REPORT TITLE:
Patient Rights


DESCRIPTION:
Implements patient rights and responsibilities task force
recommendations to the patient bill of rights and
responsibilities act and related laws. (HB1664 HD1)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        1664
HOUSE OF REPRESENTATIVES                H.B. NO.           H.D.1
TWENTIETH LEGISLATURE, 1999                                
STATE OF HAWAII                                            
                                                             
________________________________________________________________
________________________________________________________________


                   A  BILL  FOR  AN  ACT

RELATING TO HEALTH.



BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

 1      SECTION 1.  In 1998, the legislature passed the Hawaii
 
 2 Patient Bill of Rights and Responsibilities Act, Act 178, Session
 
 3 Laws of Hawaii 1998.  Under Act 178, the Patient Rights and
 
 4 Responsibilities Task Force was convened to, among other things,
 
 5 review Act 178 and determine whether consumer rights are fully
 
 6 protected and whether any further action is needed to ensure such
 
 7 protection.  The purpose of this Act represents the task force's
 
 8 recommendations for statutory revisions that ensure the
 
 9 protection of consumer rights.
 
10      SECTION 2.  Chapter 432E, Hawaii Revised Statutes, is
 
11 amended by adding four new sections to be appropriately
 
12 designated and to read as follows:
 
13      "432E-    Annual report.  The commission shall prepare and
 
14 submit to the legislature on an annual basis a report which shall
 
15 contain the number of external review hearing cases reviewed, the
 
16 type of cases reviewed, a summary of the nature of the cases
 
17 reviewed, and the disposition of the cases reviewed.  The
 
18 identities of the plan and the enrollee shall be protected from
 
19 disclosure in the report.
 

 
Page 2                                                     1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      432E-    Health insurance revolving fund.  (a)  There is
 
 2 established a revolving fund in the state treasury to be
 
 3 administered by the commissioner and to be designated as the
 
 4 health insurance revolving fund.
 
 5      (b)  The commissioner may expend moneys from the health
 
 6 insurance revolving fund to hire medical experts who will serve
 
 7 on the review panel or provide an expert medical opinion to the
 
 8 review panel and to conduct a public awareness and education
 
 9 program about managed care plans.
 
10      (c)  Beginning with fiscal year 1999-2000 and each fiscal
 
11 year thereafter, each mutual benefit society under article 1 of
 
12 chapter 432, health maintenance organization under chapter 432D,
 
13 and any other entity offering or providing health benefits or
 
14 services under the regulation of the commissioner, except an
 
15 insurer licensed to offer health insurance under article 10A,
 
16 shall deposit with the commissioner by July 1 of each year an
 
17 assessment based on a pro rata basis as imposed by the
 
18 commissioner.  The assessment shall be credited to the health
 
19 insurance revolving fund.
 
20      (d)  Moneys in the health insurance revolving fund shall not
 
21 revert to the general fund.
 
22      (e)  The commissioner shall report annually to the
 
23 legislature before the convening of each regular session as to
 
24 fund administration and expenditures.
 

 
Page 3                                                     1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      432E-    Accreditation of managed care plans.  (a)
 
 2 Beginning with calendar year 1999, the commissioner shall
 
 3 contract with one or more certified vendors of the consumer
 
 4 assessment health plan survey to conduct a survey of all managed
 
 5 care plans actively offering managed care plans in this State;
 
 6 provided that the information collected in 1999 shall be kept
 
 7 confidential such that managed care plans are provided an
 
 8 opportunity to learn whether any deficiencies exist or any
 
 9 improvements are required; provided further that the results of
 
10 the consumer assessment health plan survey after the first year
 
11 shall be available to the public.
 
12      (b)  The commissioner shall conduct a program that promotes
 
13 public awareness and education about managed care plans such that
 
14 consumers may make better or more informed choices when selecting
 
15 a managed care plan.
 
16      (c)  Beginning in the year 2000, non-accredited plans shall
 
17 submit a plan to the commissioner to achieve national
 
18 accreditation status within five years.  After the first year of
 
19 the five-year plan, each unaccredited plan shall also submit an
 
20 annual progress report to the insurance commissioner on the
 
21 status of gaining national accreditation.  The commissioner shall
 
22 determine which national accreditation organization is
 
23 appropriate for each type plan.
 

 
Page 4                                                     1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (d)  The costs to fund the survey and educational program
 
 2 shall be borne by the insurance division through the health
 
 3 insurance revolving fund established by section 432E-  .  The
 
 4 commissioner shall be permitted to assess each managed care plan
 
 5 for the actual expenses in administering the survey.
 
 6      (e)  Each mutual benefit society under article 1 of chapter
 
 7 432, health maintenance organization under chapter 432D, and any
 
 8 other entity offering or providing health benefits or services
 
 9 under the regulation of the commissioner, except an insurer
 
10 licensed to offer health insurance under article 10A of chapter
 
11 431 shall deposit with the commissioner an amount to provide for
 
12 the actual costs of the survey to be determined by the
 
13 commissioner on July 1 of each year, to be credited to the health
 
14 insurance revolving fund.  In addition, each mutual benefit
 
15 society under article 1 of chapter 432, health maintenance
 
16 organization under chapter 432D, and any other entity offering or
 
17 providing health benefits or services under the regulation of the
 
18 commissioner, except an insurer licensed to offer health
 
19 insurance under article 10A of chapter 431, shall pay to the
 
20 commissioner at a time to be determined by the commissioner, a
 
21 one-time deposit in an amount to be determined by the
 
22 commissioner, to be credited to the health insurance revolving
 
23 fund.
 

 
Page 5                                                     1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      432-    Rules.  The commissioner shall adopt rules pursuant
 
 2 to chapter 91 necessary for the purposes of this chapter."
 
