1. Notwithstanding any other provision of law that provides for the confidentiality of the information described in this section, a health maintenance organization shall, except as otherwise provided in subsection 4, provide to the person responsible for overseeing the health care plan for a group purchaser upon written request from that person not more than once each year:
(a)All claims data relating to the enrollees in a health care plan provided by the health maintenance organization pursuant to a contract with the group purchaser; or
(b)Sufficient data relating to the claims of enrollees in the health care plan to allow the group purchaser to calculate the cost-effectiveness of the benefits provided by the health maintenance organization. Such data must include, without limitation:
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1. Notwithstanding any other provision of law that provides for the confidentiality of the information described in this section, a health maintenance organization shall, except as otherwise provided in subsection 4, provide to the person responsible for overseeing the health care plan for a group purchaser upon written request from that person not more than once each year:
(a) All claims data relating to the enrollees in a health care plan provided by the health maintenance organization pursuant to a contract with the group purchaser; or
(b) Sufficient data relating to the claims of enrollees in the health care plan to allow the group purchaser to calculate the cost-effectiveness of the benefits provided by the health maintenance organization. Such data must include, without limitation:
(1) Data necessary to calculate the actual cost of obtaining medical services through the health maintenance organization, organized by medical service and category of disease;
(2) Data relating to enrollees in the health care plan who receive care, including, without limitation, demographics of such enrollees, prescriptions, office visits with a provider of health care, inpatient services and outpatient services, as used by the health maintenance organization to make calculations which are required to comply with the risk adjustment, reinsurance and risk corridor requirements of 42 U.S.C. §§ 18061, 18062 and 18063; and
(3) Such data as used to establish an experience rating for the enrollees in the health care plan, including, without limitation, coding relating to diagnostics and procedures, the total cost charged to any person for each drug, device or service made available by the health care plan and all reimbursements made to a provider of health care for such drugs, devices or services.
2. If a written request is made pursuant to subsection 1, the health maintenance organization must also provide an annual report relating to the data required to be made available pursuant to subsection 1, which must include, without limitation, sufficient detail to demonstrate the annual changes in the cost and the percentage of increase or decrease, as applicable, for each category of information made available pursuant to subsection 1.
3. A health maintenance organization shall provide the data required by this section in an aggregated form which complies with federal and state law, including, without limitation, the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, and any applicable regulations.
4. Before providing any data pursuant to subsection 1, a health maintenance organization shall ensure that a professional statistician examines the data to confirm that such data cannot be used to identify and does not provide a reasonable basis upon which to identify a person whose information is included in the report. If the professional statistician is not able to make such a confirmation, the data must not be provided by the health maintenance organization until such confirmation is obtained.
5. A health maintenance organization must provide the data required by this section in a format which is easily searchable electronically or on a secure Internet website. A health maintenance organization may only provide the data described in this section relating to the health care plan of a group purchaser to the person responsible for overseeing the health care plan for the group purchaser and not relating to the health care plan of any other group purchaser.
6. A group purchaser must have policies and procedures in place which are compliant with federal law, including, without limitation, the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, and the regulations adopted pursuant thereto, and the laws of this State to ensure the privacy and security of the data made available to the person responsible for overseeing the health care plan for a group purchaser pursuant to this section.
7. As used in this section, “group purchaser” means:
(a) An employer that employs at least 1,000 employees, at least 300 of whom are enrolled in a health care plan which is offered by a health maintenance organization; or
(b) A group of employers that cumulatively employ at least 500 employees and which has formed a trust for the purpose of funding health care benefits for at least 300 employees who are enrolled in a health care plan which is offered by a health maintenance organization.