REPORT TITLE:
Managed Care


DESCRIPTION:
Creates health insurance revolving fund; requires insurance
commissioner to conduct public education program about managed
care plans; clarifies duties of HMOs and health insurers for
emergency medical conditions; allows insurance commissioner to
conduct a review hearing of HMO patient complaints, etc. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        
THE SENATE                              S.B. NO.           1452
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.  Act 178, Session Laws of Hawaii 1998, enacted
 
 2 the Hawaii Patient Bill of Rights and Responsibilities Act to
 
 3 regulate managed care.  Act 178 also required the insurance
 
 4 commissioner to convene a task force to review various laws which
 
 5 provide protection of patient rights and responsibilities in
 
 6 regards to health care, especially managed care.  This Act
 
 7 represents the task force's recommendations for statutory
 
 8 revisions to ensure the protection of consumer rights.
 
 9      The purpose of this Act is to strengthen the protection of
 
10 consumer rights for patients in managed care plans and health
 
11 maintenance organizations.
 
12      SECTION 2.  Chapter 432E, Hawaii Revised Statutes, is
 
13 amended by adding four new sections to be appropriately
 
14 designated and to read as follows:
 
15      "§432E-A  Annual report.  The commissioner shall submit
 
16 annually to the legislature a report that shall contain the
 
17 number of external review hearing cases reviewed, the type of
 
18 cases reviewed, a summary of the nature of the cases reviewed,
 
19 and the disposition of the cases reviewed.  The identities of the
 

 
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 1 plan and the enrollee shall be protected from disclosure in the
 
 2 report.
 
 3      §432E-B  Health insurance revolving fund.  (a)  There is
 
 4 established a revolving fund in the state treasury to be
 
 5 administered by the commissioner and to be designated as the
 
 6 health insurance revolving fund.  All assessments imposed under
 
 7 subsection (c) as well as other fees, assessments, fines, and
 
 8 penalties imposed by the commissioner under this chapter shall be
 
 9 deposited into this fund.
 
10      (b)  The commissioner may expend moneys from the health
 
11 insurance revolving fund to hire medical experts to serve on a
 
12 review panel under section 432E-6(a), provide an expert medical
 
13 opinion to the review panel, or conduct a public awareness and
 
14 education program about managed care plans under section
 
15 432E-C(b).
 
16      (c)  Beginning July 1, 1999, and each year thereafter, a
 
17 mutual benefit society under article 1 of chapter 432, a health
 
18 maintenance organization under chapter 432D, and any other entity
 
19 offering or providing health benefits or services under the
 
20 regulation of the commissioner, except an insurer licensed to
 
21 offer health insurance under article 10A, shall deposit with the
 
22 commissioner by July 1 of each year an assessment imposed by the
 
23 commissioner on a pro rata basis.
 

 
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 1      (d)  Moneys in the health insurance revolving fund shall not
 
 2 revert to the general fund.
 
 3      (e)  The commissioner shall report annually to the
 
 4 legislature before the convening of each regular session as to
 
 5 fund administration and expenditures.
 
 6      §432E-C  Accreditation of managed care plans.  (a)
 
 7 Beginning January 1, 1999, the commissioner shall contract with
 
 8 one or more certified vendors of the consumer assessment health
 
 9 plan survey to conduct a survey and educational program of all
 
10 managed care plans actively offering managed care plans in this
 
11 State in order to provide managed care plans an opportunity to
 
12 learn whether any deficiencies exist or any improvements are
 
13 required; provided that the information collected shall be kept
 
14 confidential in the first year, and thereafter shall be available
 
15 to the public.
 
16      (b)  The commissioner shall conduct a program that promotes
 
17 public awareness and education about managed care plans so that
 
18 consumers may make better or more informed choices when selecting
 
19 a managed care plan.
 