 3      SECTION 3.  Section 431:10C-103, Hawaii Revised Statutes, is
 
 4 amended by adding three new definitions to be appropriately
 
 5 inserted and to read as follows:
 
 6      ""Emergency medical condition" means a medical condition
 
 7 that manifests itself by acute symptoms of sufficient severity,
 
 8 including severe pain, such that a prudent layperson, who
 
 9 possesses an average knowledge of health and medicine, could
 
10 reasonably expect the absence of immediate medical attention to
 
11 result in:
 
12      (1)  Placing the health of the individual or, with respect
 
13           to a pregnant woman, the health of the woman or her
 
14           unborn child, in serious jeopardy;
 
15      (2)  Serious impairment to bodily functions; or
 
16      (3)  Serious dysfunction of any bodily organ or part.
 
17      "Emergency services" means:
 
18      (1)  A medical screening examination, as required by federal
 
19           law, that is within the capability of the emergency
 
20           department of a hospital, including ancillary services
 
21           routinely available to the emergency department, to
 
22           evaluate an emergency medical condition; or
 

 
 
 
Page 6                                                     1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (2)  Such further medical examination and treatment, as
 
 2           required by federal law, that is within the
 
 3           capabilities of the staff and facilities available at
 
 4           the hospital including any trauma and burn center of
 
 5           the hospital to stabilize an emergency medical
 
 6           condition.
 
 7      "Stabilize" means the provision of medical treatment as may
 
 8 be necessary to assure, within reasonable medical probability,
 
 9 that no material deterioration of an individual's medical
 
10 condition is likely to result from or occur during a transfer to
 
11 another facility, if the medical condition could result in:
 
12      (1)  Placing the health of the individual or, with respect
 
13           to a pregnant woman, the health of the woman or her
 
14           unborn child, in serious jeopardy;
 
15      (2)  Serious impairment to bodily functions; or
 
16      (3)  Serious dysfunction of any bodily organ or part."
 
17      SECTION 4.  Section 432E-5, Hawaii Revised Statutes, is
 
18 amended to read as follows:
 
19      "[[]432E-5[]]  Complaints and appeals procedure for
 
20 enrollees.(a)  A managed care plan with enrollees in this State
 
21 shall establish and maintain a procedure to provide for the
 
22 resolution of an enrollee's complaints and appeals.
 

 
 
 
Page 7                                                     1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (b)  The managed care plan at all times shall make available
 
 2 its complaints and appeals procedures.  The complaints and
 
 3 appeals procedures shall be reasonably understandable to the
 
 4 average layperson and shall be provided in languages other than
 
 5 English upon request.
 
 6      (c)  A plan shall send notice of its final internal
 
 7 determination to the enrollee and the enrollee's appointed
 
 8 representative, if applicable, and the commissioner.  The notice
 
 9 shall include information regarding the enrollee's right to
 
10 request external review, the thirty day deadline for requesting
 
11 the external review, instructions on how to request external
 
12 review, and where to submit the request for external review."
 
13      SECTION 5.  Section 432E-3, Hawaii Revised Statutes, is
 
14 amended to read as follows:
 
15      "[[]432E-3[]]  Access to services.  A managed care plan
 
16 shall demonstrate to the commissioner upon request that its plan:
 
17      (1)  Makes benefits available and accessible to each
 
18           enrollee electing the managed care plan in the defined
 
19           service area with reasonable promptness and in a manner
 
20           which promotes continuity in the provision of health
 
21           care services;
 
22      (2)  Provides access to sufficient numbers and types of
 
23           providers to ensure that all covered services will be
 
24           accessible without unreasonable delay;
 

 
Page 8                                                     1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (3)  When medically necessary, provides health care services
 
 2           twenty-four hours a day, seven days a week;
 
 3      (4)  Provides a reasonable choice of qualified providers of
 
 4           women's health services such as gynecologists,
 
 5           obstetricians, certified nurse-midwives, and advanced
 
 6           practice nurses to provide preventive and routine
 
 7           women's health care services; [and]
 
 8      (5)  Provides payment or reimbursement for adequately
 
 9           documented emergency services[.] as provided in Act
 
10           246, Session Laws of Hawaii 1998; and
 
11      (6)  Allows for standing referrals to specialists who are
 
12           able to provide and coordinate primary and specialty
 
13           care for an enrollee's life threatening, chronic,
 
14           degenerative, or disabling disease or condition."
 
15      SECTION 6.  Section 432E-6, Hawaii Revised Statutes, is
 
16 amended to read as follows:
 
17      "[[]432E-6[]]  Appeals to the commissioner.(a)  After
 
18 exhausting all internal complaint and appeal procedures
 
19 available, an enrollee, or the enrollee's treating provider or
 
20 appointed representative, may appeal an adverse decision of a
 
21 managed care plan to a three member review panel appointed by the
 
22 commissioner composed of a representative from a health plan not
 
23 involved in the complaint, a provider licensed to practice and
 

 
Page 9                                                     1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1 practicing medicine in Hawaii not involved in the complaint, and
 
 2 the commissioner or the commissioner's designee in the following
 
 3 manner:
 
 4      (1)  The enrollee shall submit a request for review to the
 
 5           commissioner within thirty days from the date of the
 
 6           final determination by the managed care plan.
 
 7      (2)  Upon receipt of the request and upon a showing of good
 
 8           cause, the commissioner shall appoint the members of
 
 9           the panel and shall conduct a review hearing pursuant
 
10           to chapter 91.  Where the amount in controversy is less
 
11           than $500, the commissioner may conduct a review
 
12           hearing without appointing a review panel.
 
13      (3)  The review hearing shall be conducted as soon as
 
14           practicable taking into consideration the medical
 
15           exigencies of the case; provided that the hearing is
 
16           held no later than sixty days from the date of the
 
17           request for hearing.
 
18      (4)  The commissioner may retain an independent medical
 
19           expert who is trained in the field of medicine most
 
20           appropriately related to the matter under review and
 
21           who shall not be subject to chapters 76 and 77.  The
 
22           independent medical evidence shall be exempt from the
 
23           requirements of chapter 91.
 

