SPONSOR: |
Sen. Hall-Long & Rep. M. Smith |
|
Sen.
Lavelle, Lopez; Reps. Jaques, J. Johnson, Q. Johnson, B. Short, Bentz,
Heffernan |
DELAWARE STATE SENATE 148th GENERAL ASSEMBLY |
SENATE BILL NO. 238 |
AN ACT TO AMEND TITLE 16 OF THE DELAWARE CODE RELATING TO THE DELAWARE HEALTH INFORMATION NETWORK. |
Section 1. Amend Chapter 103, Title 16 of
the Delaware Code by designating §§ 10301 through 10308 of Title 16 as part of
a new Subchapter I by making deletions as shown by strike through and
insertions as shown by underline as follows:
Chapter 103. Delaware Health Information
Network.
Subchapter I. Purpose, Power and Duties,
and other Governing Provisions of the Delaware Health Information Network.
Section 2. Amend § 10301, Title 16 of the
Delaware Code by making deletions as shown by strike through and insertions as
shown by underline as follows:
§ 10301. Purpose.
(a)
The purpose of this subchapter chapter is to create a public
instrumentality of this State known as the Delaware Health Information Network
(“DHIN”) which is a not-for-profit body both politic and corporate, which shall
have the rights, obligations, privileges privileges, and purpose
to promote the design, implementation, operation operation, and
maintenance of facilities for public and private use of health care information
in the State. The DHIN shall be the
State’s sanctioned provider of health information exchange services.
Section 3. Amend § 10303, Title 16 of the
Delaware Code by making deletions as shown by strike through and insertions as
shown by underline as follows:
§ 10303. Powers and duties.
(a)
In furtherance of the purposes of this subchapter chapter, the
DHIN shall have the following powers and duties:
(18) The DHIN shall make Make annual
reports to the Governor and members of the General Assembly setting forth in
detail its operations and transactions, which shall include annual audits of
the books and accounts of the DHIN made by a firm of independent certified
public accountants mutually agreed to by the Auditor of Accounts and the
Director of the Office of Management and Budget; and
(19) Develop, maintain, and administer the Delaware
Health Care Claims Database under subchapter II of this chapter; and
(19) (20) Perform any and all other
activities in furtherance of the above this section.
Section 4. Amend § 10306, Title 16 of the
Delaware Code by making deletions as shown by strike through and insertions as
shown by underline as follows:
§ 10306. Regulations; resolution of disputes.
(a)
The DHIN is hereby authorized to may promulgate rules and
regulations under and pursuant to subchapter II of Chapter 101 of Title
29 to carry out the objective of this subchapter chapter. All prior
regulations and rules promulgated by the Delaware Health Care Commission in
regards to the DHIN shall remain in full force and effect until amended or
repealed by the DHIN.
(b)
To resolve disputes under this subchapter chapter, or the rules
and regulations promulgated herein under this chapter, among
participants, subscribers subscribers, or the public, the DHIN is
hereby authorized to may hear and determine case decisions under and
pursuant to subchapter III of Chapter 101 of Title 29.
Section 5. Amend Chapter 103, Title 16
of the Delaware Code by making deletions as shown by strike through and
insertions as shown by underline as follows:
Subchapter II. The Delaware Health Care
Claims Database.
§ 10311. The Delaware Health Care
Claims Database—findings; purpose; creation.
(a) The General Assembly finds that:
(1)
The establishment of effective health care data analysis and reporting
initiatives is essential to achieving the “Triple Aim” of the State’s ongoing
health care innovation efforts: improved health, health care quality and
experience, and affordability for all Delawareans.
(2)
The ongoing work of the Delaware Center for Health Innovation to transform the
State’s health care system from a fee-for-service system to a value-based system
that rewards health care providers for quality and efficiency of care is a
worthy effort, and, to that end, the General Assembly supports the
establishment of a health care claims database that would assist in the State’s
efforts to achieve the Triple Aim.