20      (c)  Beginning January 1, 2000, unaccredited plans shall
 
21 submit a plan to the commissioner to achieve national
 
22 accreditation status within five years.  After the first year of
 
23 the five-year plan, each unaccredited plan shall also submit an
 

 
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 1 annual progress report to the insurance commissioner on the
 
 2 status of gaining national accreditation.  The commissioner shall
 
 3 determine which national accreditation organization is
 
 4 appropriate for each type of plan.
 
 5      (d)  Each mutual benefit society under article 1 of chapter
 
 6 432, health maintenance organization under chapter 432D, and any
 
 7 other entity offering or providing health benefits or services
 
 8 under the regulation of the commissioner, except an insurer
 
 9 licensed to offer health insurance under article 10A of chapter
 
10 431, shall deposit with the commissioner a fee to provide for the
 
11 actual costs of the survey and educational program to be
 
12 determined by the commissioner on July 1 of each year, to be
 
13 credited to the health insurance revolving fund.  In addition,
 
14 each mutual benefit society under article 1 of chapter 432,
 
15 health maintenance organization under chapter 432D, and any other
 
16 entity offering or providing health benefits or services under
 
17 the regulation of the commissioner, except an insurer licensed to
 
18 offer health insurance under article 10A of chapter 431, shall
 
19 pay to the commissioner at a time to be determined by the
 
20 commissioner, a one-time assessment in an amount to be determined
 
21 by the commissioner, to be credited to the health insurance
 
22 revolving fund.
 
23      §432E-D  Rules.  The commissioner shall adopt rules pursuant
 

 
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 1 to chapter 91 necessary for the purposes of this chapter."
 
 2      SECTION 3.  Section 431:10C-103, Hawaii Revised Statutes, is
 
 3 amended by adding two new definitions to be appropriately
 
 4 inserted and to read as follows:
 
 5      ""Emergency medical condition" means a medical condition
 
 6 that manifests itself by acute symptoms of sufficient severity,
 
 7 including severe pain, that a prudent layperson, who possesses an
 
 8 average knowledge of health and medicine, could reasonably expect
 
 9 the absence of immediate medical attention to result in:
 
10      (1)  Placing the health of the individual, including the
 
11           health of a pregnant woman or her unborn child, in
 
12           serious jeopardy;
 
13      (2)  Serous impairment to bodily functions; or
 
14      (3)  Serious dysfunction of any bodily organ or part.
 
15      "Emergency services" means:
 
16      (1)  A medical screening examination, if required by federal
 
17           law, that is within the capability of the emergency
 
18           department of a hospital, including ancillary services
 
19           routinely available to the emergency department, to
 
20           evaluate an emergency medical condition; or
 
21      (2)  Further medical examination and treatment, if required
 
22           by federal law, that is within the capabilities of the
 
23           staff and facilities available at the hospital,
 

 
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 1           including any trauma and burn center of the hospital to
 
 2           stabilize an emergency medical condition. "Stabilize"
 
 3           means the provision of medical treatment as may be
 
 4           necessary to assure, within reasonable medical
 
 5           probability, that no material deterioration of an
 
 6           individual's medical condition is likely to result from
 
 7           or occur during a transfer to another facility, if the
 
 8           medical condition could result in placing the health of
 
 9           the individual, or the health of a pregnant woman or
 
10           her unborn child, in serious jeopardy, in serious
 
11           impairment to bodily functions, or in serious
 
12           dysfunction of any bodily organ or party."
 
13      SECTION 4.  Section 432E-3, Hawaii Revised Statutes, is
 
14 amended to read as follows:
 
15      "[[]§432E-3[]]  Access to services.  A managed care plan
 
16 shall demonstrate to the commissioner upon request that its plan:
 
17      (1)  Makes benefits available and accessible to each
 
18           enrollee electing the managed care plan in the defined
 
19           service area with reasonable promptness and in a manner
 
20           which promotes continuity in the provision of health
 
21           care services;
 
22      (2)  Provides access to sufficient numbers and types of
 
23           providers to ensure that all covered services will be
 

 
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 1           accessible without unreasonable delay;
 