 
Page 10                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1    [(3)]  (5)  After considering the enrollee's complaint, the
 
 2           plan's response, and any affidavits filed by the
 
 3           parties, the commissioner may dismiss the appeal if it
 
 4           is determined that the appeal is frivolous or without
 
 5           merit.
 
 6      (6)  The review panel shall review the adverse determination
 
 7           to determine whether the plan acted reasonably and with
 
 8           sound medical judgment.  The review panel shall
 
 9           consider the clinical standards of the plan, the
 
10           information provided, the attending physician's
 
11           recommendations, and generally accepted practice
 
12           guidelines.
 
13      (7)  The commissioner, upon a majority vote of the panel,
 
14           shall issue an order affirming, modifying, or reversing
 
15           the decision within thirty days of the hearing.
 
16      (b)  The procedure set forth in this section shall not apply
 
17 to claims or allegations of health provider malpractice,
 
18 professional negligence, or other professional fault against
 
19 participating providers.
 
20      (c)  [The commissioner may adopt rules pursuant to chapter
 
21 91 to carry out the purposes of this section.] The members of the
 
22 review panel shall have immunity from monetary liability relating
 
23 to their duties as members of the review panel.
 

 
Page 11                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (d)  An enrollee may be allowed an award of a reasonable sum
 
 2 for attorney's fees and reasonable costs of suit in an action
 
 3 brought against a plan."
 
 4      SECTION 7.  Section 432E-7, Hawaii Revised Statutes, is
 
 5 amended to read as follows:
 
 6      "[[]432E-7[]]  Information to enrollees.  (a)  The managed
 
 7 care plan shall provide to its enrollees upon enrollment and
 
 8 thereafter upon request the following information:
 
 9      (1)  A list of participating providers which shall [indicate
 
10           their specialty and whether board certification has
 
11           been attained;] be updated on a regular basis
 
12           indicating, at a minimum, their specialty and whether
 
13           the provider is accepting new patients;
 
14      (2)  A complete description of benefits, services, and
 
15           copayments;
 
16      (3)  A statement on enrollee's rights, responsibilities, and
 
17           obligations;
 
18      (4)  An explanation of the referral process, if any;
 
19      (5)  Where services or benefits may be obtained;
 
20     [(6)  [A statement regarding informed consent;
 
21     (7)]  (6) Information on complaints and appeals procedures;
 
22           and
 

 
 
 
Page 12                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1    [(8)]  (7)  The telephone number of the insurance division
 
 2           [and the office of consumer complaints].
 
 3 This information shall be provided to prospective enrollees upon
 
 4 request.
 
 5      (b)  Every managed care plan shall provide to the
 
 6 commissioner and its enrollees notice of any material change in
 
 7 [the operation of the organization initiated by the plan that
 
 8 will affect them directly within thirty days of the material
 
 9 change.] participating provider agreements, services, or benefits
 
10 where:
 
11      (1)  The change affects the organization or operation of the
 
12           managed care plan; and
 
13      (2)  The change affects enrollee's services or benefits.
 
14 The managed care plan shall provide notice to enrollees within
 
15 sixty days of the change in a format that makes the notice clear
 
16 and conspicuous such that it is readily noticeable by the
 
17 enrollee.
 
18      (c)  [For purposes of this section "material change" means a
 
19 change in participating provider agreements, services, or
 
20 benefits.] All managed care plans shall provide generic
 
21 participating provider contracts to enrollees, upon request."
 
22      SECTION 8.  Section 432E-10, Hawaii Revised Statutes, is
 
23 amended by amending subsection (a) to read as follows:
 

 
Page 13                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      "(a)  It is the policy of this State that all managed care
 
 2 plans shall adopt and comply with nationally developed and
 
 3 promulgated standards for measuring quality, outcomes, access,
 
 4 satisfaction, and utilization of services.  Every contract
 
 5 between a managed care plan and a participating provider of
 
 6 health care services shall require the participating provider to
 
 7 comply with the managed care plan's requests for any information
 
 8 necessary for the managed care plan to comply with the
 
 9 requirements of this chapter.  [The standard to be applied is the
 
10 Health Employer Data and Information Set (HEDIS) 3.0 data set, as
 
11 amended from time to time.]  The State shall require that:
 
12      (1)  Consumers, providers, managed care plans, purchasers,
 
13           and regulators shall be equitably represented in the
 
14           development of standards; and
 
15      (2)  Standards shall result in measurement and reporting
 
16           that is purposeful, valid and scientifically based,
 
17           applied in a consistent and comparable manner,
 
18           efficient and cost effective, and designed to minimize
 
19           redundancy and duplication of effort."
 
20      SECTION 9.  Act 246, Session Laws of Hawaii 1998, is amended
 
21 by amending sections 1 to 3 to read as follows:
 
22      "SECTION 1.  Chapter 431, Hawaii Revised Statutes, is
 
23 amended by adding a new section to article 10A to be
 
24 appropriately designated and to read as follows:
 

 
Page 14                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      "431:10A-   Emergency medical services.(a)  As used in
 
 2 this section unless the context otherwise requires:
 
 3      "Emergency medical condition" means a medical condition that
 
 4 manifests itself by acute symptoms of sufficient severity,
 
 5 including severe pain, such that a prudent layperson, who
 
 6 possesses an average knowledge of health and medicine, could
 
 7 reasonably expect the absence of immediate medical attention to
 
 8 result in:
 
 9      (1)  Placing the health of the individual (or, with respect
 
10           to a pregnant woman, the health of the woman or her
 
11           unborn child) in serious jeopardy;
 
12      (2)  Serious impairment to bodily functions; or
 
13      (3)  Serious dysfunction of any bodily organ or part.
 
