REPORT TITLE:
Dermatology; Direct Access


DESCRIPTION:
Requires managed health care plans that include dermatological
coverage to reimburse the plan participant or pay the provider
regardless of whether a referral or authorization has been
obtained prior to the delivery of services.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        
THE SENATE                              S.B. NO.           837
TWENTIETH LEGISLATURE, 1999                                
STATE OF HAWAII                                            
                                                             
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                   A  BILL  FOR  AN  ACT

RELATING TO MANAGED HEALTH CARE.



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

 1      SECTION 1.  Chapter 432, article I, part VI, Hawaii Revised
 
 2 Statutes, is amended by adding a new section to be appropriately
 
 3 designated and to read as follows:
 
 4      "§432:1-    Coverage for dermatological services.
 
 5 Notwithstanding any provision to the contrary, whenever any
 
 6 individual or group hospital or medical service plan contract
 
 7 provides for reimbursement or payment for dermatological
 
 8 services, the person entitled to benefits or the person
 
 9 performing the services shall be entitled to reimbursement or
 
10 payment with or without obtaining a referral or other
 
11 authorization before those services are performed.  As used in
 
12 this section, "dermatological services" means services ordinarily
 
13 and customarily rendered by a physician specializing in the
 
14 practice of dermatology."
 
15      SECTION 2.  Chapter 432, article II, part IV, Hawaii Revised
 
16 Statutes, is amended by adding a new section to be appropriately
 
17 designated and to read as follows:
 
18      "§432:2-    Coverage for dermatological services.
 
19 Notwithstanding any provision to the contrary, whenever a benefit
 

 
Page 2                                                     
                                     S.B. NO.           837
                                                        
                                                        

 
 1 contract provides for reimbursement or payment for dermatological
 
 2 services, the person entitled to benefits or the person
 
 3 performing the services shall be entitled to reimbursement or
 
 4 payment with or without obtaining a referral or other
 
 5 authorization before those services are performed.  As used in
 
 6 this section, "dermatological services" means services ordinarily
 
 7 and customarily rendered by a physician specializing in the
 
 8 practice of dermatology."
 
 9      SECTION 3.  Section 431:10A-116, Hawaii Revised Statutes, is
 
10 amended to read as follows:
 
11      "§431:10A-116  Coverage for specific services.  Every person
 
12 insured under a policy of accident and sickness insurance
 
13 delivered or issued for delivery in this State shall be entitled
 
14 to the reimbursements and coverages specified below:
 
15      (1)  Notwithstanding any provision to the contrary, whenever
 
16           a policy, contract, plan, or agreement provides for
 
17           reimbursement for any visual or optometric service
 
18           which is within the lawful scope of practice of a duly
 
19           licensed optometrist, the person entitled to benefits
 
20           or the person performing the services shall be entitled
 
21           to reimbursement whether the service is performed by a
 
22           licensed physician or by a licensed optometrist.
 
23           Visual or optometric services shall include eye or
 

 
Page 3                                                     
                                     S.B. NO.           837
                                                        
                                                        

 
 1           visual examination, or both, or a correction of any
 
 2           visual or muscular anomaly, and the supplying of
 
 3           [opthalmic] ophthalmic  materials, lenses, contact
 
 4           lenses, spectacles, eyeglasses, and appurtenances
 
 5           thereto.
 
 6      (2)  Notwithstanding any provision to the contrary, for all
 
 7           policies, contracts, plans, or agreements issued on or
 
 8           after May 30, 1974, whenever provision is made for
 
 9           reimbursement or indemnity for any service related to
 
10           surgical or emergency procedures which is within the
 
11           lawful scope of practice of any practitioner licensed
 
12           to practice medicine in this State, reimbursement or
 
13           indemnification under such policy, contract, plan, or
 
14           agreement shall not be denied when such services are
 
15           performed by a dentist acting within the lawful scope
 
16           of the dentist's license.
 
17      (3)  Notwithstanding any provision to the contrary, whenever
 
18           the policy provides reimbursement or payment for any
 
19           service which is within the lawful scope of practice of
 
20           a psychologist licensed in this State, the person
 
21           entitled to benefits or performing the service shall be
 
22           entitled to reimbursement or payment, whether the
 
23           service is performed by a licensed physician or
 

 
Page 4                                                     
                                     S.B. NO.           837
                                                        
                                                        

 
 1           licensed psychologist.
 
 2      (4)  Notwithstanding any provision to the contrary, each
 
 3           policy, contract, plan, or agreement issued on or after
 
 4           February 1, 1991, except for policies which only
 
 5           provide coverage for specified diseases or other
 
 6           limited benefit coverage, but including policies issued
 
 7           by companies subject to chapter 431, article 10A, part
 
 8           II and chapter 432, article 1 shall provide coverage
 
 9           for screening by low-dose mammography for occult breast
 
10           cancer as follows:
 
11           (A)  For women thirty-five to thirty-nine years of age,
 
12                one baseline mammogram;
 
13           (B)  For women forty to forty-nine years of age, a
 
14                mammogram every two years;
 
15           (C)  For women fifty years of age and older, an annual
 
16                mammogram; and
 
17           (D)  For a woman of any age with a history of breast
 
18                cancer or whose mother or sister has had a history
 
19                of breast cancer, a mammogram upon the
 
20                recommendation of the woman's physician.
 
