1957-S

AN ACT Relating to the creation of the medical health coverage benefit determination committee; adding a new chapter to Title 48 RCW; and providing an expiration date.

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

NEW SECTION. Sec. 1. The legislature finds that insurers, health care service contractors, and health maintenance organizations employ a variety of methods to determine whether a particular health care service or treatment will be denied because such service or treatment is considered by the insurer, contractor, or health maintenance organization to be experimental or investigative. The denial of coverage may prevent access to necessary health care services or treatment when the person seeking coverage has no other method of affording such health care service or treatment.

The legislature further finds that similarly situated persons with the same health care need but with different insurers face the possibility that one insurer will deny coverage while the other will permit coverage. Moreover, if the insurer, contractor, or health maintenance organization denies coverage, the person must resort to expensive and protracted legal proceedings when time is of the essence in obtaining needed health care service or treatment.

The inconsistency in coverage determinations and the need for expeditious and inexpensive resolution of coverage disputes requires an impartial body to build a consistent record of coverage determination and to provide efficient resolution of coverage disputes.

NEW SECTION. Sec. 2. Unless the context clearly requires otherwise, the definitions in this section apply throughout this chapter.

(1) "Board" means the health care coverage determination board.

(2) "Consumer" means an insured, subscriber, enrolled participant, or beneficiary of an insurer.

(3) "Insurer" means:

(a) Every insurer, as defined in RCW 48.01.050, having a certificate or authority to transact disability insurance as defined in RCW 48.11.030, in this state;

(b) Every health care service contractor, as defined in RCW 48.44.010(3), registered to transact business in this state;

(c) Every health maintenance organization, as defined in RCW 48.46.020(1), registered to transact business in this state;

(d) The Washington basic health plan, as defined in RCW 70.47.020(1);

(e) The Washington state health care authority, as defined in chapter 41.05 RCW;

(f) Every local government self-insured health and welfare benefit plan or program regulated under chapter 48.62 RCW; or

(g) The Washington state health insurance pool as defined in chapter 48.41 RCW.

(4) "Medical agent" means the person employed or appointed by the board to consider and review a consumer request for a coverage determination under this chapter.

NEW SECTION. Sec. 3. (1) There is hereby created in the office of the insurance commissioner the Washington health care coverage determination board consisting of five members appointed by the commissioner on the basis of their knowledge and experience in health care services. In appointing such members the commissioner shall seek to appoint members from diverse health care backgrounds including, but not limited to, medical research, pharmacology, oncology, internal medicine, gynecology, and pediatrics.

(2) Members of the board shall be appointed for a term of three years and until their successors are appointed. In the case of a vacancy, it shall be filled by appointment by the commissioner for the unexpired portion of the term in which such vacancy occurs. The terms of the first three members of the board shall be staggered so that one member shall be appointed to serve until June 1, 1994, one member until June 1, 1995, and one member until June 1, 1996.

(3) Any member of the board may be removed for inefficiency, malfeasance, or misfeasance.

(4) The board shall operate on a part-time basis and shall receive compensation on the basis of seventy-five dollars for each day spent in performance of his or her duties, but such compensation shall not exceed ten thousand dollars in a fiscal year. Each board member shall receive reimbursement for travel expenses incurred in the discharge of his or hr duties in accordance with RCW 43.03.050 and 43.03.060.

(5) The board shall as soon as practicable after the initial appointment of the members, meet and elect a chairperson and shall at least biennially thereafter meet and elect such chairperson.

(6) The principal office of the board shall be in the office of the insurance commissioner at the state capital, but it may sit or hold hearings at any other place in the state. A majority of the board shall constitute a quorum for rendering orders or decisions, adopting rules necessary for the conduct of its powers and duties, or transacting other official business, and may act though one position on the board is vacant. One or more members may hold hearings and take testimony to be reported for action by the board when authorized by rule or order of the board. The board shall perform all the powers and duties specified in this chapter or as otherwise provided by law.

NEW SECTION. Sec. 4. (1) The board shall have jurisdiction to decide appeals by insurers and consumers from determinations by a medical agent appointed or employed by the board to consider and review a consumer request for a coverage determination under this chapter.

(2) The board shall employ or from time to time shall appoint a medical agent to consider and review consumer requests for review of insurer decisions denying coverage of health care services or treatments because such services or treatments are considered by the insurer to be experimental or investigative. The medical agent must have demonstrated knowledge and abilities in health care services sufficient to make findings of fact and render an opinion related to consumer requests for coverage determinations under this chapter.

(3) Appeals to the board shall be governed by and the board shall have all powers conferred upon presiding officers under chapter 34.05 RCW. The board shall make findings of fact and prepare a written decision in each case decided by it, and such findings and decision shall be effective upon being signed by three or more members of the board and upon being filed at the board's principal office and shall be open to public inspection at all reasonable times.

(4) The board shall maintain at its principal office a copy of its findings and decisions available for public inspection.

(5) The medical agent in making a determination of whether an insurer's denial of coverage should be upheld or changed shall:

(a) Take into account findings, studies, or research conducted at qualified research centers in this country and abroad;

(b) Consider whether treating physicians find the drug or treatment efficacious or necessary for the health or survival of the patient, or whether there is a potential benefit to the public as a whole, as for example, where a disease is rare and treatment for it may remain experimental for the foreseeable future; and

(6) After considering the facts in each particular case, the medical agent shall issue a written report detailing his or her findings and conclusions and shall render a decision upholding or objecting to the insurer's denial of coverage. The medical agent's opinion shall be considered binding upon the consumer and the insurer unless appealed to the board by either the consumer or the insurer within fourteen days of receipt of notice of the agent's decision.

(7) The insurance commissioner shall provide the board with administrative, material, and staff support necessary for the proper functioning of the board.

NEW SECTION. Sec. 5. The commissioner shall adopt rules requiring all insurers to include in their policy, contract, agreement, or similar health care coverage forms a provision advising consumers that in the event of a denial of coverage based upon a decision by the insurer that such coverage is experimental or investigative, the consumer may appeal the insurer's decision to the insurance commissioner's office for review by the medical agent.

NEW SECTION. Sec. 6. (1) Based upon the decisions of the medical agent and the board, the commissioner may from time to time adopt guidelines for insurer determinations of whether a health care service or treatment is experimental or investigative.

(2) The commissioner shall publish at least once a year, and disseminate to the public and insurers, a summary of the medical agent's and the board's decisions for each individual, drug, or procedure considered.

(3) Whenever it appears from consistent decisions of the medical agent or board that a health care service or treatment is no longer considered experimental or investigative, the commissioner may adopt rules prohibiting the denial of coverage of such health care service or treatment upon that basis.

NEW SECTION. Sec. 7. This chapter shall expire on July 1, 1998.

NEW SECTION. Sec. 8. If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected.

NEW SECTION. Sec. 9. Sections 1 through 8 of this act shall constitute a new chapter in Title 48 RCW.