14      "Emergency services" means:
 
15      (1)  A medical screening examination (as required by federal
 
16           law) that is within the capability of the emergency
 
17           department of a hospital, including ancillary services
 
18           routinely available to the emergency department, to
 
19           evaluate an emergency medical condition; or
 
20      (2)  Such further medical examination and treatment (as
 
21           required by federal law) that is within the
 
22           capabilities of the staff and facilities available at
 

 
 
 
Page 15                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1           the hospital (including any trauma and burn center of
 
 2           the hospital), to stabilize an emergency medical
 
 3           condition.
 
 4      "Stabilize" means the provision of medical treatment as may
 
 5 be necessary to assure, within reasonable medical probability,
 
 6 that no material deterioration of an individual's medical
 
 7 condition is likely to result from or occur during a transfer to
 
 8 another facility, if the medical condition could result in:
 
 9      (1)  Placing the health of the individual (or with respect
 
10           to a pregnant woman, the health of the woman or her
 
11           unborn child) in serious jeopardy;
 
12      (2)  Serious impairment to bodily functions; or
 
13      (3)  Serious dysfunction of any bodily organ or part.
 
14 In the case of a woman having contractions, "stabilize" means
 
15 medical treatment as may be necessary to deliver (including the
 
16 placenta).
 
17      "Stabilized" means that no material deterioration of an
 
18 individual's medical condition, as described in this subsection,
 
19 is likely, within reasonable medical probability, to result from
 
20 or occur during the transfer of the individual from a facility,
 
21 or in the case of a woman having contractions, that the woman has
 
22 delivered (including the placenta).
 

 
 
 
Page 16                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (b)  A health plan shall cover emergency services provided
 
 2 twenty-four hours a day, seven days a week to members with
 
 3 emergency medical conditions without regard to whether the
 
 4 member, or an emergency provider treating the member, obtained
 
 5 prior authorization for these services.
 
 6      (c)  A health plan shall cover emergency services provided
 
 7 to a member at a participating emergency department if the member
 
 8 presents oneself with an emergency medical condition.
 
 9      (d)  A health plan shall cover emergency services provided
 
10 to a member at a nonparticipating emergency department up to the
 
11 point of stabilization if:
 
12      (1)  The member presents oneself with an emergency medical
 
13           condition; and
 
14      (2)  One of the following applies:
 
15           (A)  Due to circumstances beyond the member's control,
 
16                the member was unable to arrive at a participating
 
17                emergency department without serious threat to
 
18                life or health;
 
19           (B)  A prudent layperson possessing an average
 
20                knowledge of health and medicine would have
 
21                reasonably believed that, under the circumstances,
 
22                the time required to go to a participating
 
23                emergency provider or department could result in
 
24                one or more of the following:
 

 
Page 17                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1                (i)  Placing the health of the individual (or,
 
 2                     with respect to a pregnant woman, the health
 
 3                     of the woman or her unborn child) in serious
 
 4                     jeopardy;
 
 5               (ii)  Serious impairment to bodily functions; or
 
 6              (iii)  Serious dysfunction of any bodily organ or
 
 7                     part; or
 
 8           (C)  A person authorized by the health plan refers the
 
 9                member to an emergency department and does not
 
10                specify a participating emergency department.
 
11      (e)  Except as provided in subsection (f), a health plan
 
12 shall not be required to reimburse an emergency provider or an
 
13 emergency department for any services, other than those medically
 
14 necessary to stabilize a member, until:
 
15      (1)  The emergency department has contacted the member's
 
16           health benefits plan; and
 
17      (2)  There is agreement between the emergency provider and
 
18           the plan concerning treatment and services to be
 
19           provided by the emergency provider after the member is
 
20           stabilized.
 
21      (f)  A health plan shall select between the following two
 
22 options:
 

 
 
 
Page 18                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (1)  A health plan shall reimburse an emergency provider and
 
 2           an emergency department for any items or services not
 
 3           necessary to stabilize the patient but that are
 
 4           determined to be medically necessary to treat the
 
 5           illness that [lead] led the patient to believe that he
 
 6           or she had an emergency medical condition, and that a
 
 7           reasonable patient would expect to receive from a
 
 8           physician at the time of presentation[.]; or
 
 9      (2)  A health plan shall reimburse an emergency provider and
 
10           an emergency department for any items or services not
 
11           necessary to stabilize the patient but that are
 
12           determined to be medically necessary by the emergency
 
13           provider, if the emergency department:
 
14           (A)  After a documented good faith effort, is unable to
 
15                reach the enrollee's health plan:
 
16                (i)  Within thirty minutes from the initial
 
17                     examination of the enrollee; or
 
18               (ii)  If the enrollee needs to be stabilized,
 
19                     within thirty minutes of stabilization; or
 
20           (B)  Has successfully contacted the plan as required in
 
21                paragraph (A) above, and has not received a denial
 
22                from the plan within thirty minutes of the initial
 
23                contact, unless the plan is able to document that
 

 
Page 19                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1                it has made an unsuccessful good faith effort to
 
 2                reach the emergency department within thirty
 
 3                minutes after receiving the request for
 
 4                authorization; or
 
 5           (C)  Has successfully contacted the plan and has
 
 6                received a denial from a person other than a
 
 7                participating physician and:
 
 8                (i)  A participating physician authorized by the
 
 9                     plan to review denials reverses the denial;
 
10                     or
 
11               (ii)  A participating physician authorized by the
 
12                     plan to review denials fails to communicate a
 
13                     determination affirming the denial unless the
 
14                     treating physician waives the requirement for
 
15                     such determination, within thirty minutes
 
16                     after the initial denial is communicated by
 
17                     the plan; and
 
18      (3)  A health plan shall immediately arrange for an
 
19           alternate plan of treatment for the member in the event
 
20           a non-participating emergency provider and the plan are
 
21           unable to reach agreement on services necessary beyond
 
22           those immediately needed to stabilize the member, under
 
23           which:
 

 
Page 20                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1           (A)  A participating physician with privileges at the
 
 2                hospital arrives at the emergency department of
 
 3                the hospital promptly and assumes responsibility
 
 4                for the treatment of the member; or
 
 5           (B)  With the agreement of the treating physician or
 
 6                another health professional in the emergency
 
 7                department:
 
 8                (i)  Arrangement is made for transfer of the
 
 9                     member to another facility using medical
 
10                     resources consistent with the condition of
 
11                     the enrollee;
 
12               (ii)  An appointment is made with a participating
 
13                     physician or provider for treatment needed by
 
14                     the enrollee; or
 
15              (iii)  Another arrangement is made for treatment of
 
16                     the enrollee.
 
