REPORT TITLE:
Patient Rights


DESCRIPTION:
Implements the recommendations of the patient rights and
responsibilities task force to strengthen the Hawaii patient bill
of rights and responsibilities act and related laws. (HB1664 HD3)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        1664
HOUSE OF REPRESENTATIVES                H.B. NO.           H.D. 3
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.
 
 8      The purpose of this Act is to enact the task force's
 
 9 recommendations for statutory revisions that ensure the
 
10 protection of consumer rights.
 
11      SECTION 2.  Section 431:10C-103, Hawaii Revised Statutes, is
 
12 amended by adding three new definitions to be appropriately
 
13 inserted and to read as follows:
 
14      ""Emergency medical condition" means a medical condition
 
15 that manifests itself by acute symptoms of sufficient severity,
 
16 including severe pain, such that a prudent layperson, who
 
17 possesses an average knowledge of health and medicine, could
 
18 reasonably expect the absence of immediate medical attention to
 
19 result in:
 

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

 
 
 
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 1      (1)  Placing the health of the individual or, with respect
 
 2           to a pregnant woman, the health of the woman or her
 
 3           unborn child, in serious jeopardy;
 
 4      (2)  Serious impairment to bodily functions; or
 
 5      (3)  Serious dysfunction of any bodily organ or part."
 
 6      SECTION 3.  Chapter 432E, Hawaii Revised Statutes, is
 
 7 amended by adding four new sections to be appropriately
 
 8 designated and to read as follows:
 
 9      "432E-    Annual report.  The commission shall prepare and
 
10 submit to the legislature on an annual basis, a report which
 
11 shall:
 
12      (1)  Contain the number of external review hearing cases
 
13           reviewed;
 
14      (2)  The type of cases reviewed;
 
15      (3)  A summary of the nature of the cases reviewed; and
 
16      (4)  The disposition of the cases reviewed.
 
17 The identities of the plan and the enrollee shall be protected
 
18 from disclosure in the report.
 
19      432E-    Health insurance revolving fund.  (a)  There is
 
20 established a revolving fund in the state treasury to be
 
21 administered by the commissioner and to be designated as the
 
22 health insurance revolving fund.
 

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

 
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                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
 
 
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 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)  A managed care plan shall not be assessed for its pro
 
 7 rata share of the cost of conducting the consumer assessment
 
 8 health plan survey, referred to in subsection (a) if the managed
 
 9 care plan has already conducted the survey on its own.
 
10      (f)  Each mutual benefit society under article 1 of chapter
 
11 432, health maintenance organization under chapter 432D, and any
 
12 other entity offering or providing health benefits or services
 
13 under the regulation of the commissioner, except an insurer
 
14 licensed to offer health insurance under article 10A of chapter
 
15 431, shall deposit with the commissioner an amount to provide for
 
16 the actual costs of the survey to be determined by the
 
17 commissioner on July 1 of each year, to be credited to the health
 
18 insurance revolving fund.  In addition, each mutual benefit
 
19 society under article 1 of chapter 432, health maintenance
 
20 organization under chapter 432D, and any other entity offering or
 
21 providing health benefits or services under the regulation of the
 
22 commissioner, except an insurer licensed to offer health
 
23 insurance under article 10A of chapter 431, shall pay to the
 

 
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 1 commissioner at a time to be determined by the commissioner, a
 
 2 one-time deposit in an amount to be determined by the
 
 3 commissioner.  The deposit shall be credited to the health
 
 4 insurance revolving fund.
 
 5      432-    Rules.  The commissioner shall adopt rules pursuant
 
 6 to chapter 91 necessary for the purposes of this chapter."
 
 7      SECTION 4.  Section 432E-3, Hawaii Revised Statutes, is
 
 8 amended to read as follows:
 
 9      "[[]432E-3[]]  Access to services.  A managed care plan
 
10 shall demonstrate to the commissioner upon request that its plan:
 
11      (1)  Makes benefits available and accessible to each
 
12           enrollee electing the managed care plan in the defined
 
13           service area with reasonable promptness and in a manner
 
14           which promotes continuity in the provision of health
 
15           care services;
 
16      (2)  Provides access to sufficient numbers and types of
 
17           providers to ensure that all covered services will be
 
18           accessible without unreasonable delay;
 
19      (3)  When medically necessary, provides health care services
 
20           twenty-four hours a day, seven days a week;
 
21      (4)  Provides a reasonable choice of qualified providers of
 
22           women's health services such as gynecologists,
 
23           obstetricians, certified nurse-midwives, and advanced
 

 
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                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 1           practice nurses to provide preventive and routine
 
 2           women's health care services; [and]
 
 3      (5)  Provides payment or reimbursement for adequately
 
 4           documented emergency services[.] as provided in Act
 
 5           246, Session Laws of Hawaii 1998; and
 
 6      (6)  Allows for standing referrals to specialists who are
 
 7           able to provide and coordinate primary and specialty
 
 8           care for an enrollee's life-threatening, chronic,
 
 9           degenerative, or disabling disease or condition."
 
