CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 929

Author:(Luz Rivas)

As Amended Ver:August 30, 2019

Majority vote

SUMMARY:

Requires the board governing California's Health Benefits Exchange (Exchange or Covered California), to make public on the Exchange's Internet Website, plan-specific data on cost reduction efforts, quality improvements, and disparity reductions, as specified.

The Senate Amendments:

1. Make findings and declarations to ensure that Covered California is able to obtain from health plans and insurers information on cost, quality, and disparities useful in evaluating the impact of Covered California on the health delivery system and health coverage in California, including information from qualified health plan (QHP) contracts since the inception of Covered California.
2. Require comparison among QHPs to contribute to the understanding of the data and progress in achieving goals established by the Exchange through QHP contracts.
3. Require data to be disclosed pursuant to state and federal privacy laws, including the Confidentiality of Medical Information Act and the federal Health Insurance Portability and Accountability Act.
4. Prohibit records that reveal contracted rates paid by QHPs to providers and enrollee coinsurance that can be used to determine contracted rates paid by plans to providers from being subject to public disclosure.
5. Require QHPs to provide enrollee, encounter, and financial data, as specified. Requires health plans or insurers contracted with the Exchange to disclose quality and disparity data and information of the enrollees and insureds of the carrier in the individual and small group markets, but not large group, Medi-Cal, or Medicare, as specified.
6. Require the Covered California board to engage in health oversight activities relating to Exchange operations, as specified.
7. Require specified information from being subject to disclosure under the California Public Records Act, such as the deliberative process of the negotiations with entities contracting or seeking to contract with the Exchange and records that reveal contracted rates paid by QHPs to providers. Make findings and declarations that in order to protect confidential and proprietary information submitted to the Exchange, it is necessary for that information to remain confidential.

COMMENTS:

Attachment 7 to Qualified Health Plan contracts. QHP contracts sold through Covered California include an "Attachment 7," which specifically references Covered California's "Triple Aim" framework that seeks to lower costs, improve quality, and improve health outcomes, while ensuring a good choice of plans for consumers. As Covered California assesses the performance of its QHP issuers for the contracting period beginning in 2017, Covered California plans to refresh its quality improvement and delivery system reform standards and requirements and will engage in efforts that will be used to engage health plans, providers, advocates and other stakeholders as it proposes revisions to contractual terms that take effect in plan year 2021. Specifically by contract, the health plans will agree to work with Covered California to develop and implement policies and practices that will promote the Triple Aim, affecting not just the enrollees of Covered California but the health plan's entire California membership.

According to the Author:

This bill ensures Covered California has the authority to collect the data it needs to fully evaluate how a health plan is delivering care and to publish that data by health plan. In doing so, this bill helps to provide more information to the public and to patients so that patients are more educated about the best plan options for their health care needs. This bill would allow for the disaggregation of critical data in order to gather information about sub-populations and reveal trends and patterns in racial and ethnic health disparities and inequities that can be masked by larger, aggregated data. This bill would help in health disparity reduction because with high-quality data we can identify and monitor immediate health system problems and underlying social determinants of health.

Arguments in Support:

Health Access California (HAC), a cosponsor of this bill, writes that Covered California is uniquely positioned to use its authority as an active purchaser to advance health equity and delivery system improvements. HAC states that public reporting on plan-specific contract compliance with requirements on cost, quality, and disparity has been Covered California's goal. However, the first set of data made publicly available during the January 2019 Covered California Board meeting did not show plan specific results. Furthermore, HAC contends that health disparities and inequities can only be eliminated if there is high quality data that can be used to identify and monitor immediate health systems problems and underlying social determinants. This bill ensures that the Covered California reports on plan-specific data, which is critical in advancing health system transformation and health equity. The California Pan-Ethnic Health Network (CPEHN), a co-sponsor of this bill, writes that the Covered California data showed that quality improvement has been uneven with large gaps between low and high performing plans. CPEHN states as an example the 40-point spread between the lowest and highest performing plans on certain metrics like controlling high blood pressure or colorectal cancer screenings. CPEHN states that the ability to view disaggregated data is crucial in order to identify where there may be shortfalls in access to quality, equitable and affordable care and how to best address those issues.

Arguments in Opposition:

The California Association of Health Plans (CAHP) contends this bill requires health plans to provide personal health information to Covered California for individuals that purchase health coverage through the individual and small group market both on and off the Exchange market. This bill does not require personal identification information to be removed from the vast and detailed health information that is transferred to Covered California, which raises several patient privacy concerns for health plan enrollees. The information that will be transferred to Covered California under this bill is substantial and much of it is proprietary. According to CAHP, while there is an attempt in this bill to limit the public exposure of proprietary financial data, this bill still requires the submission of sensitive data, including contracted provider payment rates. The potential exposure of this information will lead to unintended consequences in the marketplace.

FISCAL COMMENTS:

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Jones-Sawyer, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

ASSEMBLY FLOOR: 77-0-3

YES: Aguiar-Curry, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, O'Donnell, Obernolte, Patterson, Petrie‑Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

ABS, ABST OR NV: Arambula, Chen, Salas

SENATE FLOOR: 40-0-0

YES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Stern, Stone, Umberg, Wieckowski, Wiener, Wilk

UPDATED:

VERSION: August 30, 2019

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0002020

 THIRD READING  

Bill No: AB 929

Author: Luz Rivas (D)

Amended: 8/30/19 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 7-0, 6/26/19

AYES: Pan, Lena Gonzalez, Hurtado, Leyva, Mitchell, Monning, Rubio

NO VOTE RECORDED: Stone, Grove

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 77-0, 5/6/19 - See last page for vote

SUBJECT: California Health Benefit Exchange: data collection

SOURCE: California Pan-Ethnic Health Network

Health Access California

DIGEST:

This bill requires a Covered California qualified health plan to report on cost reduction efforts, quality improvements, or disparity reductions. This bill requires Covered California to post annually on its Web site plan-specific data and information on cost reduction efforts, quality improvements, and disparity reductions in a manner that protects the personal information of enrollees.

Senate Floor Amendments of 8/30/19:

1. Add findings and declarations and legislative intent.
2. Require that comparison among qualified health plans (QHPs) contribute to the understanding of the data and progress in achieving goals established by Covered California through QHP contracts.
3. Prohibit the disclosure of records that reveal contracted rates paid by QHPs to providers and enrollees even if aggregated and deidentified.
4. Delete a provision that prohibits a QHP from contracting with a provider, delegated entity, pharmacy benefit manager or other entity unless data is provided consistent with this bill.
5. Clarify that a QHP contracted with Covered California must disclose, at the request of Covered California, quality and disparity data and information for all enrollees and insureds of the carrier in the individual and small group markets, but not the large group market, Medi-Cal or Medicare.