17      (g)  A health plan that arranges for, or otherwise covers,
 
18 urgent care services and comprehensive primary care may impose
 
19 different cost-sharing on the member for:
 
20      (1)  Use of an emergency department over another setting;
 
21           and
 
22      (2)  Use of a nonparticipating emergency department over a
 
23           participating emergency department unless:
 

 
Page 21                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1           (A)  Due to circumstances beyond the member's control,
 
 2                the member was unable to arrive at a participating
 
 3                emergency department without serious threat to
 
 4                life or health; or
 
 5           (B)  A prudent layperson possessing an average
 
 6                knowledge of health and medicine would have
 
 7                reasonably believed that, under the circumstances,
 
 8                the time required to go to a participating
 
 9                emergency department could result in one or more
 
10                of the following:
 
11                (i)  Placing the health of the individual (or,
 
12                     with respect to a pregnant woman, the health
 
13                     of the woman or her unborn child) in serious
 
14                     jeopardy;
 
15               (ii)  Serious impairment to bodily functions; or
 
16              (iii)  Serious dysfunction of any bodily organ or
 
17                     part.
 
18      (h)  A health plan that provides coverage for emergency
 
19 medical services shall educate members on:
 
20      (1)  Coverage for emergency medical services;
 
21      (2)  The appropriate use of emergency services, including
 
22           the use of the 911 system and other telephone access
 
23           systems used to access prehospital emergency services;
 

 
Page 22                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (3)  Any cost sharing provisions for emergency services; and
 
 2      (4)  The procedures for obtaining emergency and other
 
 3           medical services so that members are familiar with the
 
 4           location of in-plan emergency departments and with the
 
 5           location and availability of other in-plan settings at
 
 6           which they could receive medical care.
 
 7      SECTION 2.  Chapter 432, Hawaii Revised Statutes, is amended
 
 8 by adding a new section to article 1 to be appropriately
 
 9 designated and to read as follows:
 
10      "432:1-   Emergency medical services.(a)  As used in
 
11 this section unless the context otherwise requires:
 
12      "Emergency medical condition" means a medical condition that
 
13 manifests itself by acute symptoms of sufficient severity,
 
14 including severe pain, such that a prudent layperson, who
 
15 possesses an average knowledge of health and medicine, could
 
16 reasonably expect the absence of immediate medical attention to
 
17 result in:
 
18      (1)  Placing the health of the individual (or, with respect
 
19           to a pregnant woman, the health of the woman or her
 
20           unborn child) in serious jeopardy;
 
21      (2)  Serious impairment to bodily functions; or
 
22      (3)  Serious dysfunction of any bodily organ or part.
 

 
 
 
Page 23                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      "Emergency services" means:
 
 2      (1)  A medical screening examination (as required by federal
 
 3           law) that is within the capability of the emergency
 
 4           department of a hospital, including ancillary services
 
 5           routinely available to the emergency department, to
 
 6           evaluate an emergency medical condition; or
 
 7      (2)  Such further medical examination and treatment (as
 
 8           required by federal law) that is within the
 
 9           capabilities of the staff and facilities available at
 
10           the hospital (including any trauma and burn center of
 
11           the hospital), to stabilize an emergency medical
 
12           condition.
 
13      "Stabilize" means the provision of medical treatment as may
 
14 be necessary to assure, within reasonable medical probability,
 
15 that no material deterioration of an individual's medical
 
16 condition is likely to result from or occur during a transfer to
 
17 another facility, if the medical condition could result in:
 
18      (1)  Placing the health of the individual (or with respect
 
19           to a pregnant woman, the health of the woman or her
 
20           unborn child) in serious jeopardy;
 
21      (2)  Serious impairment to bodily functions; or
 
22      (3)  Serious dysfunction of any bodily organ or part.
 

 
 
 
Page 24                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1 In the case of a woman having contractions, "stabilize" means
 
 2 medical treatment as may be necessary to deliver (including the
 
 3 placenta).
 
 4      "Stabilized" means that no material deterioration of an
 
 5 individual's medical condition, as described in this subsection,
 
 6 is likely, within reasonable medical probability, to result from
 
 7 or occur during the transfer of the individual from a facility,
 
 8 or in the case of a woman having contractions, that the woman has
 
 9 delivered (including the placenta).
 
10      (b)  A health plan shall cover emergency services provided
 
11 twenty-four hours a day, seven days a week to members with
 
12 emergency medical conditions without regard to whether the
 
13 member, or an emergency provider treating the member, obtained
 
14 prior authorization for these services.
 
15      (c)  A health plan shall cover emergency services provided
 
16 to a member at a participating emergency department if the member
 
17 presents oneself with an emergency medical condition.
 
18      (d)  A health plan shall cover emergency services provided
 
19 to a member at a nonparticipating emergency department up to the
 
20 point of stabilization if:
 
21      (1)  The member presents oneself with an emergency medical
 
22           condition; and
 

 
 
 
Page 25                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (2)  One of the following applies:
 
 2           (A)  Due to circumstances beyond the member's control,
 
 3                the member was unable to arrive at a participating
 
 4                emergency department without serious threat to
 
 5                life or health;
 
 6           (B)  A prudent layperson possessing an average
 
 7                knowledge of health and medicine would have
 
 8                reasonably believed that, under the circumstances,
 
 9                the time required to go to a participating
 
10                emergency provider or department could result in
 
11                one or more of the following:
 
12                (i)  Placing the health of the individual (or,
 
13                     with respect to a pregnant woman, the health
 
14                     of the woman or her unborn child) in serious
 
15                     jeopardy;
 
16               (ii)  Serious impairment to bodily functions; or
 
17              (iii)  Serious dysfunction of any bodily organ or
 
18                     part; or
 
19           (C)  A person authorized by the health plan refers the
 
20                member to an emergency department and does not
 
21                specify a participating emergency department.
 
