including workers' compensation insurers; accident and sickness insurers;
nonprofit hospital service corporations, medical service corporations and
dental service organizations; nonprofit health service corporations; prepaid
limited health service organizations; health maintenance organizations; and
government payers, including, but not limited to, Medicaid, Medicare and the Public
Employees Insurance Agency; the term also includes any third-party
administrator including any pharmacy benefit manager, that administers a
fully-funded or self-funded plan:
A "health insurance claim" does not include:
(1) (A) Any claim paid under an individual or
group policy providing coverage only for accident, or disability income
insurance or any combination thereof; coverage issued as a supplement to
liability insurance; liability insurance, including general liability insurance
and automobile liability; credit-only insurance; coverage for on-site medical
clinics; other similar insurance coverage, which may be specified by rule,
under which benefits for medical care are secondary or incidental to other
insurance benefits; or
(2) (B) Any of the following if provided under a
separate policy, certificate, or contract of insurance: Limited scope dental
or vision benefits; benefits for long-term care, nursing home care, home health
care, community-based care, or any combination thereof; coverage for only a
specified disease or illness; or hospital indemnity or other fixed indemnity
insurance.
"Health insurance claims" shall only include information from Medicare supplemental policies if the same information is obtained with respect to Medicare.
(f) (4) "Personal identifiers" means
information relating to an individual member or insured that identifies, or can
be used to identify, locate or contact a particular individual member or
insured, including, but not limited to, the individual's name, street address,
social security number, e-mail address and telephone number.
(g) (5) "Secretary" means the Secretary
of the West Virginia Department of Health and Human Services.
(h) (6) "Third-party administrator" has
the same meaning ascribed to it in section two, article forty-six of this
chapter.
§33-4A-2. Establishment and development of an all-payer claims database.
The secretary commissioner
and chair, collectively referred to herein as the "MOU parties",
shall enter into a memorandum of understanding to shall develop an
all-payer claims database program.
(b) The memorandum of
understanding shall, at a minimum:
(1) Provide that the
commissioner secretary will have primary responsibility for the collection of
the data in order to facilitate the efficient administration of state
oversight, the secretary will have primary responsibility for the retention of
data supplied to the state under its health care oversight function, and the
chair will have primary responsibility for the dissemination of the data;
(2) Delineate the MOU
parties' roles, describe the process to develop legislative rules required by
this article, establish communication processes and a coordination plan, and
address vendor relationship management;
(3) Provide for the
development of a plan for the financial stability of the APCD, including
provision for funding by the MOU parties' agencies; and
(4) Provide for the use
of the hospital discharge data collected by the West Virginia Health Care
Authority as a tool in the validation of APCD reports
§33-4A-3. Powers of the secretary; exemption from purchasing rules.
(a) The MOU parties secretary
may:
(1) Accept gifts, bequests, grants or other funds dedicated to the furtherance of the goals of the APCD;
(2) Select a vendor to handle data collection and processing and such other tasks as deemed appropriate;
(3) Enter into agreements with other states to perform joint administrative operations, share information and assist in the development of multistate efforts to further the goals of this article: Provided, That any such agreements must include adequate protections with respect to the confidentiality of the information to be shared and comply with all state and federal laws and regulations;
(4) Enter into memoranda of understanding with other governmental agencies to carry out any of its functions, including contracts with other states to perform joint administrative functions;
(5) Attempt to ensure that the requirements with respect to the reporting of data be standardized so as to minimize the expense to parties subject to similar requirements in other jurisdictions;
(6) Enter into voluntary agreements to obtain data from payers not subject to mandatory reporting under this article; and
(7) Exempt a payer or class of payers from the requirements of this article for cause.
(b) Contracts for
professional services for the development and operation of the APCD are not
subject to the provisions of article three, chapter five-a of this code
relating to the Purchasing Division of the Department of Administration. The
award of such contracts shall be subject to a competitive process established
by the MOU parties.
(c) The MOU parties
shall make an annual report to the Governor, which shall also be filed with the
Joint Committee on Government and Finance, summarizing the activities of the
APCD in the preceding calendar year
§33-4A-4. Data subject to this article.
(a) All health care payers
shall submit data to the commissioner secretary or an entity
designated by the commissioner secretary at such times and in a
form specified in rule. Any health care payer that the commissioner secretary
determines paid or administered the payment of health insurance claims in this
state for policies on fewer than five hundred covered lives in the previous
calendar year is exempt from the requirements of this article.