ANALYSIS:

Existing law:

1. Establishes, under the federal Affordable Care Act (ACA), an advanced and refundable tax credit for qualified individuals who purchase a QHP through a health benefit exchange and cost sharing reductions for qualified individuals who choose specified plans. [26 U.S.C. 36B §1402 and 42 U.S.C. §18071]
2. Establishes Covered California as an independent entity in state government not affiliated with any state agency or department, governed by a five member board as California’s health benefit exchange. Requires the Covered California Executive Board (board) to establish and use a competitive process to select participating QHPs and other contractors. [GC §100500 -100522]
3. Requires Covered California to require QHPs to make available to the public and submit to the board, the United States Secretary of Health and Human Services, and the Insurance Commissioner or the Department of Managed Health Care, as applicable, accurate and timely disclosure of specified information. [GOV §100502]
4. Establishes, under federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which among various provisions, mandates industry-wide standards for health care information on electronic billing and other processes; and, requires the protection and confidential handling of protected health information. [42 U.S.C. §300gg, 29 U.S.C. §1181, et. seq., and 42 U.S.C. §1320d, et. seq.]
5. Defines, under HIPAA regulation, health oversight agency as an agency or authority of the United States, a state, a territory, a political subdivision of a state or territory, or an Indian tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted authority, that is authorized by law to oversee the health care system (whether public or private) or government programs in which health information is necessary to determine eligibility or compliance, or to enforce civil rights laws for which health information is relevant. [45 C.F.R. Sec. 164.501]

This bill:

1. Finds and declares that since the enactment of legislation that created Covered California, Covered California has used its authority to negotiate QHP contracts with health plans and health insurers that have moderated rate increases for individual consumers, while holding health plans and insurers accountable for improving the quality of care and reducing health disparities.
2. States legislative intent in enacting this bill that Covered California is able to obtain from health plans and insurers information on cost, quality, and disparities useful in evaluating the impact of Covered California on the health delivery system and health coverage in California, including information from QHP contracts since the inception of Covered California.
3. Requires Covered California, if it requires, or has previously required in its contracts, a QHP to report on cost reduction efforts, quality improvements, or disparity reductions, to make public, on its website, plan-specific data and information on cost reduction efforts, quality improvements, and disparity reductions.
4. Requires the data and information to be posted in a way that demonstrates the compliance and performance of a QHP with respect to cost reduction efforts, quality improvement, or disparity reduction reporting, but protects the personal information of an enrollee pursuant to the Confidentiality of Medical Information Act and the federal Health Insurance Portability and Accountability Act of 1996.
5. Requires Covered California to post the data no less than annually. Requires that comparison among QHPs contribute to the understanding of the data and progress in achieving goals established by Covered California through QHP contracts.
6. Requires a QHP to provide data on enrollees to Covered California in a form, manner, and frequency specified by Covered California. Requires the data to be disclosed by Covered California in a manner that protects the personal information of an enrollee, pursuant to state and federal privacy laws.
7. Prohibits records that reveal contracted rates paid by QHPs to providers and enrollee coinsurance that can be used to determine contracted rates paid to providers from being subject to public disclosure.
8. Requires a QHP to provide to Covered California information that Covered California identifies as necessary to conduct its duties or exercise its oversight powers and furnish the information in the form, manner and frequency specified by Covered California.
9. Requires a QHP to provide enrollee data, and other information on quality measures, including contract compliance with measures that affect individual and population health, as improvements in care coordination and patient safety, in a manner that allows for an analysis by demographic subpopulations. Requires a QHP to provide encounter data, and performance improvement strategies, payment methods, and other information necessary to monitor adherence to contract provisions designed to improve health equity and reduce health disparities on an individual and population health basis.
10. Requires a QHP to also provide financial data and information, including cost detail, claims data, encounter data, and payment methods to evaluate cost and utilization experience for enrollees. Requires enrollment data and information to include demographic, coverage, premium, product, network, and benefit design detail for each enrollee.
11. Requires a health plan or health insurer contracted with Covered California to offer a QHP, to disclose to Covered California the following information:
    1. Nongrandfathered individual market products, whether offered through Covered California or otherwise; and,
    2. Nongrandfathered small group products, whether offered through Covered California or otherwise.
12. Requires a health plan or health insurer contracted with Covered California to offer a QHP to also disclose to Covered California:
    1. Quality and disparity measures, data, and information for all of the enrollees and insureds of the carrier in all market segments, including individual, small group, but not including large group, Medi-Cal, Medicare; and,
    2. Data and information required by this bill for each of the plan years in which the QHP is or has been contracted with Covered California, including prior years.
13. Requires Covered California to engage in health oversight activities relating to its operations, including, but not limited to, audits, investigations, inspections, evaluations, analyses, data collection through routine reporting, and any other activities for oversight of Covered California and the individuals or entities regulated in connection with Covered California, including QHPs. Permits Covered California to exercise its authority directly or through its designees, and requires Covered California to act as a health oversight agency, as defined, in performing those duties.
14. Exempts, from disclosure under the California Public Records Act, records that reveal cost detail, claims data, encounter data, information about payment methods, contracted rates paid by QHPs to providers, and enrollee coinsurance or other cost sharing that can be used to determine contracted rates paid by plans to providers.
15. Finds and declares that the limitation on the public’s right of access under 13) above is necessary to protect confidential and proprietary information submitted to Covered California.

Comments

1. Author’s statement. According to the author, the process to eliminating health disparities and inequities starts with high quality data. This bill ensures Covered California has the authority to collect the data it needs to fully evaluate how a health plan is delivering care and to publish that data by health plan. In doing so, this bill helps to provide more information to the public and to patients so that patients are more educated about the best plan options for their health care needs. This bill allows for the disaggregation of critical data in order to gather information about sub-populations and reveal trends and patterns in racial and ethnic health disparities and inequities that can be masked by larger, aggregated data. This bill helps in health disparity reduction because with high-quality data we can identify and monitor immediate health system problems and underlying social determinants of health.
2. Covered California. Covered California is California's health benefit exchange where individuals and small businesses can purchase ACA compliant health insurance. In the QHP contracts, Covered California sets forth specific requirements related to improving quality, lowering costs, promoting better health and reducing health care disparities, both for the Covered California enrolled population and more broadly in the health care system. Covered California’s quality ratings show how QHPs compare on helping members get the right medical care, and on member-reported experiences of care and services. Covered California has been reporting quality ratings since it began. Several Covered California plans earned very high or top ratings, and half of the plans are rated three-star or higher on members’ getting the right medical care. But the performance standards set by the highest-performing plans indicate that some plans can do better. Covered California is working with health insurance companies to improve the quality and overall value of the coverage they offer. Key efforts include seeing that every member is matched to a primary care clinician; connecting the sickest enrollees with health care organizations that have demonstrated superior-quality care; identifying and eliminating gaps in good care across populations of people who differ by ethnicity, race or income; and advancing health care technology to improve care and eliminate unsafe practices.
3. Data collection limitations. Covered California actively negotiates with QHPs. Since the design of its first QHP contracts, Covered California has required QHPs to submit data regarding health care utilization and cost. In 2015, Covered California launched the Healthcare Evidence Initiative (HEI) under which QHPs are required to submit data regarding claims and encounters; enrollment; capitation; providers; and, plans and products. Under the HEI, QHPs submit the data to Covered California’s analytics vendor. However, QHPs do not submit complete data for analysis, including full financial information. Some QHPs do not submit data claimed to be protected by confidentiality clauses in their own agreements with providers. Because data is aggregated, Covered California is unable to determine how much the average enrollee spends out-of-pocket on Bronze vs. Silver plans or how many members reached their deductibles and in which plans. QHPs refused to submit detailed member data based on Covered California’s lack of authority in state law, so Covered California agreed to accept indirect access to data from the plans to the data aggregator as a starting point. As a result, Covered California is unable to effectively meet its commitment to be a data-drive negotiator for the benefit of consumers.
4. HIPAA. HIPAA governs how covered entities protect and secure protected health information. HIPAA also regulates the circumstances in which covered entities are permitted, but not required, to use and disclose personal health information to others for certain activities without first obtaining an individual’s authorization, including for health oversight activities. A fact sheet jointly published by the Office of the National Coordinator for Health Information Technology and the U.S. Department of Health and Human Services Office for Civil Rights, indicates that plans may disclose personal health information to a state health insurance exchange and its contractor, if the exchange granted oversight authority to contractor, for health oversight activities. In the fact sheet example, the exchange has oversight authority under state law over market conduct, operates a quality rating system, and requests that participating plans submit certain medical claims data to calculate ratings for providers.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

SUPPORT: (Verified 9/3/19)

California Pan-Ethnic Health Network (co-source)

Health Access California (co-source)

ACCESS Women’s Health Justice

Alliance of Californians for Community Empowerment Action

American Federation of State, County and Municipal Employees, AFL-CIO

California Alliance for Retired Americans

California Chronic Care Coalition

California Voices for Progress

City of Hope

Having Our Say!