22      (e)  Except as provided in subsection (f), a health plan
 
23 shall not be required to reimburse an emergency provider or an
 

 
Page 26                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1 emergency department for any services, other than those medically
 
 2 necessary to stabilize a member, until:
 
 3      (1)  The emergency department has contacted the member's
 
 4           health benefits plan; and
 
 5      (2)  There is agreement between the emergency provider and
 
 6           the plan concerning treatment and services to be
 
 7           provided by the emergency provider after the member is
 
 8           stabilized.
 
 9      (f)  A health plan shall select between the following two
 
10 options:
 
11           (1)  A health plan shall reimburse an emergency
 
12                provider and an emergency department for any items
 
13                or services not necessary to stabilize the patient
 
14                but that are determined to be medically necessary
 
15                to treat the illness that [lead] led the patient
 
16                to believe that he or she had an emergency medical
 
17                condition, and that a reasonable patient would
 
18                expect to receive from a physician at the time of
 
19                presentation[.]; or
 
20           (2)  A health plan shall reimburse an emergency
 
21                provider and an emergency department for any items
 
22                or services not necessary to stabilize the patient
 
23                but that are determined to be medically necessary
 

 
Page 27                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1                by the emergency provider, if the emergency
 
 2                department:
 
 3                (A)  After a documented good faith effort, is
 
 4                     unable to reach the enrollee's health plan:
 
 5                     (i)  Within thirty minutes from the initial
 
 6                          examination of the enrollee; or
 
 7                    (ii)  If the enrollee needs to be stabilized,
 
 8                          within thirty minutes of stabilization;
 
 9                          or
 
10                (B)  Has successfully contacted the plan as
 
11                     required in paragraph (A) above, and has not
 
12                     received a denial from the plan within thirty
 
13                     minutes of the initial contact, unless the
 
14                     plan is able to document that it has made an
 
15                     unsuccessful good faith effort to reach the
 
16                     emergency department within thirty minutes
 
17                     after receiving the request for
 
18                     authorization; or
 
19                (C)  Has successfully contacted the plan and has
 
20                     received a denial from a person other than a
 
21                     participating physician and:
 
22                     (i)  A participating physician authorized by
 
23                          the plan to review denials reverses the
 
24                          denial; or
 

 
Page 28                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1                    (ii)  A participating physician authorized by
 
 2                          the plan to review denials fails to
 
 3                          communicate a determination affirming
 
 4                          the denial unless the treating physician
 
 5                          waives the requirement for such
 
 6                          determination, within thirty minutes
 
 7                          after the initial denial is communicated
 
 8                          by the plan; and
 
 9           (3)  A health plan shall immediately arrange for an
 
10                alternate plan of treatment for the member in the
 
11                event a non-participating emergency provider and
 
12                the plan are unable to reach agreement on services
 
13                necessary beyond those immediately needed to
 
14                stabilize the member, under which:
 
15                (A)  A participating physician with privileges at
 
16                     the hospital arrives at the emergency
 
17                     department of the hospital promptly and
 
18                     assumes responsibility for the treatment of
 
19                     the member; or
 
20                (B)  With the agreement of the treating physician
 
21                     or another health professional in the
 
22                     emergency department:
 

 
 
 
Page 29                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1                     (i)  Arrangement is made for transfer of the
 
 2                          member to another facility using medical
 
 3                          resources consistent with the condition
 
 4                          of the enrollee;
 
 5                    (ii)  An appointment is made with a
 
 6                          participating physician or provider for
 
 7                          treatment needed by the enrollee; or
 
 8                   (iii)  Another arrangement is made for
 
 9                          treatment of the enrollee.
 
10      (g)  A health plan that arranges for, or otherwise covers,
 
11 urgent care services and comprehensive primary care may impose
 
12 different cost-sharing on the member for:
 
13      (1)  Use of an emergency department over another setting;
 
14           and
 
15      (2)  Use of a nonparticipating emergency department over a
 
16           participating emergency department unless:
 
17           (A)  Due to circumstances beyond the member's control,
 
18                the member was unable to arrive at a participating
 
19                emergency department without serious threat to
 
20                life or health; or
 
21           (B)  A prudent layperson possessing an average
 
22                knowledge of health and medicine would have
 
23                reasonably believed that, under the circumstances,
 

 
Page 30                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1                the time required to go to a participating
 
 2                emergency department could result in one or more
 
 3                of the following:
 
 4                (i)  Placing the health of the individual (or,
 
 5                     with respect to a pregnant woman, the health
 
 6                     of the woman or her unborn child) in serious
 
 7                     jeopardy;
 
 8               (ii)  Serious impairment to bodily functions; or
 
 9              (iii)  Serious dysfunction of any bodily organ or
 
10                     part.
 
11      (h)  A health plan that provides coverage for emergency
 
12 medical services shall educate members on:
 
13      (1)  Coverage for emergency medical services;
 
14      (2)  The appropriate use of emergency services, including
 
15           the use of the 911 system and other telephone access
 
16           systems used to access prehospital emergency services;
 
17      (3)  Any cost sharing provisions for emergency services; and
 
18      (4)  The procedures for obtaining emergency and other
 
19           medical services so that members are familiar with the
 
20           location of in-plan emergency departments and with the
 
21           location and availability of other in-plan settings at
 
22           which they could receive medical care.
 