 2      (3)  When medically necessary, provides health care services
 
 3           twenty-four hours a day, seven days a week;
 
 4      (4)  Provides a reasonable choice of qualified providers of
 
 5           women's health services such as gynecologists,
 
 6           obstetricians, certified nurse-midwives, and advanced
 
 7           practice nurses to provide preventive and routine
 
 8           women's health care services; [and]
 
 9      (5)  Provides payment or reimbursement for adequately
 
10           documented emergency services[.] as provided in this
 
11           chapter; and
 
12      (6)  Allows standing referrals to specialists capable to
 
13           provide and coordinate primary and specialty care for
 
14           an enrollee's life threatening, chronic, degenerative,
 
15           or disabling disease or condition."
 
16      SECTION 5.  Section 432E-5, Hawaii Revised Statutes, is
 
17 amended to read as follows:
 
18      "[[]§432E-5[]]  Complaints and appeals procedure for
 
19 enrollees.(a)  A managed care plan with enrollees in this State
 
20 shall establish and maintain a procedure to provide for the
 
21 resolution of an enrollee's complaints and appeals.
 
22      (b)  The managed care plan at all times shall make available
 
23 its complaints and appeals procedures.  The complaints and
 

 
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 1 appeals procedures shall be reasonably understandable to the
 
 2 average layperson and shall be provided in languages other than
 
 3 English upon request.
 
 4      (c)  A managed care plan shall send notice of its final
 
 5 internal determination to the enrollee and the enrollee's
 
 6 appointed representative, if applicable, and the commissioner.
 
 7 The notice shall include information regarding the enrollee's
 
 8 rights and procedures under section 432E-6."
 
 9      SECTION 6.  Section 432E-6, Hawaii Revised Statutes, is
 
10 amended to read as follows:
 
11      "[[]§432E-6[]]  Appeals to the commissioner.(a)  After
 
12 exhausting all internal complaint and appeal procedures
 
13 available, an enrollee, or the enrollee's treating provider or
 
14 appointed representative, may appeal an adverse decision of a
 
15 managed care plan to a three member review panel appointed by the
 
16 commissioner composed of a representative from a health plan not
 
17 involved in the complaint, a provider licensed to practice and
 
18 practicing medicine in Hawaii not involved in the complaint, and
 
19 the commissioner or the commissioner's designee in the following
 
20 manner:
 
21      (1)  The enrollee shall submit a request for review to the
 
22           commissioner within thirty days from the date of the
 
23           final determination by the managed care plan[.];
 

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

 
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 1           and with sound medical judgment.  The review panel
 
 2           shall consider the clinical standards of the plan, the
 
 3           information provided, the attending physician's
 
 4           recommendations, and generally accepted practice
 
 5           guidelines.
 
 6      The commissioner, upon a majority vote of the panel, shall
 
 7 issue an order affirming, modifying, or reversing the decision
 
 8 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.]
 
15      (c)  Members of the review panel shall be granted immunity
 
16 from liability and damages relating to their duties under this
 
17 section.
 
18      (d)  An enrollee may be allowed an award of a reasonable sum
 
19 for attorney's fees and reasonable cost of suit in an action
 
20 brought against the managed care plan."
 
21      SECTION 7.  Section 432E-7, Hawaii Revised Statutes, is
 
22 amended to read as follows:
 
23      "[[]§432E-7[]]  Information to enrollees.  (a)  The managed
 

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

 
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 1 will affect them directly within thirty days of the material
 
 2 change.] participating provider agreements, services, or
 
 3 benefits, if the change affects the organization or operation of
 
 4 the managed care plan and the enrollee's services or benefits.
 
 5 The managed care plan shall provide notice to enrollees not more
 
 6 than sixty days after the change in a format that makes the
 
 7 notice clear and conspicuous so that it is readily noticeable by
 
 8 the enrollee.
 
 9      [(c)  For purposes of this section "material change" means a
 
10 change in participating provider agreements, services, or
 
11 benefits.]
 