(b) Data submitted in accordance with this article shall be considered confidential by law and privileged, are exempt from disclosure pursuant to chapter twenty-nine-b of this code, are not open to public inspection, are not subject to subpoena, are not subject to discovery or admissible in evidence in any criminal, private civil or administrative action, are not subject to production pursuant to court order, and shall only be used and disclosed pursuant to law and legislative rules promulgated pursuant to this article.
(c)(1) Data submitted to
and retained by the APCD shall be available as a resource for the MOU
parties Secretary to continuously review health care utilization,
expenditures and performance in West Virginia and to enhance the ability of
consumers to make informed and cost-effective health care decisions.
(2) Data submitted to and retained by the APCD may, in accordance with this article and the legislative rules promulgated pursuant to this article, also be available as a resource for insurers, researchers, employers, providers, purchasers of health care, consumers and state agencies.
(d) Notwithstanding any
other provision of law to the contrary, the APCD shall not disclose any data
that contain personal identifiers. The MOU parties secretary, in
accordance with procedures and standards set forth in legislative rule, may
approve access to other data elements not prohibited from disclosure by the
APCD, as well as synthetic or created unique identifiers, for use by
researchers, including government agencies, with established protocols for
safeguarding confidential or privileged information. The MOU parties'
secretary’s use of the data shall not constitute a disclosure.
§33-4A-5. User fees; waiver.
Reasonable user fees may be
set in the manner established in legislative rule, for the right to access and
use the data available from the APCD. The chair secretary may
reduce or waive the fee if he or she determines that the user is unable to pay
the scheduled fees and that the user has a viable plan to use the data or
information in research of general value to the public health.
§33-4A-6. Enforcement; injunctive relief.
In the event of any
violation of this article or any rule adopted thereunder, the commissioner
secretary or chair may seek to enjoin a further violation in the Circuit
Court of Kanawha County. Injunctive relief ordered pursuant to this section may
be in addition to any other remedies and enforcement actions available to the
commissioner under this chapter.
§33-4A-7. Special revenue account created.
(a) There is hereby
created continued a special revenue account in the State Treasury,
designated the West Virginia All-Payer Claims Database Fund, which shall be an
interest-bearing account and may be invested in the manner permitted by article
six, chapter twelve of this code, with the interest income a proper credit to
the fund and which shall not revert to the general revenue, unless otherwise
designated in law. The fund shall be overseen by the commissioner,
secretary and chair, shall be administered by the commissioner, and
shall be used to pay all proper costs incurred in implementing the provisions
of this article.
(b) The following funds shall be paid into this account:
(1) Penalties imposed on health care payers pursuant to this article and rules promulgated hereunder;
(2) Funds received from the federal government;
(3) Appropriations from the Legislature; and
(4) All other payments, gifts, grants, bequests or income from any source.
§33-4A-8. Rule-making authority.
To effectuate the
provisions of this article, the MOU parties secretary may propose joint
rules for legislative approval in accordance with the provisions of article
three, chapter twenty-nine-a of this code as necessary to implement this
article. No actions to collect data or assess fees pursuant to this article may
be undertaken until rules promulgated hereunder are made effective. Such
rules may include, but are not limited to, the following The rules shall
include:
(a) (1) Procedures for the collection, retention,
use and disclosure of data from the APCD, including procedures and safeguards
to protect the privacy, integrity, confidentiality and availability of any
data;
(b) (2) Penalties against health care payers for
violation of rules governing the submission of data, including a schedule of
fines for failure to file data or to pay assessments;
(c) (3) Fees payable by users of the data and the
process for a waiver or reduction of user fees. Any such fees shall be established
at a level that, when considered together with other available funding sources,
is deemed necessary to sustain the operation of the APCD;
(d) (4) A proposed time frame for the creation of
the database;
(e) (5) Criteria for determining whether data collected,
beyond the listed personal identifiers, is confidential clinical data,
confidential financial data or privileged medical information, and procedures
to give affected providers and health care payers notice and opportunity to
comment in response to requests for information that may be considered
confidential or privileged; and
(f) (6) Penalties, including fines and other
administrative sanctions, that may be imposed by the commissioner secretary
for a health care payer's failure to comply with requirements of this article
and rules adopted hereunder. and
(g) Establishment of
advisory boards to provide advice to the MOU parties with respect to the
various functions of the APCD
NOTE: The purpose of this bill is to update the provisions of the all payor claims database.
Strike-throughs indicate language that would be stricken from a heading or the present law and underscoring indicates new language that would be added.