 
 
 
Page 31                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      SECTION 3.  Chapter 432D, Hawaii Revised Statutes, is
 
 2 amended by adding a new section to be appropriately designated
 
 3 and to read as follows:
 
 4      "432D-   Emergency medical services.(a)  As used in
 
 5 this section unless the context otherwise requires:
 
 6      "Emergency medical condition" means a medical condition that
 
 7 manifests itself by acute symptoms of sufficient severity,
 
 8 including severe pain, such that a prudent layperson, who
 
 9 possesses an average knowledge of health and medicine, could
 
10 reasonably expect the absence of immediate medical attention to
 
11 result in:
 
12      (1)  Placing the health of the individual (or, with respect
 
13           to a pregnant woman, the health of the woman or her
 
14           unborn child) in serious jeopardy;
 
15      (2)  Serious impairment to bodily functions; or
 
16      (3)  Serious dysfunction of any bodily organ or part.
 
17      "Emergency services" means:
 
18      (1)  A medical screening examination (as required by federal
 
19           law) that is within the capability of the emergency
 
20           department of a hospital, including ancillary services
 
21           routinely available to the emergency department, to
 
22           evaluate an emergency medical condition; or
 

 
 
 
Page 32                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (2)  Such further medical examination and treatment (as
 
 2           required by federal law) that is within the
 
 3           capabilities of the staff and facilities available at
 
 4           the hospital (including any trauma and burn center of
 
 5           the hospital), to stabilize an emergency medical
 
 6           condition.
 
 7      "Stabilize" means the provision of medical treatment as may
 
 8 be necessary to assure, within reasonable medical probability,
 
 9 that no material deterioration of an individual's medical
 
10 condition is likely to result from or occur during a transfer to
 
11 another facility, if the medical condition could result in:
 
12      (1)  Placing the health of the individual (or with respect
 
13           to a pregnant woman, the health of the woman or her
 
14           unborn child) in serious jeopardy;
 
15      (2)  Serious impairment to bodily functions; or
 
16      (3)  Serious dysfunction of any bodily organ or part.
 
17 In the case of a woman having contractions, "stabilize" means
 
18 medical treatment as may be necessary to deliver (including the
 
19 placenta).
 
20      "Stabilized" means that no material deterioration of an
 
21 individual's medical condition, as described in this subsection,
 
22 is likely, within reasonable medical probability, to result from
 
23 or occur during the transfer of the individual from a facility,
 

 
Page 33                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1 or in the case of a woman having contractions, that the woman has
 
 2 delivered (including the placenta).
 
 3      (b)  A health plan shall cover emergency services provided
 
 4 twenty-four hours a day, seven days a week to members with
 
 5 emergency medical conditions without regard to whether the
 
 6 member, or an emergency provider treating the member, obtained
 
 7 prior authorization for these services.
 
 8      (c)  A health plan shall cover emergency services provided
 
 9 to a member at a participating emergency department if the member
 
10 presents oneself with an emergency medical condition.
 
11      (d)  A health plan shall cover emergency services provided
 
12 to a member at a nonparticipating emergency department up to the
 
13 point of stabilization if:
 
14      (1)  The member presents oneself with an emergency medical
 
15           condition; and
 
16      (2)  One of the following applies:
 
17           (A)  Due to circumstances beyond the member's control,
 
18                the member was unable to arrive at a participating
 
19                emergency department without serious threat to
 
20                life or health;
 
21           (B)  A prudent layperson possessing an average
 
22                knowledge of health and medicine would have
 
23                reasonably believed that, under the circumstances,
 

 
Page 34                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1                the time required to go to a participating
 
 2                emergency provider or department could result in
 
 3                one or more of the following:
 
 4                (i)  Placing the health of the individual (or,
 
 5                     with respect to a pregnant woman, the health
 
 6                     of the woman or her unborn child) in serious
 
 7                     jeopardy;
 
 8               (ii)  Serious impairment to bodily functions; or
 
 9              (iii)  Serious dysfunction of any bodily organ or
 
10                     part;
 
11                or
 
12           (C)  A person authorized by the health plan refers the
 
13                member to an emergency department and does not
 
14                specify a participating emergency department.
 
15      (e)  Except as provided in subsection (f), a health plan
 
16 shall not be required to reimburse an emergency provider or an
 
17 emergency department for any services, other than those medically
 
18 necessary to stabilize a member, until:
 
19      (1)  The emergency department has contacted the member's
 
20           health benefits plan; and
 
21      (2)  There is agreement between the emergency provider and
 
22           the plan concerning treatment and services to be
 
23           provided by the emergency provider after the member is
 
24           stabilized.
 

 
Page 35                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (f)  A health plan shall select between the following two
 
 2 options:
 
 3      (1)  A health plan shall reimburse an emergency provider and
 
 4           an emergency department for any items or services not
 
 5           necessary to stabilize the patient but that are
 
 6           determined to be medically necessary to treat the
 
 7           illness that [lead] led the patient to believe that he
 
 8           or she had an emergency medical condition, and that a
 
 9           reasonable patient would expect to receive from a
 
10           physician at the time of presentation[.]; or
 
11      (2)  A health plan shall reimburse an emergency provider and
 
12           an emergency department for any items or services not
 
13           necessary to stabilize the patient but that are
 
14           determined to be medically necessary by the emergency
 
15           provider, if the emergency department:
 
16 ]         (A)  After a documented good faith effort, is unable to
 
17                reach the enrollee's health plan:
 
18                (i)  Within thirty minutes from the initial
 
19                     examination of the enrollee; or
 
20               (ii)  If the enrollee needs to be stabilized,
 
21                     within thirty minutes of stabilization; or
 
22           (B)  Has successfully contacted the plan as required in
 
23                paragraph (A) above, and has not received a denial
 

 
Page 36                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1                from the plan within thirty minutes of the initial
 
 2                contact, unless the plan is able to document that
 
 3                it has made an unsuccessful good faith effort to
 
 4                reach the emergency department within thirty
 
 5                minutes after receiving the request for
 
 6                authorization; or
 
 7           (C)  Has successfully contacted the plan and has
 
 8                received a denial from a person other than a
 
 9                participating physician and:
 