Hispanas Organized for Political Equality

Korean Community Center of the East Bay

Latino Coalition for a Healthy California

Los Angeles Trust for Children’s Health

National Health Law Program

San Francisco AIDS Foundation

San Francisco Senior and Disability Action

Service Employees International Union, California State Council

Services, Immigrant Rights & Education Network

Small Business Majority

Western Center on Law and Poverty

OPPOSITION: (Verified 9/3/19)

California Association of Health Plans

ARGUMENTS IN SUPPORT: Health Access California writes that while public reporting on plan-specific contract compliance with requirements on cost, quality, and disparity has been the stated goal of Covered California, the first set of data made publicly available this year did not show plan-specific results. The aggregated data showed positive results and findings, including that nine out of eleven plans increased rates of self-identified reporting on race and ethnicity, ten out of eleven offer telehealth, and six out of eleven implemented valued based payments for hospitals. However, Covered California did not provide health plan specific data so it is unknown if the eleventh plan is always the same plan. Health plans are already required to report and submit data to Covered California on a variety of activities, yet plans have asserted that the data on Covered California enrollees is a trade secret and proprietary. The California Pan-Ethnic Health Network writes that the ability to view disaggregated data is crucial in order to identify where there may be shortfalls in access to quality, equitable and affordable care and how best to address those issues. Health disparities and inequities can only be eliminated if there is high-quality data available to identify and monitor problems within health care delivery systems.

ARGUMENTS IN OPPOSITION: The California Association of Health Plans (CAHP) writes that this bill increases administrative costs on health plans and raises several policy concerns. Converting Covered California into a health oversight agency changes its existing relationship with QHPs and adds unnecessary duplication and regulatory overlap to the health care system. The information that will be transferred to Covered California is substantial and much of it proprietary, including provider payment rates, and not all of the data that QHPs consider proprietary is protected from public disclosure. As such, in geographic areas where there is only one or two plans, a competitor or new form of health plan could extract this data for their own competitive purposes. This bill also requires the disclosure and public exposure off-exchange data and information related to markets that are outside the purview of Covered California. CAHP feels there is no clear justification for why Covered California needs this data or how they will use it. CAHP requests this provision be removed from this bill.

ASSEMBLY FLOOR: 77-0, 5/6/19

AYES: Aguiar-Curry, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

NO VOTE RECORDED: Arambula, Chen, Salas

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

9/3/19 16:41:59

**** END ****

 THIRD READING  

Bill No: AB 929

Author: Luz Rivas (D)

Amended: 7/2/19 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 7-0, 6/26/19

AYES: Pan, Lena Gonzalez, Hurtado, Leyva, Mitchell, Monning, Rubio

NO VOTE RECORDED: Stone, Grove

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 77-0, 5/6/19 - See last page for vote

SUBJECT: California Health Benefit Exchange: data collection

SOURCE: California Pan-Ethnic Health Network

Health Access California

DIGEST:

This bill requires a Covered California qualified health plan to report on cost reduction efforts, quality improvements, or disparity reductions. This bill requires Covered California to post annually on its Web site plan-specific data and information on cost reduction efforts, quality improvements, and disparity reductions in a manner that protects the personal information of enrollees.

ANALYSIS:

Existing law:

1. Establishes, under the federal Affordable Care Act (ACA), an advanced and refundable tax credit for qualified individuals who purchase a qualified health plan (QHP) through a health benefit exchange and cost sharing reductions for qualified individuals who choose specified plans. [26 U.S.C. 36B §1402 and 42 U.S.C. §18071]
2. Establishes Covered California as an independent entity in state government not affiliated with any state agency or department, governed by a five member board as California’s health benefit exchange. Requires the Covered California Executive Board (board) to establish and use a competitive process to select participating QHPs and other contractors. [GC §100500 -100522]
3. Requires Covered California to require QHPs to make available to the public and submit to the board, the United States Secretary of Health and Human Services, and the Insurance Commissioner or the Department of Managed Health Care, as applicable, accurate and timely disclosure of specified information including but not limited to:
   1. Claims payment policies and practices;
   2. Periodic financial disclosures;
   3. Data on enrollment;
   4. Data on disenrollment;
   5. Data on the number of claims that are denied;
   6. Data on rating practices; and,
   7. Information on cost sharing and payments with respect to any out-of-network coverage. [GOV §100502]
4. Establishes, under federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which among various provisions, mandates industry-wide standards for health care information on electronic billing and other processes; and, requires the protection and confidential handling of protected health information. [42 U.S.C. §300gg, 29 U.S.C. §1181, et. seq., and 42 U.S.C. §1320d, et. seq.]
5. Defines, under HIPAA regulation, health oversight agency as an agency or authority of the United States, a state, a territory, a political subdivision of a state or territory, or an Indian tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted authority, that is authorized by law to oversee the health care system (whether public or private) or government programs in which health information is necessary to determine eligibility or compliance, or to enforce civil rights laws for which health information is relevant. [45 C.F.R. Sec. 164.501]

This bill:

1. Requires Covered California, if it requires, or has previously required in its contracts, a QHP to report on cost reduction efforts, quality improvements, or disparity reductions, to make public, on its website, plan-specific data and information on cost reduction efforts, quality improvements, and disparity reductions.
2. Requires the data and information to be posted in a way that demonstrates the compliance and performance of a QHP with respect to cost reduction efforts, quality improvement, or disparity reduction reporting, but protects the personal information of an enrollee. Requires Covered California to post the data no less than annually.
3. Requires a QHP to provide data on enrollees to Covered California in a form, manner, and frequency specified by Covered California. Requires the data to be disclosed by Covered California in a manner that protects the personal information of an enrollee, pursuant to state and federal privacy laws.
4. Prohibits records that reveal contracted rates paid by QHPs to providers and enrollee coinsurance that can be used to determine contracted rates paid to providers from being subject to public disclosure unless aggregated and deidentified.
5. Requires a QHP to provide to Covered California information that Covered California identifies as necessary to conduct its duties or exercise its oversight powers and furnish the information in the form, manner and frequency specified by Covered California.
6. Requires a QHP to provide enrollee data, and other information on quality measures, including contract compliance with measures that affect individual and population health, as improvements in care coordination and patient safety, in a manner that allows for an analysis by demographic subpopulations. Requires a QHP to provide encounter data, and performance improvement strategies, payment methods, and other information necessary to monitor adherence to contract provisions designed to improve health equity and reduce health disparities on an individual and population health basis.
7. Requires a QHP to also provide financial data and information, including cost detail, claims data, encounter data, and payment methods to evaluate cost and utilization experience for enrollees. Requires enrollment data and information to include demographic, coverage, premium, product, network, and benefit design detail for each enrollee.
8. Prohibits, on or after January 1, 2020, a QHP from amending, renewing, or entering into a contract with a provider, delegated entity, pharmacy benefit manager, or other entity used to provide covered benefits unless the contract requires data and information to be provided consistent with this bill.
9. Requires a health plan or health insurer contracted with Covered California to offer a QHP, to disclose to Covered California the following information:
   1. Nongrandfathered individual market products, whether offered through Covered California or otherwise; and,
   2. Nongrandfathered small group products, whether offered through Covered California or otherwise.
10. Requires a health plan or health insurer contracted with Covered California to offer a QHP to also disclose to Covered California:
    1. Quality and disparity measures, data, and information for all of the enrollees and insureds of the carrier in all market segments, including individual, small group, large group, and Medi-Cal, but not including Medicare; and,
    2. Data and information required by this bill for each of the plan years in which the QHP is or has been contracted with Covered California, including prior years.
11. Defines “disparity reduction” to mean a reduction in variation in disease occurrence, including communicable diseases and chronic conditions, as well as health outcomes between populations groups by age, geographic area, primary language, race, ethnicity, sex, gender identity, sexual orientation, and disability status.
12. Defines “financial data and information” to include, but not be limited to, cost detail, including enrollee cost sharing, allowed amounts, fee schedules, and fee-for-service equivalent amounts, and defines “personal information” as having the same meaning as set forth in existing law.
13. Requires Covered California to engage in health oversight activities relating to its operations, including, but not limited to, audits, investigations, inspections, evaluations, analyses, data collection through routine reporting, and any other activities for oversight of Covered California and the individuals or entities regulated in connection with Covered California, including QHPs. Permits Covered California to exercise its authority directly or through its designees, and requires Covered California to act as a health oversight agency, as defined, in performing those duties.
14. Exempts, from disclosure under the California Public Records Act, records that reveal cost detail, claims data, encounter data, information about payment methods, contracted rates paid by QHPs to providers, and enrollee coinsurance or other cost sharing that can be used to determine contracted rates paid by plans to providers.
15. Finds and declares that the limitation on the public’s right of access under 14) above is necessary to protect confidential and proprietary information submitted to Covered California.

