HB2582

Report Title:

Medical Evaluations; Treating Source Physician; Opinions

Description:

Requires health insurers, mutual benefit societies, and health maintenance organizations to evaluate all medical opinions and to give greater weight to medical opinions of treating source physicians than non-treating source physicians. Prescribes factors to be considered in evaluating medical opinions.

HOUSE OF REPRESENTATIVES	H.B. NO.	2582
TWENTY-THIRD LEGISLATURE, 2006
STATE OF HAWAII

A BILL FOR AN ACT

relating to evaluation of medical opinions.

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

SECTION 1. Chapter 431, Hawaii Revised Statutes, is amended by adding a new section to article 10A to be appropriately designated and to read as follows:

"§431:10A- Evaluation of medical opinions; treating source physician; opinions. Any other law to the contrary notwithstanding, each employer group health policy, contract, plan, or agreement issued or renewed in this State after December 31, 2006, shall evaluate every medical opinion received, regardless of source, concerning the policyholder and individuals covered under the policy, contract, plan, or agreement. Unless the policy, contract, plan, or agreement gives a treating source's opinion controlling weight under paragraph (2), all of the following factors shall be considered in deciding the weight given to any medical opinion:

(1) Examining relationship. Generally, more weight shall be given to the opinion of a source who has examined the policyholder or covered individual than to the opinion of a source who has not examined the policyholder or covered individual;

(2) Treatment relationship. Generally, more weight shall be given to opinions from the treating sources, since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of any medical impairment and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations. If it is found that a treating source's opinion on the issue of the nature and severity of an impairment of a policyholder or covered individual is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the case record, controlling weight shall be given to that opinion. When controlling weight is not given to the treating source's opinion, the factors listed in subparagraphs (A) and (B) shall be applied, as well as the factors in paragraphs (3) through (6) in determining the weight to give the opinion. Good reasons shall be given in any notice of determination or decision for the weight given to the treating source's opinion;

(A) Length of the treatment relationship and the frequency of examination. Generally, the longer a treating source has treated the policyholder or covered individual and the more times the policyholder or covered individual has been seen by a treating source, the more weight shall be given to the source's medical opinion. When the treating source has seen the policyholder or covered individual a number of times and long enough to have obtained a longitudinal picture of an impairment, the source's opinion shall be given more weight than would otherwise be given if it were from a nontreating source; and

(B) Nature and extent of the treatment relationship. Generally, the more knowledge a treating source has about an impairment, the more weight shall be given to the source's medical opinion. The treatment the source has provided and the kinds and extent of examinations and testing the source has performed or ordered from specialists and independent laboratories shall be considered. For example, if an ophthalmologist notices that the policyholder or covered individual has complained of neck pain during eye examinations, the ophthalmologist's opinion shall be considered with respect to the neck pain, but the opinion shall be given less weight than that of another physician who has treated the policyholder or covered individual for the neck pain. When the treating source has reasonable knowledge of an impairment, the source's opinion shall be given more weight than would otherwise be given if it were from a nontreating source;

(3) Supportability. The more a medical source presents relevant evidence to support an opinion, particularly medical signs and laboratory findings, the more weight shall be given that opinion. The better an explanation a source provides for an opinion, the more weight shall be given that opinion. Furthermore, because nonexamining sources have no examining or treating relationship with the policyholder or covered individual, the weight given to their opinions shall depend on the degree to which they provide supporting explanations for their opinions. The degree to which these opinions consider all of the pertinent evidence in a claim, including opinions of treating and other examining sources, shall be evaluated;

(4) Consistency. Generally, the more consistent an opinion is with the record as a whole, the more weight shall be given to that opinion;

(5) Specialization. Generally more weight shall be given to the opinion of a specialist about medical issues related to the specialist's area of specialty than to the opinion of a source who is not a specialist; and

(6) Other factors. When considering how much weight to give to a medical opinion, any factors pointed out by the policyholder, covered individual, or others or which the policy, contract, plan, or agreement is aware of that tend to support or contradict the opinion, shall also be considered. For example, the degree of understanding of the evidentiary requirements of a policy, contract, plan, or agreement that an acceptable medical source has, regardless of the source of that understanding, and the extent to which an acceptable medical source is familiar with the other information in the policyholder or covered individual's case record, are relevant factors that shall be considered in deciding the weight to be given to a medical opinion."

SECTION 2. Chapter 432, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

"§432- Evaluation of medical opinions; treating source physician; opinions. Any other law to the contrary notwithstanding, each individual and group hospital or medical service plan, policy, contract, or agreement issued or renewed in this State after December 31, 2006, shall evaluate every medical opinion received, regardless of source, concerning the member under the plan, policy, contract, or agreement. Unless the plan, policy, contract, or agreement gives a treating source's opinion controlling weight under paragraph (2), all of the following factors shall be considered in deciding the weight given to any medical opinion:

(1) Examining relationship. Generally, more weight shall be given to the opinion of a source who has examined the member than to the opinion of a source who has not examined the member;

(2) Treatment relationship. Generally, more weight shall be given to opinions from the treating sources, since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of any medical impairment and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations. If it is found that a treating source's opinion on the issue of the nature and severity of an impairment of a member is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the case record, controlling weight shall be given to that opinion. When controlling weight is not given to the treating source's opinion, the factors listed in subparagraphs (A) and (B) shall be applied, as well as the factors in paragraphs (3) through (6) in determining the weight to give the opinion. Good reasons shall be given in any notice of determination or decision for the weight given to the treating source's opinion;

