SENATE BILL 578

52nd legislature - STATE OF NEW MEXICO - first session, 2015

INTRODUCED BY

Linda M. Lopez

FOR THE LEGISLATIVE HEALTH AND HUMAN SERVICES COMMITTEE

AN ACT

RELATING TO HEALTH; ESTABLISHING AN ALL-PAYER CLAIMS DATABASE TO PROVIDE FOR THE SECURE STORAGE, MAINTENANCE AND ANALYSIS OF HEALTH CARE DATA; PROVIDING FOR FEES AND PENALTIES; MAKING AN APPROPRIATION.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

     SECTION 1. [NEW MATERIAL] SHORT TITLE.--This act may be cited as the "All-Payer Claims Database Act".

     SECTION 2. [NEW MATERIAL] DEFINITIONS.--As used in the All-Payer Claims Database Act:

          A. "commission" means the all-payer claims database commission;

          B. "database" means the all-payer claims database;

          C. "health information exchange" means an arrangement among persons participating in a defined secure electronic network service, such as a regional health information organization, that allows the sharing of health care information about individual patients among different health care institutions or unaffiliated providers. The use of an electronic medical record system by a health care provider, by or within a health care institution or by an organized health care arrangement as defined by the federal Health Insurance Portability and Accountability Act of 1996 does not constitute a health information exchange;

          D. "limited insurance" means a limited-benefit policy that is intended to supplement major medical coverage, including vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies, or that only issues policies for long-term care or disability income;

          E. "major medical coverage" means coverage offered under authority of the New Mexico Insurance Code or the Health Care Purchasing Act by a health insurer, nonprofit health service provider, health maintenance organization, managed care organization, fraternal benefit society or provider service organization for hospital and medical expenses. "Major medical coverage" excludes limited insurance;

          F. "reporting entity" means:

                (1) a person authorized pursuant to the New Mexico Insurance Code as a health insurer, nonprofit health service provider, health maintenance organization, managed care organization, fraternal benefit society or provider service organization to offer major medical coverage in the state;

                (2) an insurance administrator required to obtain a license pursuant to Chapter 59A, Article 12A NMSA 1978;

                (3) a pharmacy benefits manager, fiscal intermediary or other person that is by statute, contract or agreement legally responsible for payment of a claim for a health care item or service; 

                (4) the state medicaid program operated by the human services department pursuant to Title 19 or 21 of the federal Social Security Act; or

                (5) a person that provides coverage pursuant to Part C of, or to supplement coverage under, Title 18 of the federal Social Security Act Amendments of 1965, as then constituted or later amended; and

          G. "superintendent" means the superintendent of insurance.

     SECTION 3. [NEW MATERIAL] ALL-PAYER CLAIMS DATABASE--REPORTING--RULEMAKING.--

          A. By December 31, 2015, the superintendent shall adopt and promulgate rules in accordance with the recommendations of the commission to establish the "all-payer claims database" in the state.

          B. The superintendent shall contract with an entity with experience in operating a health information exchange in the state to collect, store and maintain data for the database in accordance with state and federal law.

          C. Each reporting entity in the state shall report to the entity designated pursuant to Subsection B of this section, for purposes of collection in the database, health care data specified pursuant to office of superintendent of insurance rules for the following purposes:

                (1) determining the maximum capacity and distribution of existing resources allocated to health care;

                (2) identifying the demands for health care;

                (3) allowing health care policymakers to make informed choices;

                (4) evaluating the effectiveness of intervention programs in improving health outcomes;

                (5) comparing the costs and effectiveness of various treatment settings and approaches;

                (6) providing information to consumers and purchasers of health care;

                (7) improving the quality and affordability of health care and health care coverage; and

                (8) evaluating health disparities.

