Text of section effective on April 01, 2025
Sec. 540.0353.  USE OF ENCOUNTER DATA IN DETERMINING PREMIUM PAYMENT RATES AND OTHER PAYMENT AMOUNTS.  (a)  In determining premium payment rates and other amounts paid to managed care organizations under a managed care plan, the commission may not base or derive the rates or amounts on or from encounter data, or incorporate in the determination an analysis of encounter data, unless a certifier of encounter data certifies that:
(1)  the encounter data for the most recent state fiscal year is complete, accurate, and reliable; and
(2)  there is no statistically significant variability in the encounter data attributable to incompleteness, inaccuracy, or another deficiency as compared to equivalent data for similar populations and when evaluated against professionally accepted standards.
(b)  In determining whether data is equivalent data for similar populations under Subsection (a)(2), a certifier of encounter data shall, at a minimum, consider:
(1)  the regional variation in recipient utilization patterns and health care service costs;
(2)  the range and type of health care services premium payment rates are to cover;
(3)  the number of managed care plans in the region; and
(4)  the current number of recipients in each region, including the number for each recipient category.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.