(3)
Claims data is an important component of population health research and analysis,
and that appropriate access to claims data can facilitate the development of
value-based health care purchasing and the study of the prevalence of illness
or injury across the broader population of Delaware and in particular
communities or neighborhoods.
(4) Providers
and other health care entities accepting financial risk for managing the health
care needs of a population, including the State of Delaware as a self-insured
employer, should have access to claims data as necessary to effectively manage
that risk.
(b) The purpose of this subchapter is
to create a centralized health care claims database to enable the State to more
effectively understand utilization across the continuum of health care in
Delaware and achieve the Triple Aim.
(c) The DHIN, assisted by the
Department of Health and Social Services and the Delaware Health Care
Commission as necessary, shall administer a centralized health care claims database,
known as the Delaware Health Care Claims Database.
(d) The
Delaware Health Care Claims Database is created within the DHIN to facilitate
data-driven, evidence-based improvements in access, quality, and cost of health
care and to promote and improve the public health through increased
transparency of accurate health care claims data and information. The DHIN
shall collect and maintain claims data under this subchapter.
§ 10312. Definitions.
For purposes of this chapter, unless
amended, supplemented, or otherwise modified by regulations adopted under this
chapter:
(1) “Claims data” includes required
claims data and any additional health care claims information that a voluntary
reporting entity elects, through entry into an appropriate data submission and use
agreement under this subchapter, to submit to the Delaware Health Care Claims
Database.
(2) “Health care services” means as
defined in § 6403 of Title 18.
(3) “Health insurer” means as defined in § 4004(b) of Title
18.
(4) “Provider” means a hospital or any
health care practitioner licensed, certified, or authorized under State law to
provide health care services and includes hospitals and health care
practitioners participating in group arrangements, including accountable care
organizations, in which the hospital or health care practitioners agree to
assume responsibility for the quality and cost of health care for a designed
group of beneficiaries.
(5) “Pricing information” includes the
pre-adjudicated price charged by a provider or facility to a reporting entity
for health care services, the amount paid by a patient or insured party,
including co-pays and deductibles, and the post-adjudicated price paid by a reporting
entity to a provider for health care services.
(6) “Required claims data” includes the
basic claims information that a mandatory reporting entity is required to
submit to the Delaware Health Care Claims Database by the reporting date,
including all of the following:
a. Basic demographic information,
including the patient’s gender, age, and geographic area of residency.
b. Basic information relating to an
individual episode of care, including the date and time of the patient’s
admission and discharge; the identity of the health care services provider; and
the location and type of facility, such as a hospital, office, or clinic, where
the service was provided.
c. Information describing the nature of
health care services provided to the patient in connection with the encounter,
visit, or service, including diagnosis codes.
d. Health insurance product type, such
as HMO or PPO.
e. Pricing information.
(7) “Reporting date” means a calendar
deadline, to be scheduled on a regularly recurring basis, by which required
claims data must be submitted by a mandatory reporting entity to the Delaware
Health Care Claims Database.
(8) “Mandatory reporting entity” means all
of the following entities, except as prohibited under federal law:
a. The State Employee Benefits
Committee and the Office of Management and Budget, under each entity’s
respective statutory authority to administer the State Group Health Insurance
Program in Chapter 96 of Title 29, and any health insurer, third party administrator,
or other entity that receives or collects charges, contributions, or premiums
for, or adjusts or settles health claims for, any State employee, or their
spouses or dependents, participating in the State Group Health Insurance
Program.
b. The Division of Medicaid and Medical
Assistance, with respect to services provided under programs administered under
Titles XIX and XXI of the Social Security Act.
c. Any health insurer or other entity
that is certified as a qualified health plan on the Delaware Health Insurance Marketplace
for plan year 2017 or any subsequent plan year.
d. Any federal health insurance plan
providing health care services to a resident of this State, including Medicare
and the Federal Employees Health Benefits Plan.
(9) “Third party administrator” means
as defined in § 102 of Title 18.