12      (c)  A managed care plan shall provide generic participating
 
13 provider contracts to enrollees, upon request."
 
14      SECTION 8.  Section 432E-10, Hawaii Revised Statutes, is
 
15 amended to read as follows:
 
16      "[[]§432E-10[]]  Managed care plan performance measurement
 
17 and data reporting standards.(a)  It is the policy of this
 
18 State that all managed care plans shall adopt and comply with
 
19 nationally developed and promulgated standards for measuring
 
20 quality, outcomes, access, satisfaction, and utilization of
 
21 services.  Every contract between a managed care plan and a
 
22 participating provider of health care services shall require the
 
23 participating provider to comply with the managed care plan's
 

 
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 1 requests for any information necessary for the managed care plan
 
 2 to comply with the requirements of this chapter.  [The standard
 
 3 to be applied is the Health Employer Data and Information Set
 
 4 (HEDIS) 3.0 data set, as amended from time to time.]  The State
 
 5 shall require that:
 
 6      (1)  Consumers, providers, managed care plans, purchasers,
 
 7           and regulators shall be equitably represented in the
 
 8           development of standards; and
 
 9      (2)  Standards shall result in measurement and reporting
 
10           that is purposeful, valid and scientifically based,
 
11           applied in a consistent and comparable manner,
 
12           efficient and cost effective, and designed to minimize
 
13           redundancy and duplication of effort.
 
14      (b)  All managed care plans, no less than annually, shall
 
15 report to the commissioner comparable information on performance,
 
16 including measures of quality, outcomes, access, satisfaction,
 
17 and utilization of services; provided that:
 
18      (1)  Reporting shall be based upon a core data and
 
19           information set that builds upon nationally recognized
 
20           performance measurement systems.  The core data and
 
21           information set shall include standardized measures of:
 
22           (A)  Effectiveness and appropriateness of care (the
 
23                impact of care delivered to managed care plan
 

 
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 1                enrollees, [including] for example, results of the
 
 2                plan for childhood immunizations, cholesterol
 
 3                screening, mammography screening, cervical cancer
 
 4                screening, prenatal visits in the first trimester
 
 5                of pregnancy, and diabetic retinal examinations);
 
 6           (B)  Access and availability of care (the extent to
 
 7                which plan enrollees have access to the health
 
 8                care providers they need or desire to see, and
 
 9                receive appropriate services in a timely manner,
 
10                without inappropriate barriers or inconvenience);
 
11           (C)  Satisfaction with the experience of care (the
 
12                results of the most recent enrollee satisfaction
 
13                survey using standardized survey design and
 
14                methods);
 
15           (D)  Managed care plan stability (attributes of a
 
16                managed care plan which affect its ability to
 
17                deliver high-quality care and service on a
 
18                sustained basis);
 
19           (E)  Use of services (rates of service use per 1,000
 
20                enrollees as well as percentages of enrollees who
 
21                receive specified services);
 
22           (F)  Cost of care (expenditures per enrollee per month,
 
23                premium rates for selected membership categories,
 

 
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 1                and rates of increases); and
 
 2           (G)  Managed care plan descriptive information (the
 
 3                plan name, location of headquarters, and number of
 
 4                years the plan has been in business; the model
 
 5                type of the plan; the counties in which the plan
 
 6                operates; the total number of participating
 
 7                physicians per 1,000 enrollees and the number of
 
 8                primary care physicians per 1,000 enrollees; the
 
 9                number of participating hospitals per 10,000
 
10                enrollees; the percentage of participating
 
11                physicians who are board certified; and a list of
 
12                wellness and health care education programs
 
13                offered by the plan);
 
14      (2)  Information shall be uniformly reported by managed care
 
15           plans in a standardized format, as determined by rule;
 
16      (3)  Information supplied by managed care plans shall be
 
17           subject to independent audit by the appropriate
 
18           regulatory agency or its designee to verify accuracy
 
19           and protect against misrepresentation;
 
20      (4)  Information reported by managed care plans shall be
 
21           adjusted, based on standardized methods, to control for
 
22           the effects of differences in health risk, severity of
 
23           illness, or mix of services;
 

 
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 1      (5)  A managed care plan shall ensure confidentiality of
 
 2           records and shall not disclose individually
 
 3           identifiable data or information pertaining to the
 
 4           diagnosis, treatment, or health of any enrollee, except
 
 5           as provided under law; and
 
 6      (6)  A managed care plan shall disclose to its enrollees the
 
 7           quality and satisfaction assessments used, including
 
 8           the current results of the assessments."
 