          D. The superintendent shall prescribe, by rule, standards that are consistent with standards adopted by the accredited standards committee X12 of the American national standards institute, the centers for medicare and medicaid services and the national council for prescription drug programs and that:

                (1) establish the time, place, form and manner of reporting data under this section, including but not limited to:

                     (a) requiring the use of unique patient and provider identifiers;

                     (b) specifying a uniform coding system that reflects all health care utilization and costs for health care services provided to New Mexico residents in other states; and

                     (c) establishing enrollment thresholds below which reporting will not be required; and

                (2) establish the types of data to be reported under this section, including but not limited to:

                     (a) health care claims and enrollment data used by reporting entities and paid health care claims data;

                     (b) reports, schedules, statistics or other data relating to health care costs, prices, quality, utilization or resources determined by the superintendent to be necessary to carry out the purposes of this section; and

                     (c) data related to race, ethnicity and primary language collected in a manner consistent with established national standards.

     SECTION 4. [NEW MATERIAL] ALL-PAYER CLAIMS DATABASE COMMISSION--CREATED--MEMBERSHIP--DUTIES.--

          A. By July 1, 2015, the superintendent shall contract with an entity in the state with expertise in health care cost and quality analysis to convene and coordinate the "all-payer claims database commission". By December 1, 2015, the commission shall make recommendations relating to the following:

                (1) sources among public and private entities for health care claims data in the state and the manner in which the database may receive data from these entities;

                (2) sources of funding for the establishment and operation of a database, including fees for the use of data;

                (3) the possibilities afforded in state and other applicable law for a governance structure and an operational entity that will provide for:

                     (a) the safe collection, management, storage and sharing of health care claims data;

                     (b) a public-private partnership to manage the database's duties; and

                     (c) accountability to the public and state government;

                (4) criteria for deeming persons eligible to receive data from the database and protocols for applying for the use of data;

                (5) applications for the data in the database that will achieve the goal of high-quality health care while cutting health care costs; and

                (6) entities with which the database may partner to achieve improvements in the quality and cost of health care services in the state.

          B. The commission shall meet at least once monthly at the call of the superintendent until December 2015.

          C. The commission shall consist of representatives of the following:

                (1) the medical assistance division of the human services department, appointed by the secretary of human services;

                (2) the behavioral health services division of the human services department, appointed by the secretary of human services;

                (3) the public health division of the department of health, appointed by the secretary of health;

                (4) the developmental disabilities supports division of the department of health, appointed by the secretary of health;

                (5) the corrections department, appointed by the secretary of corrections;

                (6) the university of New Mexico, appointed by the president of the university of New Mexico; and

                (7) New Mexico state university, appointed by the president of New Mexico state university.

          D. In addition to the commission members appointed pursuant to Subsection C of this section, the commission shall consist of representatives of the following entities, who shall be appointed by the superintendent:

                (1) the interagency benefits advisory committee;

                (2) the entity with experience in operating a health information exchange with which the office of superintendent of insurance contracts pursuant to Subsection B of Section 3 of the All-Payer Claims Database Act;

                (3) each reporting entity in the state;

                (4) the New Mexico primary care association;

                (5) the New Mexico hospital association;

                (6) the New Mexico medical society;

                (7) the New Mexico osteopathic medical association;

                (8) the New Mexico nurses association; and

                (9) a health care consumer advocacy organization.

     SECTION 5. [NEW MATERIAL] FEES.--The superintendent shall establish reasonable fees to users of the database to cover the costs of administering the database.

     SECTION 6. [NEW MATERIAL] CIVIL PENALTIES FOR FAILURE TO REPORT HEALTH CARE DATA.--The superintendent shall establish civil penalties for reporting entities that fail to report health care data as required pursuant to the All-Payer Claims Database Act.

     SECTION 7. APPROPRIATION.--One hundred thousand dollars ($100,000) is appropriated from the general fund to the office of superintendent of insurance for expenditure in fiscal year 2016 to cover the costs of establishing the all-payer claims database pursuant to the All-Payer Claims Database Act. Any unexpended or unencumbered balance remaining at the end of fiscal year 2016 shall revert to the general fund.

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