10      SECTION 5.  Section 432E-5, Hawaii Revised Statutes, is
 
11 amended to read as follows:
 
12      "[[]432E-5[]]  Complaints and appeals procedure for
 
13 enrollees.(a)  A managed care plan with enrollees in this State
 
14 shall establish and maintain a procedure to provide for the
 
15 resolution of an enrollee's complaints and appeals.
 
16      (b)  The managed care plan at all times shall make available
 
17 its complaints and appeals procedures.  The complaints and
 
18 appeals procedures shall be reasonably understandable to the
 
19 average layperson and shall be provided in languages other than
 
20 English upon request.
 
21      (c)  A managed care plan shall send notice of its final
 
22 internal determination to the enrollee and the enrollee's
 

 
 
 
Page 9                                                     1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 1 appointed representative, if applicable, the enrollee's treating
 
 2 provider, and the commissioner.  The notice shall include
 
 3 information:
 
 4      (1)  Regarding the enrollee's right to request external
 
 5           review;
 
 6      (2)  The thirty-day deadline for requesting the external
 
 7           review;
 
 8      (3)  Instructions on how to request external review; and
 
 9      (4)  Where to submit the request for external review."
 
10      SECTION 6.  Section 432E-6, Hawaii Revised Statutes, is
 
11 amended to read as follows:
 
12      "[[]432E-6[]]  Appeals to the commissioner.(a)  After
 
13 exhausting all internal complaint and appeal procedures
 
14 available, an enrollee, or the enrollee's treating provider or
 
15 appointed representative, may appeal an adverse decision of a
 
16 managed care plan to a [three member] three-member review panel
 
17 appointed by the commissioner composed of a representative from a
 
18 health plan not involved in the complaint, a provider licensed to
 
19 practice and practicing medicine in Hawaii not involved in the
 
20 complaint, and with the same or higher level of expertise and
 
21 experience as the treating provider, and the commissioner or the
 
22 commissioner's designee in the following manner:
 

 
 
 
Page 10                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
 
 
Page 11                                                    1664
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 1           parties, the commissioner may dismiss the appeal if it
 
 2           is determined that the appeal is frivolous or without
 
 3           merit[.];
 
 4      (6)  The review panel shall review the adverse determination
 
 5           to determine whether the plan acted reasonably and with
 
 6           sound medical judgment.  The review panel shall
 
 7           consider:
 
 8           (A)  The clinical standards of the plan;
 
 9           (B)  The information provided;
 
10           (C)  The attending physician's recommendations; and
 
11           (D)  Generally accepted practice guidelines; and
 
12      (7)  The commissioner, upon a majority vote of the panel,
 
13           shall issue an order affirming, modifying, or reversing
 
14           the decision within thirty days of the hearing.
 
15      (b)  The procedure set forth in this section shall not apply
 
16 to claims or allegations of health provider malpractice,
 
17 professional negligence, or other professional fault against
 
18 participating providers.
 
19      (c)  [The commissioner may adopt rules pursuant to chapter
 
20 91 to carry out the purposes of this section.] The members of the
 
21 review panel shall have immunity from monetary liability relating
 
22 to their duties as members of the review panel.
 

 
 
 
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 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] that shall
 
10           [indicate their specialty and whether board
 
11           certification has been attained;] be updated on a
 
12           regular basis indicating, at a minimum, their specialty
 
13           and whether 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
 

 
 
 
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 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 and operation of
 
12           the managed care plan; and
 
13      (2)  The change affects enrollees' 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 14                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
 
 
Page 15                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 1      "SECTION 1.  Chapter 431, Hawaii Revised Statutes, is
 
 2 amended by adding a new section to article 10A to be
 
 3 appropriately designated and to read as follows:
 
 4      "431:10A-   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 16                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 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 17                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 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 18                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 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 19                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 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 that
 
 5           are not 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] the patient had an emergency medical condition,
 
 9           and that a reasonable patient would expect to receive
 
10           from a 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 that
 
13           are not 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 member's health plan:
 
