Claims data disclosure.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensing and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Insurance Commissioner. Except as specified, existing law prohibits a provider of health care, a health care service plan, or contractor from disclosing medical information regarding a patient of the provider of health care or an enrollee or subscriber of a health care service plan without first obtaining an authorization. Existing law, the federal Patient Protection and Affordable Care Act (PPACA) , requires the Secretary of Health and Human Services to make available to qualified entities, as defined, specified claims data relating to Medicare in order to evaluate the performance of providers and suppliers. Existing federal regulations require a qualified entity, as defined, to comply with specified requirements for Medicare claims data error correction. This bill would provide that no contract in existence or issued, amended, or renewed on or after January 1, 2013, between a health care service plan or a health insurer and a provider or supplier, as specified, shall prohibit, condition, or in any way restrict the disclosure of claims data related to health care services provided to specified individuals, to a qualified entity, as defined. The bill would require a health care service plan or health insurer to comply with all state and federal laws and implementing regulations for the protection of data privacy and security. Because a willful violation of these requirements by a health care service plan would constitute a crime, the bill would impose a state-mandated local program. This bill would further require a qualified entity, as defined, to comply with specified requirements for error correction for all claims data received, including data received from sources other than Medicare. Because a willful violation of the act by a health care service plan would constitute a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.