(10) “Voluntary reporting entity”
includes, except as prohibited under applicable federal law, any of the
following entities, unless such entity is a mandatory reporting entity:
a. Any health insurer.
b. Any third party administrator.
c. Any entity, which is not a health
insurer or third party administrator, when such entity receives or collects
charges, contributions, or premiums for, or adjusts or settles health care
claims for, residents of this State.
§ 10313. Submission of required claims
data by mandatory reporting entities; submission of claims data by voluntary
reporting entities.
(a) Requirements for submission of
required claims data by a mandatory reporting entity.
(1) A
mandatory reporting entity shall submit required claims data to the Delaware
Health Care Claims Database by the reporting date.
(2) The
DHIN, subject to the provisions of this subchapter and regulations promulgated
under this subchapter, shall collect the required claims data from mandatory
reporting entities by the reporting date.
(3) The
DHIN shall, under § 10306 of this title, promulgate a template form for a data
submission and use agreement for the submission of required claims data by a
mandatory reporting entity.
(4) The
DHIN and each mandatory reporting entity shall execute a mutually acceptable
data submission and use agreement. Such agreement shall include procedures for
submission, collection, aggregation, and distribution of claims data and shall
provide for, at a minimum, all of the following:
a. The protection
of patient privacy and data security under provisions of this chapter and state
and federal privacy laws, including the federal Health Insurance Portability
and Accountability Act; Titles XIX and XXI of the Social Security Act; and the
Health Information Technology for Economic and Clinical Health (HITECH) Act,
and all other applicable state and federal laws relating to the privacy and
security of protected health information.
b. The
identification of any claims data, in addition to required claims data, that
the mandatory reporting entity elects to submit to the Delaware Health Care
Claims Database.
c. A
detailed summary of how claims data submitted by the mandatory reporting entity
may be used for geographic, demographic, economic, and peer group comparisons.
d. A
representation and warranty that the DHIN shall, abide to the fullest extent
possible, by nationally recognized data collection standards and methods,
including the standards promulgated by the APCD Council or successor
organization, to establish and maintain the database in a cost-effective manner
and to facilitate uniformity among various health care claims databases of
other states and specification of data fields to be included in the submitted
claims, consistent with such national standards, allowing for exemptions when
submitting entities do not collect the specified data or pay on a per-claim
basis.
(5) Exclusions from required claims data reporting requirement. The
required claims data reporting requirements under this subchapter, and any
rules and regulations promulgated under this chapter, do not apply to required
claims data created for any employee welfare benefit plan or other employee
health plan that is regulated by the Employee Retirement Income Security Act of
1974 (ERISA), 88 Stat. 829, as amended, 29 U. S. C. §1001 et seq., unless
otherwise permitted by federal law or regulation.
(b) Submission of claims data by a
voluntary reporting entity.
(1) The
DHIN shall collect claims data from voluntary reporting entities under the
terms and conditions of the applicable data submission and use agreement.
(2) The
DHIN may promulgate regulations to clarify the types of claims data that may be
submitted by a voluntary reporting entity.
(3) The
DHIN and any voluntary reporting entity that elects to submit claims data to
the Delaware Health Care Claims Database shall execute a mutually acceptable
data submission and use agreement. The DHIN shall publish a template form data
submission and use agreement that includes the required data submission and use
agreement provisions under paragraph (a)(4) of this Section.
(c) Unless modified or supplemented by
regulations promulgated under this chapter, in instances where more than one
entity is involved in the administration of a policy, a health insurer shall be
responsible for submitting the claims data on policies that it has written, and
the third party administrator shall be responsible for submitting claims data
on self-insured plans that it administers.
§ 10314. External and public reporting
of claims data.
(a) The DHIN
shall provide Delaware health care payers, providers, and purchasers with
access to the Delaware Health Care Claims Database for the purpose of
facilitating the design and evaluation of alternative delivery and payment
models, including population health research and provider risk-sharing
arrangements.