18                (i)  Within thirty minutes from the initial
 
19                     examination of the member; or
 
20               (ii)  If the member needs to be stabilized, within
 
21                     thirty minutes of stabilization;
 
22                or
 

 
 
 
Page 20                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 1           (B)  Has successfully contacted the plan as required in
 
 2                paragraph (A) above, and has not received a denial
 
 3                from the plan within thirty minutes of the initial
 
 4                contact, unless the plan is able to document that
 
 5                it has made an unsuccessful good faith effort to
 
 6                reach the emergency department within thirty
 
 7                minutes after receiving the request for
 
 8                authorization;
 
 9                or
 
10           (C)  Has successfully contacted the plan and has
 
11                received a denial from a person other than a
 
12                participating physician and:
 
13                (i)  A participating physician authorized by the
 
14                     plan to review denials reverses the denial;
 
15                     or
 
16               (ii)  A participating physician authorized by the
 
17                     plan to review denials fails to communicate a
 
18                     determination affirming the denial unless the
 
19                     treating physician waives the requirement for
 
20                     such determination, within thirty minutes
 
21                     after the initial denial is communicated by
 
22                     the plan;
 
23           and
 

 
Page 21                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 1      (3)  A health plan shall immediately arrange for an
 
 2           alternate plan of treatment for the member in the event
 
 3           a nonparticipating emergency provider and the plan are
 
 4           unable to reach agreement on services necessary beyond
 
 5           those immediately needed to stabilize the member, under
 
 6           which:
 
 7           (A)  A participating physician with privileges at the
 
 8                hospital arrives at the emergency department of
 
 9                the hospital promptly and assumes responsibility
 
10                for the treatment of the member; or
 
11           (B)  With the agreement of the treating physician or
 
12                another health professional in the emergency
 
13                department:
 
14                (i)  Arrangement is made for transfer of the
 
15                     member to another facility using medical
 
16                     resources consistent with the condition of
 
17                     the member;
 
18               (ii)  An appointment is made with a participating
 
19                     physician or provider for treatment needed by
 
20                     the member; or
 
21              (iii)  Another arrangement is made for treatment of
 
22                     the member.
 

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

 
Page 23                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 1      (h)  A health plan that provides coverage for emergency
 
 2 medical services shall educate members on:
 
 3      (1)  Coverage for emergency medical services;
 
 4      (2)  The appropriate use of emergency services, including
 
 5           the use of the 911 system and other telephone access
 
 6           systems used to access prehospital emergency services;
 
 7      (3)  Any [cost sharing] cost-sharing provisions for
 
 8           emergency services; and
 
 9      (4)  The procedures for obtaining emergency and other
 
10           medical services so that members are familiar with the
 
11           location of in-plan emergency departments and with the
 
12           location and availability of other in-plan settings at
 
13           which they could receive medical care."
 
14      SECTION 2.  Chapter 432, Hawaii Revised Statutes, is amended
 
15 by adding a new section to article 1 to be appropriately
 
16 designated and to read as follows:
 
17      "432:1-   Emergency medical services.(a)  As used in
 
18 this section unless the context otherwise requires:
 
19      "Emergency medical condition" means a medical condition that
 
20 manifests itself by acute symptoms of sufficient severity,
 
21 including severe pain, such that a prudent layperson, who
 
22 possesses an average knowledge of health and medicine, could
 
23 reasonably expect the absence of immediate medical attention to
 
24 result in:
 

 
Page 24                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
 
 
Page 25                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
 
 
Page 26                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 1      (d)  A health plan shall cover emergency services provided
 
 2 to a member at a nonparticipating emergency department up to the
 
 3 point of stabilization if:
 
 4      (1)  The member presents oneself with an emergency medical
 
 5           condition; and
 
 6      (2)  One of the following applies:
 
 7           (A)  Due to circumstances beyond the member's control,
 
 8                the member was unable to arrive at a participating
 
 9                emergency department without serious threat to
 
10                life or health;
 
11           (B)  A prudent layperson possessing an average
 
12                knowledge of health and medicine would have
 
13                reasonably believed that, under the circumstances,
 
14                the time required to go to a participating
 
15                emergency provider or department could result in
 
16                one or more of the following:
 
17                (i)  Placing the health of the individual (or,
 
18                     with respect to a pregnant woman, the health
 
19                     of the woman or her unborn child) in serious
 
20                     jeopardy;
 
21               (ii)  Serious impairment to bodily functions; or
 
22              (iii)  Serious dysfunction of any bodily organ or
 
23                     part;
 

 
Page 27                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
Page 28                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
Page 29                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
 
 
Page 30                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
 
 
Page 31                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 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      (h)  A health plan that provides coverage for emergency
 
21 medical services shall educate members on:
 
22      (1)  Coverage for emergency medical services;
 

 
 
 
Page 32                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
Page 33                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
Page 34                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
Page 35                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 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;
 
19                or
 
20           (C)  A person authorized by the health plan refers the
 
21                member to an emergency department and does not
 
22                specify a participating emergency department.
 