10                (i)  A participating physician authorized by the
 
11                     plan to review denials reverses the denial;
 
12                     or
 
13               (ii)  A participating physician authorized by the
 
14                     plan to review denials fails to communicate a
 
15                     determination affirming the denial unless the
 
16                     treating physician waives the requirement for
 
17                     such determination, within thirty minutes
 
18                     after the initial denial is communicated by
 
19                     the plan; and
 
20      (3)  A health plan shall immediately arrange for an
 
21           alternate plan of treatment for the member in the event
 
22           a non-participating emergency provider and the plan are
 
23           unable to reach agreement on services necessary beyond
 

 
Page 37                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1           those immediately needed to stabilize the member, under
 
 2           which:
 
 3           (A)  A participating physician with privileges at the
 
 4                hospital arrives at the emergency department of
 
 5                the hospital promptly and assumes responsibility
 
 6                for the treatment of the member; or
 
 7           (B)  With the agreement of the treating physician or
 
 8                another health professional in the emergency
 
 9                department:
 
10                (i)  Arrangement is made for transfer of the
 
11                     member to another facility using medical
 
12                     resources consistent with the condition of
 
13                     the enrollee;
 
14               (ii)  An appointment is made with a participating
 
15                     physician or provider for treatment needed by
 
16                     the enrollee; or
 
17              (iii)  Another arrangement is made for treatment of
 
18                     the enrollee.
 
19      (g)  A health plan that arranges for, or otherwise covers,
 
20 urgent care services and comprehensive primary care may impose
 
21 different cost-sharing on the member for:
 
22      (1)  Use of an emergency department over another setting;
 
23           and
 

 
Page 38                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (2)  Use of a nonparticipating emergency department over a
 
 2           participating emergency department unless:
 
 3           (A)  Due to circumstances beyond the member's control,
 
 4                the member was unable to arrive at a participating
 
 5                emergency department without serious threat to
 
 6                life or health; or
 
 7           (B)  A prudent layperson possessing an average
 
 8                knowledge of health and medicine would have
 
 9                reasonably believed that, under the circumstances,
 
10                the time required to go to a participating
 
11                emergency department could result in one or more
 
12                of the following:
 
13                (i)  Placing the health of the individual (or,
 
14                     with respect to a pregnant woman, the health
 
15                     of the woman or her unborn child) in serious
 
16                     jeopardy;
 
17               (ii)  Serious impairment to bodily functions; or
 
18              (iii)  Serious dysfunction of any bodily organ or
 
19                     part.
 
20      (i)  A health plan that provides coverage for emergency
 
21 medical services shall educate members on:
 
22      (1)  Coverage for emergency medical services;
 

 
 
 
Page 39                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      (2)  The appropriate use of emergency services, including
 
 2           the use of the 911 system and other telephone access
 
 3           systems used to access prehospital emergency services;
 
 4      (3)  Any cost sharing provisions for emergency services; and
 
 5      (4)  The procedures for obtaining emergency and other
 
 6           medical services so that members are familiar with the
 
 7           location of in-plan emergency departments and with the
 
 8           location and availability of other in-plan settings at
 
 9           which they could receive medical care."
 
10      SECTION 10.  Upon approval of this Act, each mutual benefit
 
11 society under article 1 of chapter 432, Hawaii Revised Statutes,
 
12 health maintenance organization under chapter 432D, Hawaii
 
13 Revised Statutes, and any other entity offering or providing
 
14 health benefits or services under the regulation of the
 
15 commissioner, except an insurer licensed to offer health
 
16 insurance under article 10A of chapter 431, Hawaii Revised
 
17 Statutes, shall pay to the commissioner at a time determined by
 
18 the commissioner, a one-time deposit in an amount not to exceed
 
19 an aggregate amount of $150,000, to be credited to the health
 
20 insurance revolving fund.
 
21      SECTION 11.  There is appropriated out of the health
 
22 insurance revolving fund the sum of $100,000, or so much thereof
 
23 as may be necessary for fiscal year 1999-2000, and the same sum,
 

 
Page 40                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1 or so much thereof as may be necessary for fiscal year 2000-2001
 
 2 to carry out the purposes of this Act.
 
 3      SECTION 12.  The sums appropriated shall be expended by the
 
 4 department of commerce and consumer affairs for the purposes of
 
 5 this Act.
 
 6      SECTION 13.  There is appropriated out of the health
 
 7 insurance revolving fund the sum of $50,000, or so much thereof
 
 8 as may be necessary for fiscal year 1999-2000, and the same sum,
 
 9 or so much thereof as may be necessary for fiscal year 2000-2001
 
10 to carry out the purposes of this Act.
 
11      SECTION 14.  The sums appropriated shall be expended by the
 
12 department of commerce and consumer affairs for the purposes of
 
13 this Act.
 
14      SECTION 15.  There is appropriated out of the health
 
15 insurance revolving fund the sum of $          , or so much
 
16 thereof as may be necessary for fiscal year 1999-2000, and the
 
17 same sum, or so much thereof as may be necessary for fiscal year
 
18 2000-2001 to carry out the purposes of this Act.
 
19      SECTION 16.  The sums appropriated shall be expended by the
 
20 department of commerce and consumer affairs for the purposes of
 
21 this Act.
 
22      SECTION 17.  Statutory material to be repealed is bracketed.
 
23 New statutory material is underscored.
 

 
Page 41                                                    1664
                                     H.B. NO.           H.D.1
                                                        
                                                        

 
 1      SECTION 18.  This Act shall take effect on July 1, l999;
 
 2 provided that sections 3, 5, and 9 of this Act are repealed on
 
 3 July 1, 2003, and that sections 431:10C-103, and 432E-3, Hawaii
 
 4 Revised Statutes, are reenacted in the form in which they read on
 
 5 the day before the effective date of this Act.