(1) Claims data provided to the
Delaware Health Care Claims Database shall only be provided to a requesting
party when a majority of the DHIN Board of Directors, or of a subcommittee established
under the DHIN’s bylaws for purposes of administering the Health Care Claims
Database, determines that the claims data should be provided to the requesting
party to facilitate the purposes of this subchapter.
a. The determination under paragraph (a)(1)
of this section shall be reduced to writing and provided to the requesting party.
b. The determination under paragraph
(a)(1) of this section shall be final and not subject to appeal, and there is
no private right of action to a requesting party against the DHIN or any other
party to enforce the requirements of this section.
(2) The DHIN shall, in consultation
with the Delaware Health Care Commission, promulgate rules and regulations
regarding the appropriate form and content of an application to receive claims
data, providing examples of requests for claims data that will generally be
deemed consistent with the purposes of this subchapter.
(b) Claims data
provided to a requesting party under this section shall be provided under the
DHIN’s existing confidentiality and data security protocols and in compliance
with all applicable state and federal laws relating to the privacy and security
of protected health information, including compliance, to the fullest extent
practicable consistent with the purposes under this subchapter, with guidance
found in Statement 6 of the Department of Justice and Federal Trade Commission
Enforcement Policy regarding the exchange of price and cost information. Individually
identifiable patient health information shall be maintained by providers and
purchasers in accordance with all applicable state and federal laws relating to
the confidentiality and security of protected health information and any
additional privacy and security requirements set forth in regulations promulgated
under this chapter.
(c) The
Office of Management and Budget, State Employee Benefits Committee, Division of
Public Health, and Division of Medicaid and Medical Assistance shall have
access to all claims data reported by the Delaware Health Care Claims Database
under this subchapter at no cost for the purposes of public health improvement
research and activities. These entities
are authorized to enter into appropriate agreements with the DHIN to allow the
Delaware Health Care Claims Database to perform data warehousing and analytics
functions that have been performed pursuant to the existing statutory authority
of the Office of Management and Budget, the State Employee Benefits Committee,
or the Department of Health and Social Services.
(d) The DHIN
may promulgate regulations to make available to the public certain
non-individually identifiable data extracts and analyses, as the DHIN
determines is consistent with, and necessary to, achieve the goals and policies
of this subchapter. Prior to the release of such data extracts and analyses,
the same processes identified in subsection (e) of this section shall be
completed.
(e) The DHIN
shall promulgate regulations to notify a mandatory reporting entity or
voluntary reporting entity when claims data submitted by the mandatory
reporting entity or voluntary reporting entity may be released for a purpose permitted
under this subchapter and provide the mandatory reporting entity or voluntary
reporting entity with an opportunity to comment on the data release request
prior to its release. Any comments received from a mandatory reporting entity
or voluntary reporting entity during the comment period shall be reviewed,
considered, and responded to by DHIN prior to the data release. If a party
requesting the release of data is identified by a mandatory reporting entity or
voluntary reporting entity as a potential competitor of the reporting entity,
the DHIN shall limit disclosure of any pricing information that includes
post-adjudicated claims data, to the fullest extent practicable and consistent
with the purposes of this subchapter, to a summary format that allows for
analysis without revealing contracted pricing information.
(f) The DHIN
shall promulgate regulations to ensure confidentiality, privacy, and security
protections of health care data and all other information collected, stored, or
released by DHIN, subject to all applicable state and federal health care
privacy, confidentiality, and data security laws.
§ 10315. Funding of Delaware Health
Care Claims Database.
(a) The DHIN
may not require any mandatory reporting entity, voluntary reporting entity, or provider
to pay any cost or fee to submit or verify the accuracy of claims data or
otherwise to enable the operation of the Delaware Health Care Claims Database
with respect to required claims data submissions.
(b) The DHIN
may enter contracts under § 10303(11) of this title with individuals and
entities who voluntarily subscribe to access the database.
(c) The
DHIN, with the assistance of the Department of Health and Social Services,
shall develop short-term and long-term funding strategies for the creation and
operation of the Delaware Health Care Claims Database that may include public
and private grant funding, subscriptions for access to data reports, access
fees, and revenue for specific data projects, subject to the limitations of
this section.