 
 
 
Page 36                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
Page 37                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
Page 38                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

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

 
Page 39                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 1                     resources consistent with the condition of
 
 2                     the member;
 
 3               (ii)  An appointment is made with a participating
 
 4                     physician or provider for treatment needed by
 
 5                     the member; or
 
 6              (iii)  Another arrangement is made for treatment of
 
 7                     the member.
 
 8      (g)  A health plan that arranges for, or otherwise covers,
 
 9 urgent care services and comprehensive primary care may impose
 
10 different cost-sharing on the member for:
 
11      (1)  Use of an emergency department over another setting;
 
12           and
 
13      (2)  Use of a nonparticipating emergency department over a
 
14           participating emergency department unless:
 
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; or
 
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 department could result in one or more
 
24                of the following:
 

 
Page 40                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 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.
 
 8      [(i)](h)  A health plan that provides coverage for emergency
 
 9 medical services shall educate members on:
 
10      (1)  Coverage for emergency medical services;
 
11      (2)  The appropriate use of emergency services, including
 
12           the use of the 911 system and other telephone access
 
13           systems used to access prehospital emergency services;
 
14      (3)  Any [cost sharing] cost-sharing provisions for
 
15           emergency services; and
 
16      (4)  The procedures for obtaining emergency and other
 
17           medical services so that members are familiar with the
 
18           location of in-plan emergency departments and with the
 
19           location and availability of other in-plan settings at
 
20           which they could receive medical care."
 
21      SECTION 10.  Upon approval of this Act, each mutual benefit
 
22 society under article 1 of chapter 432, Hawaii Revised Statutes,
 
23 health maintenance organization under chapter 432D, Hawaii
 

 
Page 41                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 1 Revised Statutes, and any other entity offering or providing
 
 2 health benefits or services under the regulation of the
 
 3 commissioner, except an insurer licensed to offer health
 
 4 insurance under article 10A of chapter 431, Hawaii Revised
 
 5 Statutes, shall pay to the commissioner at a time determined by
 
 6 the commissioner, a one-time deposit in an amount not to exceed
 
 7 an aggregate amount of $150,000, to be credited to the health
 
 8 insurance revolving fund.
 
 9      SECTION 11.  There is appropriated out of the health
 
10 insurance revolving fund the sum of $100,000 or so much thereof
 
11 as may be necessary for fiscal year 1999-2000 and the same sum or
 
12 so much thereof as may be necessary for fiscal year 2000-2001 to
 
13 carry out the purposes of this Act.
 
14      The sums appropriated shall be expended by the department of
 
15 commerce and consumer affairs for the purposes of this Act.
 
16      SECTION 12.  There is appropriated out of the health
 
17 insurance revolving fund the sum of $50,000 or so much thereof as
 
18 may be necessary for fiscal year 1999-2000 and the same sum or so
 
19 much thereof as may be necessary for fiscal year 2000-2001 to
 
20 carry out the purposes of this Act.
 
21      The sums appropriated shall be expended by the department of
 
22 commerce and consumer affairs for the purposes of this Act.
 

 
 
 
Page 42                                                    1664
                                     H.B. NO.           H.D. 3
                                                        
                                                        

 
 1      SECTION 13.  There is appropriated out of the health
 
 2 insurance revolving fund the sum of $         or so much thereof
 
 3 as may be necessary for fiscal year 1999-2000 and the same sum or
 
 4 so much thereof as may be necessary for fiscal year 2000-2001 to
 
 5 carry out the purposes of this Act.
 
 6      The sums appropriated shall be expended by the department of
 
 7 commerce and consumer affairs for the purposes of this Act.
 
 8      SECTION 14.  Statutory material to be repealed is bracketed.
 
 9 New statutory material is underscored.
 
10      SECTION 15.  This Act shall take effect on July 1, l999;
 
11 provided that sections 2, 4, and 9 of this Act are repealed on
 
12 July 1, 2003, and that sections 431:10C-103 and 432E-3, Hawaii
 
13 Revised Statutes, are reenacted in the form in which they read on
 
14 the day before the effective date of this Act.