Comments

1. Author’s statement. According to the author, the process to eliminating health disparities and inequities starts with high quality data. This bill ensures Covered California has the authority to collect the data it needs to fully evaluate how a health plan is delivering care and to publish that data by health plan. In doing so, this bill helps to provide more information to the public and to patients so that patients are more educated about the best plan options for their health care needs. This bill allows for the disaggregation of critical data in order to gather information about sub-populations and reveal trends and patterns in racial and ethnic health disparities and inequities that can be masked by larger, aggregated data. This bill helps in health disparity reduction because with high-quality data we can identify and monitor immediate health system problems and underlying social determinants of health.
2. Covered California. Covered California is California's health benefit exchange where individuals and small businesses can purchase ACA compliant health insurance. In the QHP contracts, Covered California sets forth specific requirements related to improving quality, lowering costs, promoting better health and reducing health care disparities, both for the Covered California enrolled population and more broadly in the health care system. Covered California’s quality ratings show how QHPs compare on helping members get the right medical care, and on member-reported experiences of care and services. Covered California has been reporting quality ratings since it began. Several Covered California plans earned very high or top ratings, and half of the plans are rated three-star or higher on members’ getting the right medical care. But the performance standards set by the highest-performing plans indicate that some plans can do better. Covered California is working with health insurance companies to improve the quality and overall value of the coverage they offer. Key efforts include seeing that every member is matched to a primary care clinician; connecting the sickest enrollees with health care organizations that have demonstrated superior-quality care; identifying and eliminating gaps in good care across populations of people who differ by ethnicity, race or income; and advancing health care technology to improve care and eliminate unsafe practices.
3. Data collection limitations. Covered California actively negotiates with QHPs. Since the design of its first QHP contracts, Covered California has required QHPs to submit data regarding health care utilization and cost. In 2015, Covered California launched the Healthcare Evidence Initiative (HEI) under which QHPs are required to submit data regarding claims and encounters; enrollment; capitation; providers; and, plans and products. Under the HEI, QHPs submit the data to Covered California’s analytics vendor. However, QHPs do not submit complete data for analysis, including full financial information. Some QHPs do not submit data claimed to be protected by confidentiality clauses in their own agreements with providers. Because data is aggregated, Covered California is unable to determine how much the average enrollee spends out-of-pocket on Bronze vs. Silver plans or how many members reached their deductibles and in which plans. QHPs refused to submit detailed member data based on Covered California’s lack of authority in state law, so Covered California agreed to accept indirect access to data from the plans to the data aggregator as a starting point. As a result, Covered California is unable to effectively meet its commitment to be a data-drive negotiator for the benefit of consumers.
4. HIPAA. HIPAA governs how covered entities protect and secure protected health information. HIPAA also regulates the circumstances in which covered entities are permitted, but not required, to use and disclose personal health information to others for certain activities without first obtaining an individual’s authorization, including for health oversight activities. A fact sheet jointly published by the Office of the National Coordinator for Health Information Technology and the U.S. Department of Health and Human Services Office for Civil Rights, indicates that plans may disclose personal health information to a state health insurance exchange and its contractor, if the exchange granted oversight authority to contractor, for health oversight activities. In the fact sheet example, the exchange has oversight authority under state law over market conduct, operates a quality rating system, and requests that participating plans submit certain medical claims data to calculate ratings for providers.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: No

SUPPORT: (Verified 8/12/19)

California Pan-Ethnic Health Network (co-source)

Health Access California (co-source)

ACCESS Women’s Health Justice

Alliance of Californians for Community Empowerment Action

American Federation of State, County and Municipal Employees, AFL-CIO

California Alliance for Retired Americans

California Chronic Care Coalition

California Voices for Progress

City of Hope

Having Our Say!

Hispanas Organized for Political Equality

Korean Community Center of the East Bay

Latino Coalition for a Healthy California

Los Angeles Trust for Children’s Health

National Health Law Program

San Francisco AIDS Foundation

San Francisco Senior and Disability Action

Service Employees International Union, California State Council

Services, Immigrant Rights & Education Network

Small Business Majority

Western Center on Law and Poverty

OPPOSITION: (Verified 8/12/19)

California Association of Health Plans

ARGUMENTS IN SUPPORT: Health Access California writes that while public reporting on plan-specific contract compliance with requirements on cost, quality, and disparity has been the stated goal of Covered California, the first set of data made publicly available this year did not show plan-specific results. The aggregated data showed positive results and findings, including that nine out of eleven plans increased rates of self-identified reporting on race and ethnicity, ten out of eleven offer telehealth, and six out of eleven implemented valued based payments for hospitals. However, Covered California did not provide health plan specific data so it is unknown if the eleventh plan is always the same plan. Health plans are already required to report and submit data to Covered California on a variety of activities, yet plans have asserted that the data on Covered California enrollees is a trade secret and proprietary. The California Pan-Ethnic Health Network writes that the ability to view disaggregated data is crucial in order to identify where there may be shortfalls in access to quality, equitable and affordable care and how best to address those issues. Health disparities and inequities can only be eliminated if there is high-quality data available to identify and monitor problems within health care delivery systems.

ARGUMENTS IN OPPOSITION: The California Association of Health Plans (CAHP)writes that this bill increases administrative costs on health plans and raises several policy concerns. Converting Covered California into a health oversight agency changes its existing relationship with QHPs and adds unnecessary duplication and regulatory overlap to the health care system. The information that will be transferred to Covered California is substantial and much of it proprietary, including provider payment rates, and not all of the data that QHPs consider proprietary is protected from public disclosure. As such, in geographic areas where there is only one or two plans, a competitor or new form of health plan could extract this data for their own competitive purposes. This bill also requires the disclosure and public exposure off-exchange data and information related to markets that are outside the purview of Covered California. CAHP feels there is no clear justification for why Covered California needs this data or how they will use it. CAHP requests this provision be removed from this bill.

ASSEMBLY FLOOR: 77-0, 5/6/19

AYES: Aguiar-Curry, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Dahle, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Santiago, Smith, Mark Stone, Ting, Voepel, Waldron, Weber, Wicks, Wood, Rendon

NO VOTE RECORDED: Arambula, Chen, Salas

Prepared by: Teri Boughton / HEALTH / (916) 651-4111

8/14/19 15:11:24

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 929

SUBJECT: California Health Benefit Exchange: data collection

SUMMARY:

1. Requires a Covered California qualified health plan to report on cost reduction efforts, quality improvements, or disparity reductions. Requires Covered California to post annually on its website plan-specific data on cost reduction efforts, quality improvements, and disparity reductions in a manner that protects the personal information of enrollees.

