HOUSE OF REPRESENTATIVES	H.B. NO.	937
TWENTY-EIGHTH LEGISLATURE, 2015
STATE OF HAWAII

A BILL FOR AN ACT

RELATING TO THE MEDICAID MANAGED CARE PROGRAM.

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

     SECTION 1.  In 1994, the State of Hawaii medicaid program began using a managed care delivery system called QUEST.  QUEST stands for Quality care, Universal access, Efficient utilization, Stabilizing costs, and Transforming the way health care is provided.  QUEST provides medically necessary primary and acute care to families, parent or caretaker relatives, and children.  In 2009, the State of Hawaii medicaid program implemented a second program provided through a managed care delivery system called QUEST Expanded Access (QExA).  QExA provides primary and acute care services, as well as long term care services, to individuals who are over sixty-five years of age, or determined to be disabled or legally blind.

     Effective January 1, 2015, the QUEST and QExA managed care programs will be combined and replaced by the QUEST Integration program, also provided through a managed care delivery system.  The purpose of this measure is to amend statutes that refer to QUEST and QExA and change the terminology to read "medicaid managed care" or "medicaid managed care program".

     SECTION 2.  Section 346-41.5, Hawaii Revised Statutes, is amended to read as follows:

     "Section 346-41.5 Hawaii qualified health centers. If the [QUEST] medicaid managed care program is implemented, the department shall provide a supplemental capitation program for the uninsured with enabling services based on an annual cost-based determination to all Hawaii qualified health centers [(HQHCs)] and to any nonprofit entity having a majority of Hawaii qualified health centers as board members.

     For the purposes of this section, "enabling services" includes enabling services as defined by federally qualified health center standards.  The department shall have the administrative flexibility to expend funds through [QUEST] medicaid managed care contracts, through a modified voucher system, or through chapter [42D.] 42F.  Hawaii qualified health centers receiving these supplemental payments shall reconcile their costs on an annual basis."

     SECTION 3.  Section 346-53.64, Hawaii Revised Statutes, is amended by amending subsection (a) to read as follows:

     "(a)  Services eligible for prospective payment system reimbursement are those services that are furnished by a federally qualified health center or rural health clinic that are:

     (1)  Within the legal authority of a federally qualified health center to deliver, as defined in section 1905 of the Social Security Act;

     (2)  Actually provided by the federally qualified health center, either directly or under arrangements;

     (3)  Covered benefits under the medicaid program, as defined in section 4231 of the State Medicaid Manual and the Hawaii medicaid state plan;

     (4)  Provided to a recipient eligible for medicaid benefits;

     (5)  Delivered exclusively by health care professionals, including physicians, physician's assistants, nurse practitioners, nurse midwives, clinical social workers, clinical psychologists, and other persons acting within the lawful scope of their license or certificate to provide services;

     (6)  Provided at the federally qualified health center's practice site, a hospital emergency room, in an inpatient setting, at the patient's place of residence, including long term care facilities, or at another medical facility; and

     (7)  Within the scope of services provided by the State under its fee-for-service medicaid program and its [health QUEST] medicaid managed care program, on and after August 1994, and as amended from time to time."

     SECTION 4.  Section 346-59.4, Hawaii Revised Statutes, is amended to read as follows:

     "Section 346-59.4 Medical assistance to other children.  The department shall provide state-funded medical assistance, of up to two hundred per cent of the federal poverty level for Hawaii, to persons less than nineteen years of age who are:

     (1)  Legal permanent residents who arrived after August 22, 1996;

     (2)  Persons who are permanently residing under color of law; and

     (3)  Nonimmigrants from the Trust Territories of the Pacific Islands who are citizens of:

         (A)  The Marshall Islands;

         (B)  The Federated States of Micronesia; or

         (C)  Palau,

          as defined by the Compact of Free Association Act of 1985, P.L. 99-239, or the Compact of Free Association between the United States and the Government of Palau, P.L. 99-658,

who are otherwise eligible for benefits under the State's medicaid [programs, including QUEST] program and the State's children health insurance program, but are ineligible due to restricted eligibility rules imposed by title XXI of the Social Security Act, the Personal Responsibility and Work Reconciliation Act of 1996, the Compact of Free Association Act of 1985, P.L. 99-239, the Compact of Free Association between the United States and the Government of Palau, P.L. 99-658, or any other provision of federal law denying medical assistance to nonimmigrants who are citizens of the Marshall Islands, the Federated States of Micronesia, or Palau."

     SECTION 5.  Section 346-59.9, Hawaii Revised Statutes, is amended by amending subsection (a) to read as follows:

     "(a)  This section shall apply only to the [QUEST, QUEST Expanded Access,] medicaid managed care, and fee-for-service programs administered by the department when the department or the department's contracted health plan is the primary insurer.  When the department is the secondary insurer, the department and its contracted health plans shall be responsible only for the secondary insurer’s share of any psychotropic medication covered by the primary insurer."

     SECTION 6.  Section 346-59.9, Hawaii Revised Statutes, is amended by amending subsection (g) to read:

     "(g)  The department and its [QUEST] medicaid managed care contracted health plans shall have the authority to investigate fraud, abuse, or misconduct."

     SECTION 7.  Section 346-352, Hawaii Revised Statutes, is amended to read as follows:

     "§346-352  Preauthorization exemption for certain physicians and physician assistants.  Any physician or physician assistant licensed in this State who treats a medicaid recipient patient suffering from the human immunodeficiency virus, acquired immune deficiency syndrome, or hepatitis C, or who is a patient in need of transplant immunosuppressives, may prescribe any medications approved by the United States Food and Drug Administration and that are eligible for Omnibus Budget Reconciliation Rebates Act (OBRA), that are necessary to treat the condition, without having to comply with the requirements of any preauthorization procedure established by any other provision of this chapter. This section shall not apply to [QUEST] medicaid managed care medical plans."

     SECTION 8.  Section 461-10.5, Hawaii Revised Statutes, is amended by amending subsection (d) to read as follows:

     "(d)  Remote dispensing pharmacies shall not provide medications to patients with health insurance coverage, except for:

     (1)  Patients covered by [QUEST;] medicaid managed care programs;

     (2)  Patients served at a facility operated by a health maintenance organization regulated pursuant to chapter 432D; or

     (3)  Patients residing on an island without a pharmacy or in remote areas without an existing pharmacy within a five mile radius.  A remote dispensing pharmacy established pursuant to this subsection may continue to operate in the same location if a pharmacy is subsequently established on the same island as the remote dispensing pharmacy or in the remote area without an existing pharmacy within a five mile radius; provided that the remote dispensing pharmacy shall no longer be authorized to dispense controlled substances."

     SECTION 9.  Statutory material to be repealed is bracketed and stricken.  New statutory material is underscored.

     SECTION 10.  This Act shall take effect upon its approval.

INTRODUCED BY:	_____________________________
	BY REQUEST

Report Title:

Medicaid Managed Care Program

Description:

Amends the QUEST and QUEST Expanded Access references in the Hawaii Revised Statutes to remove language that refers to specific programs and replace it with "medicaid managed care".  The name change also authorizes all Medicaid managed care health plans to subject prescription drugs for conditions covered in section 346-352, Hawaii Revised Statutes, to prior authorization procedures.

The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.