REPORT TITLE:
Medical Directors; Licensure

DESCRIPTION:
Requires that medical directors of managed health care plans be
licensed to practice medicine in Hawaii.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                            325         
HOUSE OF REPRESENTATIVES                H.B. NO.           
TWENTIETH LEGISLATURE, 1999                                
STATE OF HAWAII                                            
                                                             
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                   A  BILL  FOR  AN  ACT

RELATING TO HEALTH.



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

 1      SECTION 1.  The legislature finds and declares that medical
 
 2 necessity decisions are clinical decisions and should be made by
 
 3 physicians who have a medical license to practice in the state
 
 4 where the patient care occurs.  The medical director of any
 
 5 managed health care plan, in making "medical decisions," should
 
 6 therefore be subject to the standards and review of the Hawaii
 
 7 board of medical examiners or board of osteopathic examiners in
 
 8 the same manner as a practicing physician, and should be held to
 
 9 the same medical malpractice liability to which an individual
 
10 practicing physician is subject.
 
11      The purpose of this Act is to require that medical directors
 
12 of managed care plans be licensed to practice medicine in Hawaii.
 
13      SECTION 2.  The Hawaii Revised Statutes is amended by adding
 
14 a new chapter to be appropriately designated and to read as
 
15 follows:  
 
16                            "CHAPTER 
 
17             LICENSURE OF MANAGED CARE PLAN DIRECTORS
 
18       -1 Definitions.  As used in this chapter:
 

 
Page 2                                         325         
                                     H.B. NO.           
                                                        
                                                        

 
 1      "Managed care plan" means any plan, regardless of form,
 
 2 offered or administered by any person or entity, including but
 
 3 not limited to an insurer governed by chapter 431, a mutual
 
 4 benefit society governed by chapter 432, a health maintenance
 
 5 organization governed by chapter 432D, a preferred provider
 
 6 organization, a point of service organization, a health insurance
 
 7 issuer, a fiscal intermediary, a payor, a prepaid health care
 
 8 plan, or any other mixed model, that provides for the financing
 
 9 or delivery of health care services or benefits to enrollees
 
10 through:
 
11      (1)  Arrangements with selected providers or provider
 
12           networks to furnish health care services or benefits;
 
13           and
 
14      (2)  Financial incentives for enrollees to use participating
 
15           providers and procedures provided by a plan;
 
16      "Medical director" means the person who recommends denial of
 
17 coverage or payment, or determines that a service should not be
 
18 provided, based on medical necessity or appropriate standards.
 
19      "Medical necessity" means the standard for health care
 
20 services as determined by physicians and health care providers in
 
21 accordance with the prevailing practices and standards of the
 
22 medical profession and community.
 
23         -2  Licensure of managed care plan medical directors.
 

 
Page 3                                         325         
                                     H.B. NO.           
                                                        
                                                        

 
 1 The medical director of any managed care plan providing services
 
 2 in the State must have an unlimited license to practice medicine
 
 3 in the State pursuant to chapter 453, relating to the practice of
 
 4 medicine or chapter 460, relating to the practice of osteopathic
 
 5 medicine." 
 
 6      SECTION 3.  This Act shall take effect upon its approval.
 
 7 
 
 8                           INTRODUCED BY:  _______________________