Report Title:

Medicaid; QUEST; DHS; Positive Enrollment; Request for Proposals



Requires DHS to include in its request for proposals for QUEST providers various provisions to safeguard against disruption of services that may be caused by positive enrollment.



S.B. NO.













Relating to Health Care.





SECTION 1. The legislature finds that the department of human services has instituted a positive enrollment policy whereby a QUEST recipient must reenroll in the recipient's health plan within ten days. If the recipient fails to do so, the department of human services automatically assigns the individual to a health plan, which may or may not be the recipient's existing plan.

The legislature further finds that these positive enrollment requirements cause confusion, delay in needed health care procedures, disrupt case management, and result in the loss of contact between QUEST recipients and their current primary care providers. Further, positive enrollment incurs additional costs and imposes additional administrative burdens on QUEST providers and the department of human services.

The department of human services advocates the policy of positive enrollment as a means of increasing competition among service providers, lowering the cost of healthcare overall, allowing for new plans to enter into the market, and expanding the scope of services provided to QUEST recipients. The legislature finds that it is important to strike a balance between the benefits of positive enrollment and the potential adverse consequences of the policy by allowing the department of human services to implement the policy with limitations.

The purpose of this Act is to place limitations on the department of human services positive enrollment policy to minimize disruption of health care services and confusion among QUEST recipients.

SECTION 2. Chapter 346, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

"346‑   Medicaid managed care; request for proposal requirements. (a) A request for proposal issued by the department for health plans to provide health care services to eligible QUEST recipients shall include the following provisions:

(1) All individuals who are existing members of QUEST health plans shall be required to select a health plan during an initial enrollment period that shall last for a period of sixty days;

(2) In the event that QUEST recipients do not enroll within the sixty-day period, the department shall:

(A) Assign a number of randomly selected QUEST recipients who have not enrolled that is equivalent to no more than five per cent of the total number of QUEST recipients to a health plan according to an automatic assignment algorithm created by the department and described in the request for proposal, provided;

(i) A QUEST recipient who is automatically assigned may have an additional ninety days after the automatic assignment to select a different health plan for any reason;

(ii) If the automatically-assigned QUEST recipient mistakenly goes to a previous plan's provider for an appointment, there shall be no disruption in receipt of service, whether or not that provider is included in the new plan, and the QUEST recipient shall receive treatment at that time and the department shall reimburse the provider; and

(iii) An automatically-assigned QUEST recipient shall have the opportunity to opt out of the health care plan to which the recipient was assigned during the recipient's first visit to a provider under the assigned plan, regardless of the length of time between the automatic assignment and the individual's visit to the provider; and

(B) Assign QUEST recipients who have not enrolled and who were not randomly selected as provided in subparagraph A, if any, to the health plan in which they were enrolled at the start of the initial enrollment period.

(b) The department shall conduct a public awareness campaign to educate medicaid QUEST recipients about their new plan options, including a provider directory of fully contracted providers in each plan to assist beneficiaries in their decision-making.

(c) The director of human services shall adopt, amend, or repeal rules, pursuant to chapter 91, to provide for the request for proposal requirements included in this section."

SECTION 3. New statutory material is underscored.

SECTION 4. This Act shall take effect upon its approval.