2023 California Code › Health and Safety Code - HSC › DIVISION 107 - HEALTH CARE ACCESS AND INFORMATION › PART 2 - HEALTH POLICY AND PLANNING › CHAPTER 8.5 - Health Care Payments Data Program › Section 127673.

127673. (a) The department shall develop guidance to require data submission from the entities specified in this chapter. The guidance shall include a methodology for the collection, validation, refinement, analysis, comparison, review, and improvement of health care data to be submitted by entities specified in this chapter, including, but not limited to, data from fee-for-service, capitated, integrated delivery system, and other alternative, value-based, payment sources, and any other form of payment to health care providers and suppliers by health plans, health insurers, or other entities described in this chapter.
(b) Notwithstanding any other state law, for the purpose of providing information for inclusion in the system, mandatory submitters shall, and voluntary submitters may, provide health care data, including claim and encounter, member enrollment, provider and supplier information, nonclaims-based payments, premiums, and pharmacy rebate data, and provide all of the following to the department:
(1) Utilization data from the health care service plans’ and insurers’ medical payments or, in the case of entities that do not use payments data, including, but not limited to, integrated delivery systems, encounter data consistent with the core set of data elements for data submission proposed by the All-Payer Claims Database Council, the University of New Hampshire, and the National Association of Health Data Organizations.
(2) Pricing information for health care items, services, and medical and surgical episodes of care gathered from payments for covered health care items and services, including contracted rates, allowed amounts, fee schedules, and other information regarding the cost of care necessary to determine the amounts paid by health plans, health insurers, and public programs to health care providers, suppliers, and other entities. This shall include nonclaims-based payment information such as deductibles, copayments, and coinsurance and other information as needed to determine the total cost of care.
(3) Personally identifiable information that the mandatory submitter is otherwise required to collect, which may include detailed patient identifiers such as first and last name, address, date of birth, gender or gender identity, and Social Security Number or individual taxpayer identification number, in order to support analyses, including, but not limited to, longitudinal, public health impacts, and social determinants of health analyses. Personally identifiable information shall be subject to the privacy protections of this chapter and shall not be publicly available, except as specified in this chapter.
(4) Personal health information that the mandatory submitter is otherwise required to collect, which may include age, gender, gender identity, race, ethnicity, sexual orientation, health status, health condition, and any other data elements that constitute personal health information in this chapter.
(c) For purposes of this chapter, “mandatory submitters” include all of the following:
(1) A health care service plan, including a specialized health care service plan.
(2) An insurer licensed to provide health insurance, as defined in Section 106 of the Insurance Code, including dental-only insurance.
(3) A self-insured plan subject to Section 1349.2, or a state entity, city, county, or other political subdivision of the state, or a public joint labor management trust, that offers self-insured or multiemployer-insured plans that pay for or reimburse any part of the cost of health care services.
(4) The State Department of Health Care Services, for those enrolled in Medi-Cal and other insurance affordability programs, whether enrolled in Medi-Cal managed care, fee-for-service Medi-Cal, or any other payment arrangement.
(d) The department will accept, at its discretion, voluntarily submitted data. For purposes of this chapter, “voluntary submitters” include, but are not limited to:
(1) A self-insured employer that is not subject to Section 1349.2.
(2) A multiemployer self-insured plan that is responsible for paying for health care services provided to beneficiaries.
(3) The trust administrator for a multiemployer self-insured plan.
(4) A provider, as defined in paragraph (2) of subdivision (b) of Section 1367.50, that is a hospital or clinic.
(5) A supplier, as defined in paragraph (3) of subdivision (b) of Section 1367.50, that has an independent scope of practice and submits claims electronically.
(e) On or before December 31, 2021, the department shall adopt emergency regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 to implement this chapter, including on all of the following:
(1) Plan size thresholds for submitters, with consideration given to implementation costs for both the submitter and the department. Thresholds shall not apply to qualified health plans offered by the California Health Benefit Exchange or submitters covering more than a total of 50,000 Californians through both Medicare Advantage plans and the private plans and insurance described in subdivision (b).
(2) Required and exempted lines of business.
(3) Coordination of submission in cases where submitters contract with other entities to administer health care benefits.
(4) The content, file formats, and timelines for data submission, and the methods of data collection. In the development of regulations, the department shall consider national, regional, and other all-payer claims databases’ standards.
(5) Frequency of submission by health plans, insurers, and other mandatory submitters of all core data, including claims, encounters, eligibility, and provider files.
(6) Frequency of submission of nonclaims payment data files.
(f) The initial adoption, by the department, of regulations implementing subdivision (e) shall be deemed to be an emergency and necessary to avoid serious harm to the public peace, health, safety, or general welfare for purposes of Sections 11346.1 and 11349.6 of the Government Code. Any emergency regulation adopted pursuant to this section shall be repealed by operation of law unless the adoption, amendment, or repeal of the regulation is promulgated by the department pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code within two years of the initial adoption of the emergency regulation. After the adoption of the emergency regulation pursuant to subdivision (e), the department may thereafter establish regulations pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code.
(g) (1) A qualified health plan shall submit information either directly or through the California Health Benefit Exchange, as determined by the exchange.
(2) The State Department of Health Care Services shall submit information for those enrolled in Medi-Cal and other insurance affordability programs, whether enrolled in Medi-Cal managed care, fee-for-service Medi-Cal, or any other payment arrangement.
(h) (1) In its initial implementation, the department shall seek data for the three years prior to the effective date of this chapter.
(2) In ongoing administration of the system, the department shall provide data for no less than three years and may seek data for longer time periods to support the intent of this chapter.
(i) To the extent possible, the department shall incorporate into the system any data collected by the department from providers and suppliers, including hospital discharge abstract data records and emergency care data records provided to the department by health facilities and ambulatory surgery data records provided to the department by ambulatory surgical centers.
(j) The department may accept and incorporate into the system any available information that will further the goals of the program.
(k) (1) On or before March 1, 2024, the department shall submit a report to the Legislature that includes all of the following:
(A) Claims data reported by mandatory submitters.
(B) Claims data reported by voluntary submitters.
(C) Data on the covered lives reported, percentage of the population for which the department has data, the number of self-insured plans, providers and suppliers who have voluntarily submitted data, variation of completeness of data across geographic regions, such as the California Health Benefit Exchange’s rating regions, the extent of data submitted on hospitals, physicians, and physician groups, the extent to which mandatory and voluntary submitters are submitting data specified in subdivision (b), frequency of submission of all core data, including claims, encounters, eligibility, and provider files, frequency of submission of nonclaims payment data files, and any other information that is available to determine if hospital and physician data are captured.
(D) A cost estimate if providers and suppliers become mandatory submitters.
(E) The number of data requests from qualified applicants and their data uses.
(2) The department may request the data release committee established pursuant to Section 127673.84 to assist with the report.
(3) The report shall be submitted in compliance with Section 9795 of the Government Code.
(l) Entities regulated pursuant to Article 4.7 (commencing with Section 742.20) of Part 2 of Division 1 of the Insurance Code are exempt from this chapter.
(m) The program performs public health activities described in subdivision (b) of Section 164.512 of Title 45 of the Code of Federal Regulations. The information collected in accordance with this chapter is necessary to carry out projects with public health purposes.
(n) Article 8 (commencing with Section 1798.30) of Chapter 1 of Title 1.8 of Part 4 of Division 3 of the Civil Code shall not apply to records and personal information collected by the system pursuant to this section.
(Amended by Stats. 2021, Ch. 143, Sec. 94. (AB 133) Effective July 27, 2021.)