Existing law:

1. Establishes, under the federal Affordable Care Act (ACA), an advanced and refundable tax credit for qualified individuals who purchase a qualified health plan (QHP) through a health benefit exchange and cost sharing reductions for qualified individuals who choose specified plans. [26 U.S.C. 36B §1402 and 42 U.S.C. §18071]
   
2. Establishes Covered California as an independent entity in state government not affiliated with any state agency or department, governed by a five member board as California’s health benefit exchange. Requires the Covered California Executive Board (board) to establish and use a competitive process to select participating QHPs and other contractors. [GC §100500 -100522]
   
3. Requires Covered California to require QHPs to make available to the public and submit to the board, the United States Secretary of Health and Human Services, and the Insurance Commissioner or the DMHC, as applicable, accurate and timely disclosure of specified information including but not limited to:
   1. Claims payment policies and practices;
   2. Periodic financial disclosures;
   3. Data on enrollment;
   4. Data on disenrollment;
   5. Data on the number of claims that are denied;
   6. Data on rating practices; and,
   7. Information on cost sharing and payments with respect to any out-of-network coverage.[GOV §100502]
4. Establishes, under federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which among various provisions, mandates industry-wide standards for health care information on electronic billing and other processes; and, requires the protection and confidential handling of protected health information. [42 U.S.C. §300gg, 29 U.S.C. §1181, et. seq., and 42 U.S.C. §1320d, et. seq.]
   
5. Defines, under HIPAA regulation, health oversight agency as an agency or authority of the United States, a State, a territory, a political subdivision of a State or territory, or an Indian tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted authority, that is authorized by law to oversee the health care system (whether public or private) or government programs in which health information is necessary to determine eligibility or compliance, or to enforce civil rights laws for which health information is relevant. [45 C.F.R. Sec. 164.501]
   
6. Defines “personal information” as any information that is maintained by an agency that identifies or describes an individual, including, but not limited to, his or her name, social security number, physical description, home address, home telephone number, education, financial matters, and medical or employment history. It includes statements made by, or attributed to, the individual. [CIV §1798.3]

This bill:

1. Requires Covered California, if it requires, or has previously required in its contracts, a QHP to report on cost reduction efforts, quality improvements, or disparity reductions, to make public, on its website, plan-specific data on cost reduction efforts, quality improvements, and disparity reductions.
2. Requires the data to be posted in a way that demonstrates the compliance and performance of a QHP with respect to cost reduction efforts, quality improvement, or disparity reduction reporting, but protects the personal information of an enrollee. Requires Covered California to post the data no less than annually.
3. Requires a QHP to provide data on enrollees to Covered California in a form, manner, and frequency specified by Covered California. Requires the data to be made public by Covered California in a manner that protects the personal information of an enrollee, pursuant to state and federal privacy laws.
   
4. Prohibits records that reveal contracted rates paid by QHPs to providers and enrollee coinsurance that can be used to determine contracted rates paid to providers from being subject to public disclosure unless aggregated and deidentified.
   
5. Requires a QHP to provide to Covered California information that Covered California identifies as necessary to conduct its duties or exercise its oversight powers and furnish the information in the form, manner and frequency specified by Covered California.
   
6. Requires a QHP to provide enrollee data, and other information on quality measures, including contract compliance with measures that affect individual and population health, as improvements in care coordination and patient safety, in a manner that allows for an analysis by demographic subpopulations. Requires a QHP to provide encounter data, and performance improvement strategies, payment methods, and other information necessary to monitor adherence to contract provisions designed to improve health equity and reduce health disparities on an individual and population health basis.
   
7. Requires a QHP to also provide financial data and information, including cost detail, claims data, encounter data, and payment methods to evaluate cost and utilization experience for enrollees. Requires enrollment data and information to include demographic, coverage, premium, product, network, and benefit design detail for each enrollee.
   
8. Prohibits, on or after January 1, 2020, a QHP from amending, renewing, or entering into a contract with a provider, delegated entity, pharmacy benefit manager, or other entity used to provide covered benefits unless the contract requires data and information to be provided consistent with this bill.
   
9. Requires a health plan or health insurer contracted with Covered California to offer a QHP, to disclose to Covered California the following information:
   1. Nongrandfathered individual market products, whether offered through Covered California or otherwise; and,
   2. Nongrandfathered small group products, whether offered through Covered California or otherwise.
      
10. Requires a health plan or health insurer contracted with Covered California to offer a QHP to also disclose to Covered California:
    1. Quality and disparity measures, data, and information for all of the enrollees and insureds of the carrier in all market segments, including individual, small group, large group, and Medi-Cal, but not including Medicare; and,
    2. Data and information required by this bill for each of the plan years in which the QHP is or has been contracted with Covered California, including prior years.
       
11. Defines “disparity reduction” to mean a reduction in variation in disease occurrence, including communicable diseases and chronic conditions, as well as health outcomes between populations groups by age, geographic area, primary language, race, ethnicity, sex, gender identity, sexual orientation, and disability status.
    
12. Defines “financial data and information” to include, but not be limited to, cost detail, including enrollee cost sharing, allowed amounts, fee schedules, and fee-for-service equivalent amounts, and defines “personal information” as having the same meaning as set forth in existing law.
    
13. Requires Covered California to engage in health oversight activities relating to its operations, including, but not limited to, audits, investigations, inspections, evaluations, analyses, data collection through routine reporting, and any other activities for oversight of Covered California and the individuals or entities regulated in connection with Covered California, including QHPs. Permits Covered California to exercise its authority directly or through its designees, and requires Covered California to act as a health oversight agency, as defined, in performing those duties.
14. Exempts, from disclosure under the California Public Records Act, records that reveal cost detail, claims data, encounter data, information about payment methods, contracted rates paid by QHPs to providers, and enrollee coinsurance or other cost sharing that can be used to determine contracted rates paid by plans to providers.
15. Finds and declares that the limitation on the public’s right of access under 14) above is necessary to protect confidential and proprietary information submitted to Covered California.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, costs to Covered California are expected to be minor and absorbable (California Health Trust Fund).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, the process to eliminating health disparities and inequities starts with high quality data. This bill ensures Covered California has the authority to collect the data it needs to fully evaluate how a health plan is delivering care and to publish that data by health plan. In doing so, this bill helps to provide more information to the public and to patients so that patients are more educated about the best plan options for their health care needs. This bill would allow for the disaggregation of critical data in order to gather information about sub-populations and reveal trends and patterns in racial and ethnic health disparities and inequities that can be masked by larger, aggregated data. This bill would help in health disparity reduction because with high-quality data we can identify and monitor immediate health system problems and underlying social determinants of health.
   
2. Covered California. Covered California is California's health benefit exchange where individuals and small businesses can purchase ACA compliant health insurance. Through Covered California, individuals who qualify can get Advanced Premium Tax Credits funded by the federal government and for some with lower incomes, additional cost sharing reductions. There are 11 participating plans serving over 1.4 million Californians who purchase insurance through Covered California. Individuals who purchase health insurance outside of Covered California also benefit from Covered California's selective contracting, standardized benefit designs, and premium rate negotiations because QHPs must also offer those same products at the same premium prices. In the QHP contracts, Covered California sets forth specific requirements related to improving quality, lowering costs, promoting better health and reducing health care disparities, both for the Covered California enrolled population and more broadly in the health care system.
   