Section 6. Effective date. This Act
shall take effect on January 1, 2017.
Section 7. Transitional provision. A
mandatory reporting entity may not be required to submit claims data to the
Delaware Health Care Claims Database until at least 180 days after the DHIN
promulgates final regulations setting forth the specific format and other
requirements for claims data submission, including the form, medium, and
content of the required data elements.
Section 8. Severability. If any
provision of this Act, or the application of this Act to any person, thing, or
circumstances is determined by a Court to be invalid, such invalidity shall not
affect the provisions or application of this Act that can be given effect
without the invalid provisions or application, and to this end the provisions
of this Act are declared to be severable.
SYNOPSIS
This Act establishes a Delaware
Health Care Claims Database to be administered and operated within the
existing framework of the Delaware Health Information Network. Sixteen states
have enacted legislation to create health care claims databases which are
generally referred to as an “All Payer Claims Database” or a “Multi Payer
Claims Database”. In short, this Act will help Delaware
answer the following questions: (1) How much does Delaware spend on health care? (2) How much does a service cost at a specific facility? (3) How have health care prices changed over time? (4) Are Delaware’s efforts to establish value-based alternatives to
the traditional “fee for service” health care system effective? The Delaware Health Care Claims
Database will help advance the ongoing work to transform the State’s health
care system from a fee-for-service system to a value-based system that
rewards health care providers for quality and efficiency of care. To complete
that transformation, health care providers and other health care entities
accepting financial risk for a population must have an appropriate level of
access to health care claims data—particularly data that provides some
transparency into health care pricing. Centralized and standardized access to
claims data is also critical to maximizing population health initiatives,
including the study of occurrences of injury or illness across the continuum
of care in Delaware or in specific neighborhoods. This Act sets forth the
basic structure and parameters of the Health Care Claims Database, subject to
further guidance to be set forth in rules and regulations to be promulgated
by the DHIN, in continued consultation with the Department of Health and
Social Services, the Health Care Commission, and stakeholders in the health
care community. Specific Requirements for Claims Data
Reporting This Act requires certain types of
claims data defined as “required claims data” to be reported by the entities
specified as “mandatory reporting entities” in the Act. The Act only mandates
reporting of claims data for the Medicaid Program, the State Group Health Insurance
Program, and any qualified health plan in the Delaware Health Insurance
Marketplace for plan year 2017 and any subsequent plan year. This Act also
authorizes health insurers and providers who are not required to participate
in the Health Care Claims Database to voluntarily report “claims data”
pursuant to appropriate data submission and use agreements between the
voluntary reporting entity and the DHIN. In both mandatory and voluntary
claims data reporting, the Delaware Health Care Claims Database will maintain
the privacy and confidentiality of individually identifiable health
information in accordance with all federal and state privacy and security
laws, including compliance with guidance found in Statement 6 of the
Department of Justice and Federal Trade Commission Enforcement Policy
regarding the exchange of price and cost information, and with appropriate
limits on the disclosure of potentially proprietary contracted unit price
information. In order to comply with a recent decision of the United States
Supreme Court, the mandatory reporting requirements of this Act do not apply
to self-insured commercial health plans that are regulated pursuant to the
Employee Retirement Income Security Act of 1974 (ERISA). The Delaware Health Care Claims Database will be administered and operated by the DHIN Board of Directors, whose membership consists of a broad coalition of health care stakeholder representatives, including representatives of hospitals, physicians, providers, insurers, the business community, and government officials. This Act authorizes the DHIN Board, or a subcommittee established by the DHIN Board to administer the APCD, to review a request for claims data to determine if the requesting party or entity should have access to the requested claims data for a legitimate purpose in accordance with the goals of the statute. The determination by the DHIN Board shall be made in accordance with its bylaws, including those pertaining to conflict of interest recusal, and is not subject to appeal or to any other private right of action. This Act is revenue-neutral; it will be funded with grant money and other independent funding sources to be identified by the DHIN, in accordance with the DHIN’s existing statutory authority. |
Author: Senator Hall-Long