 9      SECTION 9.  Act 246, Session Laws of Hawaii 1989, is amended
 
10 by amending section 1, section 431:10A-  (f), Hawaii Revised
 
11 Statutes, to read as follows: 
 
12      "(f)  A health plan shall select between the following two
 
13 options:
 
14      (1)  A health plan shall reimburse an emergency provider and
 
15           an emergency department for any items or services not
 
16           necessary to stabilize the patient but that are
 
17           determined to be medically necessary to treat the
 
18           illness that lead the patient to believe that he or she
 
19           had an emergency medical condition, and that a
 
20           reasonable patient would expect to receive from a
 
21           physician at the time of presentation[.]; or
 
22      (2)  A health plan shall reimburse an emergency provider and
 
23           an emergency department for any items or services not
 

 
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 1           necessary to stabilize the patient but that are
 
 2           determined to be medically necessary by the emergency
 
 3           provider, if the emergency department:
 
 4           (A)  After a documented good faith effort, is unable to
 
 5                reach the enrollee's health plan:
 
 6                (i)  Within thirty minutes from the initial
 
 7                     examination of the enrollee; or
 
 8               (ii)  If the enrollee needs to be stabilized,
 
 9                     within thirty minutes of stabilization; or
 
10           (B)  Has successfully contacted the plan as required in
 
11                subparagraph (A), and has not received a denial
 
12                from the plan within thirty minutes of the initial
 
13                contact, unless the plan is able to document that
 
14                it has made an unsuccessful good faith effort to
 
15                reach the emergency department within thirty
 
16                minutes after receiving the request for
 
17                authorization; 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
 

 
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                                     S.B. NO.           1452
                                                        
                                                        

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

 
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                                     S.B. NO.           1452
                                                        
                                                        

 
 1                     the enrollee;
 
 2               (ii)  An appointment is made with a participating
 
 3                     physician or provider for treatment needed by
 
 4                     the enrollee; or
 
 5              (iii)  Another arrangement is made for treatment of
 
 6                     the enrollee."
 
 7      SECTION 10.  Act 246, Session Laws of Hawaii 1998, is
 
 8 amended by amending section 2, section 432:1-   (f), Hawaii
 
 9 Revised Statutes, to read as follows:
 
10      "(f)  A health plan shall select between the following two
 
11 options:
 
12      (1)  A health plan shall reimburse an emergency provider and
 
13           an emergency department for any items or services not
 
14           necessary to stabilize the patient but that are
 
15           determined to be medically necessary to treat the
 
16           illness that lead the patient to believe that he or she
 
17           had an emergency medical condition, and that a
 
18           reasonable patient would expect to receive from a
 
19           physician at the time of presentation[.]; or
 
20      (2)  A health plan shall reimburse an emergency provider and
 
21           an emergency department for any items or services not
 
22           necessary to stabilize the patient but that are
 
23           determined to be medically necessary by the emergency
 

 
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                                     S.B. NO.           1452
                                                        
                                                        

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

 
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                                     S.B. NO.           1452
                                                        
                                                        

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

 
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 1                     physician or provider for treatment needed by
 
 2                     the enrollee; or
 
 3              (iii)  Another arrangement is made for treatment of
 
 4                     the enrollee."
 