3. Quality improvement. Covered California’s quality ratings show how QHPs compare on helping members get the right medical care, and on member-reported experiences of care and services. Covered California has been reporting quality ratings since it began. These ratings play an important role in helping Californians get better care at affordable prices. California health plans perform well in most areas. Several Covered California plans earned very high or top ratings, and half of the plans are rated three-star or higher on members’ getting the right medical care. But the performance standards set by the highest-performing plans indicate that some plans can do better. Covered California is working with health insurance companies to improve the quality and overall value of the coverage they offer. Key efforts include seeing that every member is matched to a primary care clinician; connecting the sickest enrollees with health care organizations that have demonstrated superior-quality care; identifying and eliminating gaps in good care across populations of people who differ by ethnicity, race or income; and advancing health care technology to improve care and eliminate unsafe practices.

Beginning with the 2014 plan year, Covered California set forth standards and strategy for quality improvement and delivery system reform in a Model Contract where many any of these standards and strategies are outlined in "Attachment 7"of the contract. One standard requires QHPs to develop systems to collect clinical data as a supplement to the annual Healthcare Effectiveness Data and Information Set (HEDIS) process developed by the National Committee for Quality Assurance (NCQA), such as diabetes lab results and blood pressure readings. QHPs must track quality measures on diabetes, hypertension, asthma and depression by racial or ethnic group or both, including for the health plan or insurer's full book of business, excluding Medicare.

1. Data collection limitations. Covered California actively negotiates with QHPs and leverages its role to drive improvements in the market by setting forth specific QHP contract requirements related to improving quality, lowering costs, promoting better health and reducing health disparities for both its enrolled population, and more broadly, in the health care system. Since the design of its first QHP contracts, Covered California has required QHPs to submit data regarding health care utilization and cost. In 2015, Covered California launched the Healthcare Evidence Initiative (HEI) under which QHPs are required to submit data regarding claims and encounters; enrollment; capitation; providers; and, plans and products. Under the HEI, QHPs submit the data to Covered California’s analytics vendor. However, QHPs do not submit complete data for analysis, including full financial information. Some QHPs do not submit data claimed to be protected by confidentiality clauses in their own agreements with providers. Because data is aggregated, Covered California is unable to determine how much the average enrollee spends out-of-pocket on Bronze vs. Silver plans or how many members reached their deductibles and in which plans. QHPs refused to submit detailed member data based on Covered California’s lack of authority in state law, so Covered California agreed to accept indirect access to data from the plans to the data aggregator as a starting point. As a result, Covered California is unable to effectively meet its commitment to be a data-drive negotiator for the benefit of consumers.
2. HIPAA. HIPAA governs how covered entities protect and secure protected health information. HIPAA also regulates the circumstances in which covered entities are permitted, but not required, to use and disclose personal health information to others for certain activities without first obtaining an individual’s authorization, including for health oversight activities. A fact sheet jointly published by the Office of the National Coordinator for Health Information Technology and the U.S. Department of Health and Human Services Office for Civil Rights, indicates that plans may disclose personal health information to a state health insurance exchange and its contractor, if the exchange granted oversight authority to contractor, for health oversight activities. In the fact sheet example, the exchange has oversight authority under state law over market conduct, operates a quality rating system, and requests that participating plans submit certain medical claims data to calculate ratings for providers.
3. Related legislation. AB 1063 (Petrie-Norris) requires statutory authority from the Legislature before a state innovation waiver is requested from HHS pursuant to Section 1332 of the ACA. AB 1063 is pending on the Senate Floor.
   
4. Prior legislation. AB 2275 (Arambula) would have required the Department of Health Care Services (DHCS) to establish a quality assessment and performance improvement program for all Medi-Cal managed care plans, through which the plans, commencing January 1, 2021, would have required to meet a minimum performance level that improves quality of care and reduces health disparities for beneficiaries, as specified. AB 2275 was vetoed by Governor Brown, who indicated that:

This bill would require DHCS to establish a quality assessment and performance improvement program for Medi-Cal managed care plans. DHCS, however, is required by federal law to have an external organization conduct periodic quality reviews of its managed care program. DHCS also requires extensive plan-specific quality improvement projects. Adopting these statutory requirements will duplicate current efforts while adding significant costs to Medi-Cal.

1. Support. Health Access California writes that while public reporting on plan-specific contract compliance with requirements on cost, quality, and disparity has been the stated goal of Covered California, the first set of data made publicly available this year did not show plan-specific results. The aggregated data showed positive results and findings, including that nine out of eleven plans increased rates of self-identified reporting on race and ethnicity, ten out of eleven offer telehealth, and six out of eleven implemented valued based payments for hospitals. However, Covered California did not provide health plan specific data so it is unknown if the eleventh plan is always the same plan. Health plans are already required to report and submit data to Covered California on a variety of activities, yet plans have asserted that the data on Covered California enrollees is a trade secret and proprietary. The California Pan-Ethnic Health Network writes that the ability to view disaggregated data is crucial in order to identify where there may be shortfalls in access to quality, equitable and affordable care and how best to address those issues. Health disparities and inequities can only be eliminated if there is high-quality data available to identify and monitor problems within health care delivery systems.
   
2. Oppose unless amended. The California Association of Health Plans writes that this bill increases administrative costs on health plans and raises several policy concerns. Converting Covered California into a health oversight agency changes its existing relationship with QHPs and adds unnecessary duplication and regulatory overlap to the health care system. The information that will be transferred to Covered California is substantial and much of it proprietary, including provider payment rates, and not all of the data that QHPs consider proprietary is protected from public disclosure. As such, in geographic areas where there is only one or two plans, a competitor or new form of health plan could extract this data for their own competitive purposes. This measure also requires the disclosure and public exposure off-exchange data and information related to markets that are outside the purview of Covered California. CAHP feels there is no clear justification for why Covered California needs this data or how they will use it. CAHP requests this provision be removed from this bill.
   
3. Amendments. GOV 100503.5 (b) (2) That Data shall be made public by the Exchange must be done in a manner that protects the personal information of an enrollee, pursuant to state and federal privacy laws.
   

SUPPORT AND OPPOSITION:

Support: California Pan-Ethnic Health Network (cosponsor)

Health Access California (cosponsor)

ACCESS Women’s Health Justice

Alliance of Californians for Community Empowerment Action

American Federation of State, County and Municipal Employees (AFSCME-AFL-CIO)

California Alliance for Retired Americans

California Chronic Care Coalition

California Voices for Progress

City of Hope

Having Our Say!

Health Access California

Hispanas Organized for Political Equality

Korean Community Center of the East Bay

Latino Coalition for a Healthy California

Los Angeles Trust for Children’s Health

National Health Law Program

San Francisco AIDS Foundation

San Francisco Senior and Disability Action

Service Employees International Union, California State Council

Services, Immigrant Rights & Education Network

Small Business Majority

Western Center on Law and Poverty

Oppose: California Association of Health Plans

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 929

Author:(Luz Rivas)

As Introduced Ver:February 20, 2019

Majority vote

SUMMARY:

Requires the board governing California’s Health Benefits Exchange (Exchange), also known as Covered California, to make public on the Exchange’s Internet Website, plan-specific data on cost reduction efforts, quality improvements, and disparity reductions, as specified.

Major Provisions

COMMENTS:

Attachment 7 to Qualified Health Plan (QHP) contracts. QHP contracts sold through Covered California include an "Attachment 7," which specifically references Covered California's "Triple Aim" framework that seeks to lower costs, improve quality, and improve health outcomes, while ensuring a good choice of plans for consumers. Beginning with the 2014 plan year, Covered California set forth its standards and strategy for quality improvement and delivery system reform in its QHP Issuer Model Contract, updated in 2017. As Covered California assesses the performance of its QHP issuers for the contracting period beginning in 2017, Covered California also plans to refresh its quality improvement and delivery system reform standards and requirements. Covered California will engage in efforts that will be used to engage health plans, providers, advocates and other stakeholders as it proposes revisions to contractual terms that take effect in plan year 2021. Covered California intends to share summary findings and seek initial feedback from stakeholders in early 2019. Specifically by contract, the health plans will agree to work with Covered California to develop and implement policies and practices that will promote the Triple Aim, affecting not just the enrollees of Covered California but the health plan's entire California membership.

