HOUSE OF REPRESENTATIVES
TWENTY-NINTH LEGISLATURE, 2017
STATE OF HAWAII
A BILL FOR AN ACT
RELATING TO HEALTH INSURANCE.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:
SECTION 1. The legislature finds that, in health care decisions and services, the physician-patient relationship is of paramount importance and shall not be subject to third-party intrusion. Prior authorization, or prospective review, requirements for coverage of health care services can prioritize attempted cost savings over optimal patient care. The legislature finds that prospective review requirements should not be permitted to hinder effective patient care or to intrude on health care practice or services provided by a licensed professional health care provider. Further, any prospective review program shall include the use of transparent, written clinical review criteria and review by appropriate physicians to ensure a fair process for patients.
The purpose of this Act is to require all health carriers and utilization review organizations to provide a fair, transparent, and consistent prospective review process to ensure optimal patient care.
SECTION 2. Chapter 432E, Hawaii Revised Statutes, is amended by adding five new sections to be appropriately designated and to read as follows:
"§432E- Special provisions for prospective review; non-emergency services. (a) Notwithstanding any other provision of this chapter to the contrary, if a health carrier or utilization review organization requires prospective review of a health care service other than an emergency service, the carrier or organization shall certify the service or make a final adverse determination and notify the enrollee and the enrollee's health care provider within:
(1) Two business days for non-urgent services; and
(2) One business day for urgent services,
of obtaining all necessary information required under section 432E-34(i).
(b) If a health carrier or utilization review organization fails to comply with this section in any prospective review for non-emergency services, the non-emergency services that are the subject of the prospective review shall be deemed to be certified.
432E- Special provisions for prospective review; pre-hospital transportation; emergency services. (a) A health carrier or utilization review organization shall not require prospective review for certification of pre-hospital transportation or for the provision of emergency services.
(b) A health carrier or utilization review organization shall allow an enrollee or the enrollee's health care provider a minimum of twenty-four hours following an emergency admission or the provision of emergency service to notify the carrier or organization of the admission or provision of emergency service. If the admission or provision of emergency services occurs on a holiday or weekend, the carrier or organization shall allow an enrollee or provider until the next business day to provide notification.
(c) A health carrier or utilization review organization shall certify emergency services necessary to screen and stabilize an enrollee. If the enrollee's health care provider attests in writing to the carrier or organization within seventy-two hours of an enrollee's admission or the provision of emergency service to the enrollee that the enrollee's condition required emergency services, the attestation shall create a presumption that the admission or emergency service was medically necessary. A presumption pursuant to this section shall be rebuttable only if the carrier or organization establishes, by clear and convincing evidence, that the admission or service was not medically necessary.
(d) A determination of medical necessity or appropriateness of an emergency admission or emergency service shall not be based on the provision of services by a provider or facility that is not a participating provider. Restrictions on coverage of emergency admissions or emergency services by any provider shall not be more restrictive than those that apply to participating providers.
(e) For emergency admissions or services that require immediate post-evaluation or post-stabilization services, a health carrier or utilization review organization shall certify the service or issue a final adverse determination within sixty minutes of receiving a request for prospective review.
(f) If a health carrier or utilization review organization fails to comply with this section in any prospective review for emergency services, the emergency services that are the subject of the prospective review shall be deemed to be certified.
§432E- Special provisions for prospective review; form of notice. (a) Notice of an adverse determination or determination of specific exclusion based on a prospective review shall be provided to the health care provider that initiated the prospective review by fax, by mail, by electronic transmission, or verbally, at the election of the health care provider.
(b) Notice required under this section shall include:
(1) The name, title, address, telephone number, board certification status or eligibility, and applicable professional license number issued by each state of licensure of the health care provider responsible for making the determination;
(2) The clinical review criteria, if any, and any internal rule, guideline, or protocol on which the health carrier or utilization review organization relied to make the determination and an explanation of how those provisions apply to the specific medical circumstances at issue;
(3) Information for the enrollee and the enrollee's health care provider that describes the procedure for requesting a copy of any report developed by personnel in making the determination; and
(4) Information that explains the enrollee or health care provider's right to appeal the determination, including:
(A) Instructions concerning how to perfect an appeal and for submission of written materials supporting the appeal; and
(B) Contact information through which the enrollee and health care provider may report complaints concerning the health carrier or utilization review organization to the commissioner, the Hawaii medical board, or other appropriate state regulatory agency.