21                The services provided in this paragraph are
 
22           subject to any coinsurance provisions which may be in
 
23           force in these policies, contracts, plans, or
 

 
Page 5                                                     
                                     S.B. NO.           837
                                                        
                                                        

 
 1           agreements.  The commissioner shall annually review the
 
 2           age and frequency guidelines for mammographic screening
 
 3           recommended by the American Cancer Society, and shall
 
 4           accordingly adjust the age and frequency requirements
 
 5           under subparagraphs (A) to (C) by rule, if necessary.
 
 6                For the purpose of this paragraph, the term "low-
 
 7           dose mammography" means the x-ray examination of the
 
 8           breast using equipment dedicated specifically for
 
 9           mammography, including but not limited to the x-ray
 
10           tube, filter, compression device, screens, films, and
 
11           cassettes, with an average radiation exposure delivery
 
12           of less than one rad mid-breast, with two views for
 
13           each breast.  An insurer may provide the services
 
14           required by this paragraph through contracts with
 
15           providers; provided that the contract is determined to
 
16           be a cost-effective means of delivering the services
 
17           without sacrifice of quality and meets the approval of
 
18           the director of health.
 
19      (5)  (A)  (i)  Notwithstanding any provision to the
 
20                     contrary, whenever a policy, contract, plan,
 
21                     or agreement provides coverage for the
 
22                     children of the insured, that coverage shall
 
23                     also extend to the date of birth of any
 

 
Page 6                                                     
                                     S.B. NO.           837
                                                        
                                                        

 
 1                     newborn child to be adopted by the insured;
 
 2                     provided that the insured gives written
 
 3                     notice to the insurer of the insured's
 
 4                     intent to adopt the child prior to the
 
 5                     child's date of birth or within thirty days
 
 6                     after the child's birth or within the time
 
 7                     period required for enrollment of a natural
 
 8                     born child under the policy, contract plan,
 
 9                     or agreement of the insured, whichever period
 
10                     is longer; provided, however, if the adoption
 
11                     proceedings are not successful, the insured
 
12                     shall reimburse the insurer for any expenses
 
13                     paid for the child.
 
14               (ii)  Where notification has not been received by
 
15                     the insurer prior to the child's birth or
 
16                     within the specified period following the
 
17                     child's birth, insurance coverage shall be
 
18                     effective from the first day following the
 
19                     insurer's receipt of legal notification of
 
20                     the insured's ability to consent for
 
21                     treatment of the infant for whom coverage is
 
22                     sought.
 
23           (B)  When the insured is a member of a health
 

 
Page 7                                                     
                                     S.B. NO.           837
                                                        
                                                        

 
 1                maintenance organization (HMO), coverage of an
 
 2                adopted newborn is effective:
 
 3                (i)  From the date of birth of the adopted newborn
 
 4                     when the newborn is treated from birth
 
 5                     pursuant to a provider contract with the
 
 6                     health maintenance organization, and written
 
 7                     notice of enrollment in accord with the
 
 8                     health maintenance organization's usual
 
 9                     enrollment process is provided within thirty
 
10                     days of the date the insured notifies the
 
11                     health maintenance organization of the
 
12                     insured's intent to adopt the infant for whom
 
13                     coverage is sought; or
 
14               (ii)  From the first day following receipt by the
 
15                     health maintenance organization of written
 
16                     notice of the insured's ability to consent
 
17                     for treatment of the infant for whom coverage
 
18                     is sought and enrollment of the adopted
 
19                     newborn in accord with the health maintenance
 
20                     organization's usual enrollment process if
 
21                     the newborn has been treated from birth by a
 
22                     provider not contracting or affiliated with
 
23                     the health maintenance organization.
 

 
Page 8                                                     
                                     S.B. NO.           837
                                                        
                                                        

 
 1      (6)  Notwithstanding any provision to the contrary, whenever
 
 2           a policy, contract, plan, or agreement provides for
 
 3           reimbursement or payment for dermatological services,
 
 4           the person entitled to benefits or the person
 
 5           performing the services shall be entitled to
 
 6           reimbursement or payment with or without obtaining a
 
 7           referral or other authorization before those services
 
 8           are performed.  As used in this section,
 
 9           "dermatological services" means services ordinarily and
 
10           customarily rendered by a physician specializing in the
 
11           practice of dermatology."
 
12      SECTION 4.  Statutory material to be repealed is bracketed.
 
13 New statutory material is underscored.
 
14      SECTION 5.  This Act shall take effect upon its approval.
 
15 
 
16                           INTRODUCED BY:  _______________________