According to the Author:

According to the author, the process to eliminating health disparities and inequities starts with high quality data. This bill ensures Covered California has the authority to collect the data it needs to fully evaluate how a health plan is delivering care and to publish that data by health plan. In doing so, this bill helps to provide more information to the public and to patients so that patients are more educated about the best plan options for their health care needs. This bill would allow for the disaggregation of critical data in order to gather information about sub-populations and reveal trends and patterns in racial and ethnic health disparities and inequities that can be masked by larger, aggregated data. This bill would help in health disparity reduction because with high-quality data we can identify and monitor immediate health system problems and underlying social determinants of health.

Arguments in Support:

Health Access California (HAC), a cosponsor of this bill, writes that Covered California is uniquely positioned to use its authority as an active purchaser to advance health equity and delivery system improvements. HAC states that public reporting on plan-specific contract compliance with requirements on cost, quality, and disparity has been Covered California’s goal. However, the first set of data made publicly available during the January 2019 Covered California Board meeting did not show plan specific results. Furthermore, HAC contends that health disparities and inequities can only be eliminated if there is high quality data that can be used to identify and monitor immediate health systems problems and underlying social determinants. The California Pan-Ethnic Health Network (CPEHN), a co-sponsor of this bill, writes that the Covered California data showed that quality improvement has been uneven with large gaps between low and high performing plans. CPEHN states as an example the 40-point spread between the lowest and highest performing plans on certain metrics like controlling high blood pressure or colorectal cancer screenings. CPEHN states that the ability to view disaggregated data is crucial in order to identify where there may be shortfalls in access to quality, equitable and affordable care and how to best address those issues.

Arguments in Opposition:

None.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee, costs to Covered California are expected to be minor and absorbable (California Health Trust Fund).

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bloom, Bonta, Brough, Calderon, Carrillo, Chau, Diep, Eggman, Fong, Gabriel, Jones-Sawyer, Maienschein, Obernolte, Petrie-Norris, Quirk, Robert Rivas

UPDATED:

VERSION: February 20, 2019

CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0000285

Date of Hearing: April 24, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 929

Author:(Luz Rivas) – As Introduced Ver:February 20, 2019

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires Covered California to make public on its internet website plan-specific data to be provided by contracting health plans on cost reduction efforts, quality improvements and disparity reductions. It also requires health plans to provide enrollee-specific data in manner specified by the Covered California.

FISCAL EFFECT:

Costs to Covered California are expected to be minor and absorbable (California Health Trust Fund).

COMMENTS:

1. Purpose. According to the author, the process to eliminating health disparities and inequities starts with high quality data. The author notes it is important to make transparent disaggregate data in order to gather information about sub-populations and reveal trends and patterns in racial and ethnic health disparities and inequities that can be masked by larger, aggregated data. This bill is sponsored by Health Access California and the

California Pan-Ethnic Health Network and has no opposition.

1. Covered California. Unlike some other state health insurance exchanges that allow any plan that wishes to sell coverage to be included in their marketplaces, Covered California is an “active purchaser” of health insurance. This means the agency negotiates cost and quality to limit which health plans are able to be sold. Contracts sold through Covered California include an "Attachment 7," which specifically references Covered California's "Triple Aim" framework that seeks to lower costs, improve quality and improve health outcomes while ensuring a good choice of plans for consumers. For instance, Covered California requires issuers to submit data by race and ethnicity on 14 disease control and management measures for four conditions: diabetes, asthma, hypertension and depression. This bill would require the public posting of cost, quality and health disparity data requested by Covered California.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: March 26, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 929

Author:(Luz Rivas) – As Introduced Ver:February 20, 2019

SUBJECT: California Health Benefit Exchange: data collection.

SUMMARY: Requires the board governing California’s Health Benefits Exchange (Exchange), also known as Covered California, to make public on the Exchange’s Internet Website, plan-specific data on cost reduction efforts, quality improvements, and disparity reductions, as specified. Specifically, this bill:

1. Requires the Covered California board, to make public on the Exchange’s Internet Website, plan-specific data on cost reduction efforts, quality improvements, and disparity reductions, if the Covered California board requires, or has previously required in its contracts with health plans, a qualified health plan (QHP) to report on cost reduction efforts, quality improvements, or disparity reductions.
2. Requires data, pursuant to 1) above, to be posted in a way that demonstrates the compliance and performance of a health plan with respect to cost reduction effort, quality improvement, or disparity reduction reporting, but protects the enrollee’s personal information.
3. Requires data, pursuant to 1) above, to be posted no less than annually.
4. Requires QHPs to provide data on enrollees to the Exchange in a form and manner specified by the Exchange. Allows data to be made public by the Exchange in a way that protects the personal information of an enrollee, pursuant to state and federal privacy laws.
5. Defines personal information consistent with existing law.

EXISTING LAW:

1. Establishes the federal Patient Protection and Affordable Care Act (ACA), which enacts various health care coverage market reforms including the availability of health insurance exchanges.
2. Establishes, in state government, Covered California, as an independent public entity not affiliated with an agency or department, and requires the Exchange to compare and make available through selective contracting, health insurance for individual and small business purchasers, as authorized under the ACA. Specifies the powers and duties of the board governing the Exchange, and requires the board to facilitate the purchase of QHPs though the Exchange by qualified individuals and small employers.
3. Establishes under federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which sets standards for privacy of individually identifiable health information and security standards for the protection of electronic protected health information, including, through regulations, that a HIPAA covered entity may not condition the provision of treatment, payment, enrollment in the health plan, or eligibility for benefits on the provision of an authorization, except under specified circumstances. Provides that if HIPAA’s provisions conflict with state law, the provision that is most protective of patient privacy prevails.
4. Prohibits, under the state Confidentiality of Medical Information Act, a provider of health care, a health care service plan, a contractor, a corporation and its subsidiaries and affiliates, or any business that offers software or hardware to consumers, including a mobile application or other related device, as defined, from intentionally sharing, selling, using for marketing, or otherwise using any medical information, as defined, for any purpose not necessary to provide health care services to a patient, except as expressly authorized by the patient, enrollee, or subscriber, as specified, or as otherwise required or authorized by law. States that a violation of these provisions that results in economic loss or personal injury to a patient is a crime.
5. Defines personal information as any information that is maintained by an agency that identifies or describes an individual, including, but not limited to, his or her name, social security number, physical description, home address, home telephone number, education, financial matters, and medical or employment history.
6. Makes available, under federal law, Medicare data for the evaluation of the performance of providers of services and suppliers, to qualified entities, defined as a public or private entity that is qualified as determined by the Secretary of the federal Department of Health and Human Services (HHS), to use to evaluate the performance of providers of services and suppliers on measures of quality, efficiency, effectiveness, and resource use, and applies other requirements to qualified entities as the HHS Secretary may specify, such as ensuring security of data.

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, the process to eliminating health disparities and inequities starts with high quality data. This bill ensures Covered California has the authority to collect the data it needs to fully evaluate how a health plan is delivering care and to publish that data by health plan. In doing so, this bill helps to provide more information to the public and to patients so that patients are more educated about the best plan options for their health care needs. This bill would allow for the disaggregation of critical data in order to gather information about sub-populations and reveal trends and patterns in racial and ethnic health disparities and inequities that can be masked by larger, aggregated data. This bill would help in health disparity reduction because with high-quality data we can identify and monitor immediate health system problems and underlying social determinants of health.
2. BACKGROUND.
   1. ACA. Enacted in March 2010, the ACA provides the framework, policies, regulations and guidelines for the implementation of comprehensive health care reform by the states. The ACA expands access to quality, affordable insurance and health care. As of January 1, 2014, insurers are no longer able to deny coverage or charge higher premiums based on preexisting conditions. These aspects of the ACA, along with tax credits for low and middle income people buying insurance on their own in new health benefit exchanges, make it easier for people with preexisting conditions to gain insurance coverage.
      
