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 SD1)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        1664
HOUSE OF REPRESENTATIVES                H.B. NO.           H.D. 3
TWENTIETH LEGISLATURE, 1999                                S.D. 1
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:
 
23      (1)  Placing the health of the individual or, with respect
 

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

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

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

 
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 1 for the actual expenses in administering the survey.
 
 2      (e)  A managed care plan shall not be assessed for its pro
 
 3 rata share of the cost of conducting the consumer assessment
 
 4 health plan survey under subsection (a) if the managed care plan
 
 5 has already conducted the survey on its own.
 
 6      (f)  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 not to exceed an aggregate amount
 
22 of $150,000.  The deposit shall be credited to the health
 
23 insurance revolving fund.
 

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

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

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

 
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 1           the panel and shall conduct a review hearing pursuant
 
 2           to chapter 91.  Where the amount in controversy is less
 
 3           than $500, the commissioner may conduct a review
 
 4           hearing without appointing a review panel;
 
 5      (3)  The review hearing shall be conducted as soon as
 
 6           practicable taking into consideration the medical
 
 7           exigencies of the case; provided that the hearing is
 
 8           held no later than sixty days from the date of the
 
 9           request for hearing;
 
10      (4)  The commissioner may retain an independent medical
 
11           expert who is trained in the field of medicine most
 
12           appropriately related to the matter under review and
 
13           who shall not be subject to chapters 76 and 77.  The
 
14           independent medical evidence shall be exempt from the
 
15           requirements of section 91-9(g);
 
16     [(3)] (5)  After considering the enrollee's complaint, the
 
17           plan's response, and any affidavits filed by the
 
18           parties, the commissioner may dismiss the appeal if it
 
19           is determined that the appeal is frivolous or without
 
20           merit[.];
 
21      (6)  The review panel shall review the adverse determination
 
22           to determine whether the plan acted reasonably and with
 
23           sound medical judgment.  The review panel shall
 

 
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 1           consider:
 
 2           (A)  The clinical standards of the plan;
 
 3           (B)  The information provided;
 
 4           (C)  The attending physician's recommendations; and
 
 5           (D)  Generally accepted practice guidelines; and
 
 6      (7)  The commissioner, upon a majority vote of the panel,
 
 7           shall issue an order affirming, modifying, or reversing
 
 8           the decision within thirty days of the hearing.
 
 9      (b)  The procedure set forth in this section shall not apply
 
10 to claims or allegations of health provider malpractice,
 
11 professional negligence, or other professional fault against
 
12 participating providers.
 
13      (c)  [The commissioner may adopt rules pursuant to chapter
 
14 91 to carry out the purposes of this section.] The members of the
 
15 review panel shall have immunity from monetary liability relating
 
16 to their duties as members of the review panel.
 
17      (d)  An enrollee may be allowed, at the commissioner's
 
18 discretion, an award of a reasonable sum for attorney's fees and
 
19 reasonable costs of suit in an action brought against a plan."
 
20      SECTION 7.  Section 432E-7, Hawaii Revised Statutes, is
 
21 amended to read as follows:
 
22      "[[]432E-7[]]  Information to enrollees.  (a)  The managed
 
23 care plan shall provide to its enrollees upon enrollment and
 

 
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 1 thereafter upon request the following information:
 
 2      (1)  A list of participating providers [which] that shall
 
 3           [indicate their specialty and whether board
 
 4           certification has been attained;] be updated on a
 
 5           regular basis indicating, at a minimum, their specialty
 
 6           and whether the provider is accepting new patients;
 
 7      (2)  A complete description of benefits, services, and
 
 8           copayments;
 
 9      (3)  A statement on enrollee's rights, responsibilities, and
 
10           obligations;
 
11      (4)  An explanation of the referral process, if any;
 
12      (5)  Where services or benefits may be obtained;
 
13     [(6)  A statement regarding informed consent;
 
14      (7)] (6) Information on complaints and appeals procedures;
 
15           and
 
16     [(8)] (7)  The telephone number of the insurance division
 
17           [and the office of consumer complaints].
 
18 This information shall be provided to prospective enrollees upon
 
19 request.
 
20      (b)  Every managed care plan shall provide to the
 
21 commissioner and its enrollees notice of any material change in
 
22 [the operation of the organization initiated by the plan that
 
23 will affect them directly within thirty days of the material
 

 
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 1 change.] participating provider agreements, services, or benefits
 
 2 where:
 
 3      (1)  The change affects the organization and operation of
 
 4           the managed care plan; and
 
 5      (2)  The change affects enrollees' services or benefits.
 
 6 The managed care plan shall provide notice to enrollees within
 
 7 sixty days of the change in a format that makes the notice clear
 
 8 and conspicuous such that it is readily noticeable by the
 
 9 enrollee.
 
10      (c)  [For purposes of this section "material change" means a
 
11 change in participating provider agreements, services, or
 
12 benefits.] All managed care plans shall provide generic
 
13 participating provider contracts to enrollees, upon request."
 
