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THE SENATE |
S.B. NO. |
287 |
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TWENTY-NINTH LEGISLATURE, 2017 |
S.D. 1 |
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STATE OF HAWAII |
H.D. 2 |
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PROPOSED |
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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 prior approval for medical services, also known as precertification or preauthorization, refers to health insurer requirements that certain physician-ordered treatments or services must be approved in advance by the insurer or by a medical review service contracted by the insurer before the insurer will provide final reimbursement or payment.
The legislature further finds that while preauthorization may be a useful and necessary tool, insurers should make patients and health care providers aware, in advance, of the medical policies insurers use when making preauthorization decisions. Currently, there is no requirement that insurers disclose the medical policies used for preauthorization decisions before those decisions are made. This lack of disclosure can lead to confusion and frustration for health care providers and their patients. Further, the lack of clarity around preauthorization decisions may cause unnecessary and sometimes harmful delays in the administration of proper patient care. Moreover, requiring insurers to provide advance notice of their preauthorization standards and criteria will help ensure that preauthorization decisions are appropriately evidence-based.
Accordingly, the purpose of this Act is to:
(1) Require all health insurers in the State to disclose on, or have accessible through, their public websites all medical policies that the health insurers use when making preauthorization decisions related to medical treatment or service;
(2) Prohibit insurers from requiring preauthorization that causes undue delay in a patient's receipt of medical treatment or services; and
(3) Clarify insurer and licensed health care provider liability for patient injuries caused by preauthorization delays.
The requirements of this Act shall also apply to all health benefits plans under chapter 87A, Hawaii Revised Statutes.
SECTION 2. Chapter 431, Hawaii Revised Statutes, is amended by adding two new sections to article 10A to be appropriately designated and to read as follows:
"§431:10A- Preauthorization; undue delay; liability. (a) Notwithstanding any provision of the law to the contrary, no insurer shall require preauthorization of medical services or treatments so as to cause an undue delay in a patient's receipt of medical treatment or services.
(b) For the purposes of this section, "undue delay" means an unreasonable delay in medical treatment or services that may cause the exacerbation or worsening of a health condition due to:
(1) Insufficient time to obtain a first-time preauthorization from an insurer or unwarranted rejection by an insurer of a first-time preauthorization;
(2) Administrative difficulties or delays in receiving preauthorization from insurers; and
(3) Difficulties arising from noncommunication by insurers on the tests and procedures that require preauthorization;
provided that response times for preauthorization requests that exceed the response times permitted for preauthorization requests by medicaid, medicare, or other federal plans or programs for the same medical treatment or service shall be deemed an "undue delay".
(c) Notwithstanding any provision of the law to the contrary, a licensed health care provider shall not be civilly liable for injury to a patient that was caused by the insurer's undue delay in preauthorizing medical treatment or services.
(d) A patient shall have an individual right to enforce the provision of this section.
§431:10A- Disclosure of medical policies. Any insurer that requires preauthorization of a medical treatment or service shall disclose on, or have accessible through, its public web site any medical policies that the insurer uses for preauthorization decisions. The disclosure or link to access the medical policies on the insurer's public website shall be prominently displayed and readily accessible for consumers. The medical policies shall include a listing of medical services that may be subject to preauthorization review, the preauthorization application procedure, the preauthorization determination criteria, and the procedure to appeal a denial decision."
SECTION 3. Chapter 432, Hawaii Revised Statutes, is amended by adding a new section to article 1 to be appropriately designated and to read as follows:
"§432:1- Disclosure of medical policies. Any mutual benefit society that requires preauthorization of a medical treatment or service shall disclose on, or have accessible through, its public web site any medical policies that the mutual benefit society uses for preauthorization decisions. The disclosure or link to access the medical policies on the mutual benefit society's public website shall be prominently displayed and readily accessible for consumers. The medical policies shall include a listing of medical services that may be subject to preauthorization review, the preauthorization application procedure, the preauthorization determination criteria, and the procedure to appeal a denial decision."
SECTION 4. Chapter 432, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:
"§432D- Disclosure of medical policies. Any health maintenance organization that requires preauthorization of a medical treatment or service shall disclose on, or have accessible through, its public web site any medical policies that the health maintenance organization uses for preauthorization decisions. The disclosure or link to access the medical policies on the health maintenance organization's public website shall be prominently displayed and readily accessible for consumers. The medical policies shall include a listing of medical services that may be subject to preauthorization review, the preauthorization application procedure, the preauthorization determination criteria, and the procedure to appeal a denial decision."
SECTION 5. Section 432D-23, Hawaii Revised Statutes, is amended to read as follows:
"§432D-23 Required provisions and
benefits. Notwithstanding any provision of law to the contrary, each
policy, contract, plan, or agreement issued in the State after January 1, 1995,
by health maintenance organizations pursuant to this chapter, shall include
benefits provided in sections 431:10-212, 431:10A-115, 431:10A-115.5,
431:10A-116, 431:10A-116.2, 431:10A-116.5, 431:10A-116.6, 431:10A-119,
431:10A-120, 431:10A-121, 431:10A-122, 431:10A-125, 431:10A-126, 431:10A-132,
431:10A-133, 431:10A-134, 431:10A-140, [and 431:10A-134,] 431:10A- ,
431:10A- , and chapter 431M."
SECTION 6. Notwithstanding any other law to the contrary, the preauthorization prohibition and disclosure requirements established under sections 2, 3, and 4 of this Act shall apply to all health benefits plans under chapter 87A, Hawaii Revised Statutes, issued, renewed, modified, altered, or amended on or after the effective date of this Act.
SECTION 7. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.
SECTION 8. This Act does not affect rights and duties that matured, penalties that were incurred, and proceedings that were begun before its effective date.
SECTION 9. This Act shall take effect on July 1, 2018; provided that sections 2, 3, 4, and 5 of this Act shall take effect on January 1, 2019.
Report Title:
Preauthorization; Disclosure; Health Insurance; Medical Policies
Description:
Requires all health insurers, including health benefits plans under chapter 87A, HRS, to disclose on, or have accessible through, their public web sites any medical policies used for making preauthorization decisions. Prohibits preauthorization requirements if they cause undue delays in the receipt of medical treatment. (SB287 HD2 PROPOSED)
The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.