 5      SECTION 11.  Act 246, Session Laws of Hawaii 1998, is
 
 6 amended by amending section 3, section 432D-  (f), Hawaii Revised
 
 7 Statutes, to read as follows:
 
 8      "(f)  A health plan shall select between the following two
 
 9 options:
 
10      (1)  A health plan shall reimburse an emergency provider and
 
11           an emergency department for any items or services not
 
12           necessary to stabilize the patient but that are
 
13           determined to be medically necessary to treat the
 
14           illness that lead the patient to believe that he or she
 
15           had an emergency medical condition, and that a
 
16           reasonable patient would expect to receive from a
 
17           physician at the time of presentation[.]; or
 
18           (2)  A health plan shall reimburse an emergency
 
19                provider and an emergency department for any items
 
20                or services not necessary to stabilize the patient
 
21                but that are determined to be medically necessary
 
22                by the emergency provider, if the emergency
 
23                department:
 

 
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                                     S.B. NO.           1452
                                                        
                                                        

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

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

 
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                                     S.B. NO.           1452
                                                        
                                                        

 
 1                     the enrollee; or
 
 2              (iii)  Another arrangement is made for treatment of
 
 3                     the enrollee."
 
 4      SECTION 12.  Upon approval of this Act, every mutual benefit
 
 5 society under article 1 of chapter 432, Hawaii Revised Statutes,
 
 6 health maintenance organization under chapter 432D, Hawaii
 
 7 Revised Statutes, and any other entity offering or providing
 
 8 health benefits or services under the regulation of the insurance
 
 9 commissioner, except an insurer licensed to offer health
 
10 insurance under article 10A of chapter 431, Hawaii Revised
 
11 Statutes, shall pay to the commissioner at a time determined by
 
12 the commissioner, a one-time assessment in an amount not to
 
13 exceed the aggregate amount of $150,000, to be credited to the
 
14 health insurance revolving fund established under section 432E-B,
 
15 Hawaii Revised Statutes.
 
16      SECTION 13.  There is appropriated out of the health
 
17 insurance revolving fund established under section 432E-B, Hawaii
 
18 Revised Statutes, the sum of $100,000, or so much thereof as may
 
19 be necessary for fiscal year 1999-2000, and the same sum, or so
 
20 much thereof as may be necessary for fiscal year 2000-2001, to
 
21 carry out the purposes of this Act.
 
22      The sums appropriated shall be expended by the department of
 
23 commerce and consumer affairs.
 

 
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                                     S.B. NO.           1452
                                                        
                                                        

 
 1      SECTION 14.  There is appropriated out of the health
 
 2 insurance revolving fund established under section 432E-B, Hawaii
 
 3 Revised Statutes, the sum of $50,000, or so much thereof as may
 
 4 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 carry out the purposes of this Act.
 
 7      The sums appropriated shall be expended by the department of
 
 8 commerce and consumer affairs.
 
 9      SECTION 15.  There is appropriated out of the health
 
10 insurance revolving fund established under section 432E-B, Hawaii
 
11 Revised Statutes, the sum of $          , or so much thereof as
 
12 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,
 
14 to carry out the purposes of this Act.
 
15      The sums appropriated shall be expended by the department of
 
16 commerce and consumer affairs.
 
17      SECTION 16.  In codifying new sections added by this Act,
 
18 the revisor shall substitute the appropriate section numbers for
 
19 the letters used in designating the new sections of this Act.
 
20      SECTION 17.  Statutory material to be repealed is bracketed.
 
21 New statutory material is underscored.
 
22      SECTION 18.  This Act shall take effect upon its approval;
 
23 provided that sections 13, 14, and 15 shall take effect on
 

 
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                                     S.B. NO.           1452
                                                        
                                                        

 
 1 July 1, 1999; and provided further that sections 3, 4, 9, 10, and
 
 2 11 of this Act shall be repealed on July 1, 2003, and section
 
 3 431:10C-103, Hawaii Revised Statutes, and section 432E-3, Hawaii
 
 4 Revised Statutes, are reenacted in the form in which they read on
 
 5 the day before the approval of this Act. 
 
 6 
 
 7                           INTRODUCED BY:  _______________________