(A) Length of the treatment relationship and the frequency of examination. Generally, the longer a treating source has treated the member and the more times the member has been seen by a treating source, the more weight shall be given to the source's medical opinion. When the treating source has seen the member a number of times and long enough to have obtained a longitudinal picture of an impairment, the source's opinion shall be given more weight than would otherwise be given if it were from a nontreating source; and

(B) Nature and extent of the treatment relationship. Generally, the more knowledge a treating source has about an impairment, the more weight shall be given to the source's medical opinion. The treatment the source has provided and the kinds and extent of examinations and testing the source has performed or ordered from specialists and independent laboratories shall be considered. For example, if an ophthalmologist notices that a member has complained of neck pain during eye examinations, the ophthalmologist's opinion shall be considered with respect to the neck pain, but the opinion shall be given less weight than that of another physician who has treated the member for the neck pain. When the treating source has reasonable knowledge of an impairment, the source's opinion shall be given more weight than would otherwise be given if it were from a nontreating source;

(3) Supportability. The more a medical source presents relevant evidence to support an opinion, particularly medical signs and laboratory findings, the more weight shall be given that opinion. The better an explanation a source provides for an opinion, the more weight shall be given that opinion. Furthermore, because nonexamining sources have no examining or treating relationship with the member, the weight given to their opinions shall depend on the degree to which they provide supporting explanations for their opinions. The degree to which these opinions consider all of the pertinent evidence in a claim, including opinions of treating and other examining sources, shall be evaluated;

(4) Consistency. Generally, the more consistent an opinion is with the record as a whole, the more weight shall be given to that opinion;

(6) Other factors. When considering how much weight to give to a medical opinion, any factors pointed out by the member or others or which the plan, policy, contract, or agreement is aware of that tend to support or contradict the opinion, shall also be considered. For example, the degree of understanding of the evidentiary requirements of a plan, policy, contract, or agreement that an acceptable medical source has, regardless of the source of that understanding, and the extent to which an acceptable medical source is familiar with the other information in the member's case record, are relevant factors that shall be considered in deciding the weight to be given to a medical opinion."

SECTION 3. Chapter 432D, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

"§432D- Evaluation of medical opinions; treating source physician; opinions. Any other law to the contrary notwithstanding, each policy, plan, contract, or agreement issued or renewed in this State after December 31, 2006, shall evaluate every medical opinion received, regardless of source, concerning the enrollee or subscriber under the policy, plan, contract, or agreement. Unless the policy, plan, contract, or agreement gives a treating source's opinion controlling weight under paragraph (2), all of the following factors shall be considered in deciding the weight given to any medical opinion:

(1) Examining relationship. Generally, more weight shall be given to the opinion of a source who has examined the enrollee or subscriber than to the opinion of a source who has not examined the enrollee or subscriber;

(2) Treatment relationship. Generally, more weight shall be given to opinions from the treating sources, since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of any medical impairment and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations. If it is found that a treating source's opinion on the issue of the nature and severity of an impairment of an enrollee or subscriber is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the case record, controlling weight shall be given to that opinion. When controlling weight is not given to the treating source's opinion, the factors listed in subparagraphs (A) and (B) shall be applied, as well as the factors in paragraphs (3) through (6) in determining the weight to give the opinion. Good reasons shall be given in any notice of determination or decision for the weight given to the treating source's opinion;

(A) Length of the treatment relationship and the frequency of examination. Generally, the longer a treating source has treated the enrollee or subscriber and the more times the enrollee or subscriber has been seen by a treating source, the more weight shall be given to the source's medical opinion. When the treating source has seen the enrollee or subscriber a number of times and long enough to have obtained a longitudinal picture of an impairment, the source's opinion shall be given more weight than would otherwise be given if it were from a nontreating source; and

(B) Nature and extent of the treatment relationship. Generally, the more knowledge a treating source has about an impairment, the more weight shall be given to the source's medical opinion. The treatment the source has provided and the kinds and extent of examinations and testing the source has performed or ordered from specialists and independent laboratories shall be considered. For example, if an ophthalmologist notices that an enrollee or subscriber has complained of neck pain during eye examinations, the ophthalmologist's opinion shall be considered with respect to the neck pain, but the opinion shall be given less weight than that of another physician who has treated the enrollee or subscriber for the neck pain. When the treating source has reasonable knowledge of an impairment, the source's opinion shall be given more weight than would otherwise be given if it were from a nontreating source;

(3) Supportability. The more a medical source presents relevant evidence to support an opinion, particularly medical signs and laboratory findings, the more weight shall be given that opinion. The better an explanation a source provides for an opinion, the more weight shall be given that opinion. Furthermore, because nonexamining sources have no examining or treating relationship with the enrollee or subscriber, the weight given to their opinions shall depend on the degree to which they provide supporting explanations for their opinions. The degree to which these opinions consider all of the pertinent evidence in a claim, including opinions of treating and other examining sources, shall be evaluated;

(4) Consistency. Generally, the more consistent an opinion is with the record as a whole, the more weight shall be given to that opinion;

(6) Other factors. When considering how much weight to give to a medical opinion, any factors pointed out by the enrollee or subscriber or others or which the policy, plan, contract, or agreement is aware of that tend to support or contradict the opinion, shall also be considered. For example, the degree of understanding of the evidentiary requirements of a policy, plan, contract, or agreement that an acceptable medical source has, regardless of the source of that understanding, and the extent to which an acceptable medical source is familiar with the other information in the enrollee's or subscriber's case record, are relevant factors that shall be considered in deciding the weight to be given to a medical opinion."

SECTION 4. New statutory material is underscored.

SECTION 5. This Act shall take effect on July 1, 2006.

INTRODUCED BY:	_____________________________