(c) When certification of any health care service is restricted or denied due to a step therapy or fail first protocol in favor of an alternate health care service preferred by the health carrier or utilization review organization, the notice required by this section shall include:
(1) An explanation of the applicable protocol; and
(2) Instructions, including a phone number and other contact information, for a clear and convenient process to expeditiously request an override of or exception to that protocol.
§432E- Special provisions for prospective review; retrospective denial; waiver prohibited. (a) No health carrier or utilization review organization shall revoke, limit, condition, or otherwise restrict a certification pursuant to a prospective review for a period of forty-five working days from the date of authorization. Any contractual or other provision attempting to disclaim payment for services that have been certified pursuant to a prospective review shall be void.
(b) No provision of this chapter pertaining to prospective review of any admission or health care service shall be waived by contract or otherwise. Any contract or agreement that purports to waive any provision subject to this section shall be void.
§432E- Special provisions for prospective review; disclosure requirements. (a) Every health carrier or utilization review organization that requires prospective review of any health care services shall make readily available on its website to enrollees, health care providers, and the general public:
(1) All current prospective review requirements and restrictions, including required clinical review criteria; and
(2) Statistics regarding prospective review certifications and adverse determinations, organized according to:
(A) Physician specialty;
(B) Medication, diagnostic test, or procedure requested;
(C) Indication offered; and
(D) Reason for certification or denial.
Disclosures made pursuant to this section may be in a form as provided by the commissioner and shall be described in detail and in easily understandable language.
(b) Prior to implementing any proposed new or amended prospective review requirement or restriction, a health carrier or utilization review organization shall:
(1) Provide all health care providers contracted with the carrier or organization with written notice of the new or amended requirement or restriction no less than sixty days before its implementation; and
(2) Update the website information required under subsection (a) to reflect the new or amended requirement or restriction."
SECTION 3. Section 432E-1, Hawaii Revised Statutes, is amended as follows:
1. By adding a new definition to read:
""Urgent services" means health care services provided to an enrollee when, in the experience of a physician with knowledge of the enrollee's medical condition:
(1) The enrollee's life, health, or ability to regain maximum function will be seriously jeopardized; or
(2) The enrollee could be subjected to severe pain that cannot be adequately managed,
without the health care services at issue."
2. By amending the definition of "prospective review" to read:
""Prospective review" means a
utilization review conducted prior to an admission or a course of treatment[
and includes any health carrier or utilization review organization's
requirement that an enrollee or health care provider notify the carrier or
organization prior to providing a health care service."
SECTION 4. Section 432E-1.4, Hawaii Revised Statutes, is amended by amending subsection (b) to read as follows:
"(b) A health intervention is medically necessary if it is recommended by the treating physician or treating licensed health care provider, is approved by the health plan's medical director or physician designee, and is:
(1) For the purpose of treating a medical condition;
(2) The most appropriate delivery or level of service, considering potential benefits and harms to the patient;
(3) Known to be effective in improving health outcomes; provided that:
(A) Effectiveness is determined first by scientific evidence;
(B) If no scientific evidence exists, then by professional standards of care; and
(C) If no professional standards of care exist
or if they exist but are outdated or contradictory, then by expert opinion; [
(4) Cost-effective for the medical condition being
treated compared to alternative health interventions, including no
intervention. For purposes of this paragraph, cost-effective shall not
necessarily mean the lowest price[
(5) Not primarily for the economic benefit of a health carrier or purchaser or for the convenience of a patient, treating provider, or other health care provider."
SECTION 5. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.
SECTION 6. This Act shall take effect upon its approval.
Prospective Review; Health Insurance Coverage
Specifies procedural, disclosure, notice, and other requirements for prospective reviews required by health carriers or utilization review organizations prior to certification of coverage for health care services. (HB248 HD2)
The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.