      The ACA required exchanges, also known as Marketplaces, to be established in every state by January 1, 2014, otherwise the federal government will establish one in the state. The central purpose of these new Marketplaces is to enable low and moderate income individuals, and small employers to obtain affordable health coverage. Individuals and small businesses are able to purchase private health insurance through a variety of insurance Marketplace models throughout the United States. Each state electing to establish a new Marketplace must adopt the federal standards in law and rule, and have in effect a state law or regulation that implements these standards. If a state elects not to establish a Marketplace, the ACA requires HHS to establish and operate one in that state. The new Marketplaces are required to carry out a number of different functions, including determining eligibility and enrolling individuals in appropriate plans; conducting plan management activities; assisting consumers; ensuring plan accountability; and providing financial management.
   2. Covered California. California was the first state in the nation to enact legislation creating an Exchange under the ACA. Covered California facilitates the purchase of QHPs by individuals and small employers and develops standard benefit designs to allow consumers to shop and compare QHP products. As an active purchaser of health insurance, Covered California negotiates premiums and QHP contract provisions, such as its “Triple Aim” framework that seeks to lower costs, improve quality, and improve health outcomes, while ensuring a good choice of plans for consumers. Covered California has served 3.5 million Californians since 2014. As of June 2018, Covered California had approximately 1.4 million members who have active health insurance.
      
   3. Attachment 7 to QHP contracts. QHP contracts sold through Covered California include an "Attachment 7," which specifically references Covered California's "Triple Aim" framework that seeks to lower costs, improve quality, and improve health outcomes, while ensuring a good choice of plans for consumers. Beginning with the 2014 plan year, Covered California set forth its standards and strategy for quality improvement and delivery system reform in its QHP Issuer Model Contract, updated in 2017. As Covered California assesses the performance of its QHP issuers for the contracting period beginning in 2017, Covered California also plans to refresh its quality improvement and delivery system reform standards and requirements. Covered California will engage in efforts that will be used to engage health plans, providers, advocates and other stakeholders as it proposes revisions to contractual terms that take effect in plan year 2021. Covered California intends to share summary findings and seek initial feedback from stakeholders in early 2019. Specifically by contract, the health plans will agree to work with Covered California to develop and implement policies and practices that will promote the Triple Aim, affecting not just the enrollees of Covered California but the health plan's entire California membership.
   4. January 2019 Board Meeting. At the January 2019 Covered California board meeting, Covered California presented on its “Policies Promoting Accountability and Delivery Reform” and described the early results of its assessment of the performance of QHP issuers for the contracting period beginning in 2017. Examples of early results include the following:
      1. QHP issuers are required to report the extent to which they support and use technology to assist in providing higher quality, accessible, patient-centered care to enrollees. The results indicated the following:
         1. Ten of 11 QHP issuers (covering 1,329,150 or 99% of enrollees in 2017)
            offer telehealth services;
         2. Five of 11 QHP issuers (covering 775,250 or 58% of enrollees in 2017)
            offer primary care telehealth visits at the same cost of a primary care visit or less; and,
         3. Four of 11 QHP issuers (covering 553,900 or 41% of enrollees in 2017)
            offer primary care telehealth visits at no cost share.
      2. Covered California requires QHP issuers to achieve 80% self-identification of racial and ethnic identity (R/E) by 2019 and encourages use of various data collection methods beyond the enrollment form to identify membership and to understand disparities in care. Covered California requires QHP issuers to submit data by R/E group on 14 disease control and management measures for four conditions: diabetes, asthma, hypertension and depression. Issuers submit data for all lines of business excluding Medicare. This work helps “track, trend, and improve” care across R/E groups. The results indicated the following:
         1. In 2017, nine of 11 QHP issuers have seen increases in the self-identification rate over 2015;
         2. 6 QHP issuers have met and exceeded the 80% target a year early; three have exceeded 95%;
         3. QHP issuers have increased identification rates due to improved data collection and incorporation of best practices in asking enrollees for R/E information; and,
         4. Covered California is working with QHP issuers to analyze early condition-specific data and to address challenges related to data quality, small denominators, and data interpretation.
3. SUPPORT. Health Access California (HAC), a cosponsor of this bill, writes that Covered California is uniquely positioned to use its authority as an active purchaser to advance health equity and delivery system improvements. HAC states that public reporting on plan-specific contract compliance with requirements on cost, quality, and disparity has been Covered California’s goal. However, the first set of data made publicly available during the January 2019 Covered California Board meeting did not show plan specific results. Furthermore, HAC contends that health disparities and inequities can only be eliminated if there is high quality data that can be used to identify and monitor immediate health systems problems and underlying social determinants. The California Pan-Ethnic Health Network (CPEHN), a co-sponsor of this bill, writes that the Covered California data showed that quality improvement has been uneven with large gaps between low and high performing plans. CPEHN states as example the 40-point spread between the lowest and highest performing plans on certain metrics like controlling high blood pressure or colorectal cancer screenings. CPEHN states that the ability to view disaggregated data is crucial in order to identify where there may be shortfalls in access to quality, equitable and affordable care and how to best address those issues.
4. RELATED LEGISLATION.
   1. AB 1309 (Bauer-Kahan) extends enrollment periods for the individual market until January 31st, and will be heard in the Assembly Health Committee on April 2, 2019.
   2. AB 1063 (Petrie-Norris) requires the Exchange to obtain statutory authority from the Legislature before seeking a state innovation waiver from HHS pursuant to Section 1332 of the ACA.
5. PREVIOUS LEGISLATION.
   1. AB 2275 (Arambula) would have required the Department of Health Care Services (DHCS) to establish a quality assessment and performance improvement program for all Medi-Cal managed care plans, through which the plans, commencing January 1, 2021, would have required to meet a minimum performance level that improves quality of care and reduces health disparities for beneficiaries, as specified. AB 2275was vetoed by the Governor, who indicated that “this bill would require DHCS to establish a quality assessment and performance improvement program for Medi-Cal managed care plans. DHCS, however, is required by federal law to have an external organization conduct periodic quality reviews of its managed care program. DHCS also requires extensive plan-specific quality improvement projects. Adopting these statutory requirements will duplicate current efforts while adding significant costs to Medi-Cal.”
   2. AB 1602 (John A Pérez), Chapter 655, Statutes of 2010, and SB 900 (Alquist), Chapter 659, Statutes of 2010, established the Exchange in California and delineate its powers and duties.
   3. ABX1 2 (Pan), Chapter 1, Statutes of 2013-14 First Extraordinary Session and SBX1 2 (Hernandez), Chapter 2, Statutes of 2013-14 First Extraordinary Session, established health insurance market reforms contained in the ACA specific to individual purchasers, such as prohibiting insurers from denying coverage based on preexisting conditions; and, make conforming changes to small employer health insurance laws resulting from final federal regulations.

REGISTERED SUPPORT / OPPOSITION:

Support

Health Access California (sponsor)

California Pan-Ethnic Health Network (sponsor)

Alliance Of Californians For Community Empowerment (Acce) Action
American Federation Of State, County And Municipal Employees, Afl-Cio
California State Council Of Service Employees
California Voices For Progress
Korean Community Center Of The East Bay
Latino Coalition For A Healthy California
National Health Law Program
San Francisco Aids Foundation
San Francisco Senior And Disability Action
Small Business Majority
The Los Angeles Trust For Children's Health
Western Center On Law & Poverty, Inc.

Opposition

None on file.

Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097