14      SECTION 8.  Section 432E-10, Hawaii Revised Statutes, is
 
15 amended by amending subsection (a) to read as follows:
 
16      "(a)  It is the policy of this State that all managed care
 
17 plans shall adopt and comply with [nationally developed]
 
18 nationally-developed and [promulgated] adopted standards for
 
19 measuring quality, outcomes, access, satisfaction, and
 
20 utilization of services.  Every contract between a managed care
 
21 plan and a participating provider of health care services shall
 
22 require the participating provider to comply with the managed
 
23 care plan's requests for any information necessary for the
 

 
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 1 managed care plan to comply with the requirements of this
 
 2 chapter.  [The standard to be applied is the Health Employer Data
 
 3 and Information Set (HEDIS) 3.0 data set, as amended from time to
 
 4 time.]  The State shall require that:
 
 5      (1)  Consumers, providers, managed care plans, purchasers,
 
 6           and regulators shall be equitably represented in the
 
 7           development of standards; and
 
 8      (2)  Standards shall result in measurement and reporting
 
 9           that is purposeful, valid and scientifically based,
 
10           applied in a consistent and comparable manner,
 
11           efficient and cost effective, and designed to minimize
 
12           redundancy and duplication of effort."
 
13      SECTION 9.  Act 246, Session Laws of Hawaii 1998, is amended
 
14 by amending sections 1 to 3 to read as follows:
 
15      "SECTION 1.  Chapter 431, Hawaii Revised Statutes, is
 
16 amended by adding a new section to article 10A to be
 
17 appropriately designated and to read as follows:
 
18      "431:10A-   Emergency medical services.(a)  As used in
 
19 this section unless the context otherwise requires:
 
20      "Emergency medical condition" means a medical condition that
 
21 manifests itself by acute symptoms of sufficient severity,
 
22 including severe pain, such that a prudent layperson, who
 
23 possesses an average knowledge of health and medicine, could
 

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

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

 
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 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;
 

 
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 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 provider and
 
18           an emergency department for any items or services that
 
19           are not necessary to stabilize the patient but that are
 
20           determined to be medically necessary to treat the
 
21           illness that [lead] led the patient to believe that [he
 
22           or she] the patient had an emergency medical condition,
 
23           and that a reasonable patient would expect to receive
 

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

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

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

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

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

 
Page 24                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 25                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 26                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 27                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 28                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 29                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 30                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 31                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.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.
 
 8      (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 3.  Chapter 432D, Hawaii Revised Statutes, is
 
22 amended by adding a new section to be appropriately designated
 
23 and to read as follows:
 

 
Page 32                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

 
 1      "432D-   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
 
23           the hospital (including any trauma and burn center of
 

 
Page 33                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 34                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 35                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

 
 1                     with respect to a pregnant woman, the health
 
 2                     of the woman or her unborn child) in serious
 
 3                     jeopardy;
 
 4               (ii)  Serious impairment to bodily functions; or
 
 5              (iii)  Serious dysfunction of any bodily organ or
 
 6                     part;
 
 7                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:
 
23      (1)  A health plan shall reimburse an emergency provider and
 

 
Page 36                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 37                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 38                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 39                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

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

 
Page 40                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

 
 1           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 10.  Upon approval of this Act, each mutual benefit
 
 8 society under article 1 of chapter 432, Hawaii Revised Statutes,
 
 9 health maintenance organization under chapter 432D, Hawaii
 
10 Revised Statutes, and any other entity offering or providing
 
11 health benefits or services under the regulation of the
 
12 commissioner, except an insurer licensed to offer health
 
13 insurance under article 10A of chapter 431, Hawaii Revised
 
14 Statutes, shall pay to the commissioner at a time determined by
 
15 the commissioner, a one-time deposit in an amount not to exceed
 
16 an aggregate amount of $150,000, to be credited to the health
 
17 insurance revolving fund.
 
18      SECTION 11.  There is appropriated out of the health
 
19 insurance revolving fund the sum of $100,000 or so much thereof
 
20 as may be necessary for fiscal year 1999-2000 and the same sum or
 
21 so much thereof as may be necessary for fiscal year 2000-2001 to
 
22 hire medical experts for the three-member review panel.
 
23      The sums appropriated shall be expended by the department of
 

 
Page 41                                                    1664
                                     H.B. NO.           H.D. 3
                                                        S.D. 1
                                                        

 
 1 commerce and consumer affairs for the purposes of this Act.
 
 2      SECTION 12.  There is appropriated out of the health
 
 3 insurance revolving fund the sum of $50,000 or so much thereof as
 
 4 may be necessary for fiscal year 1999-2000 and the same sum or so
 
 5 much thereof as may be necessary for fiscal year 2000-2001 to
 
 6 develop an educational awareness program regarding managed health
 
 7 care in Hawaii.
 
 8      The sums appropriated shall be expended by the department of
 
 9 commerce and consumer affairs for the purposes of this Act.
 
10      SECTION 13.  There is appropriated out of the health
 
11 insurance revolving fund the sum of $         or so much thereof
 
12 as may be necessary for fiscal year 1999-2000 and the same sum or
 
13 so much thereof as may be necessary for fiscal year 2000-2001 to
 
14 carry out the purposes of this Act.
 
15      The sums appropriated shall be expended by the department of
 
16 commerce and consumer affairs for the purposes of this Act.
 
17      SECTION 14.  Statutory material to be repealed is bracketed.
 
18 New statutory material is underscored.
 
19      SECTION 15.  This Act shall take effect on July 1, 1999;
 
20 provided that sections 2, 4, and 9 of this Act are repealed on
 
21 July 1, 2003, and that sections 431:10C-103 and 432E-3, Hawaii
 
22 Revised Statutes, are reenacted in the form in which they read on
 
23 the day before the effective date of this Act.