BP BHEAD INT H

AN ACT Relating to the creation of the medical health coverage benefit determination committee; adding a new section to chapter 48.02 RCW; and creating a new section.

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

NEW SECTION. Sec. 1. The legislature finds and declares that the right of people to obtain access to health care in all its facets is impaired when insurance coverage is denied because the proposed procedure is considered to be experimental, investigative, or involves the use of new technology.

The legislature finds that denials may be appropriate in those limited instances where the proposed procedure has not been shown to be under continued scientific testing, to not have a demonstrable benefit for a particular illness or disease, or has not been proven to be safe or efficacious.

The legislature further finds that the lack of an impartial body to assist those making these decisions is detrimental to the interest of both the patient and the health coverage provider.

NEW SECTION. Sec. 2. A new section is added to chapter 48.02 RCW to read as follows:

There is hereby created a committee to be known as the medical health coverage benefit determination committee.

(1) Unless the context clearly requires otherwise, the following definitions apply throughout this section.

(a) "Committee" means the medical health coverage benefit determination committee created in this section.

(b) "Health care provider" means:

(i) A physician licensed under chapter 18.71 RCW or any other licensed, certified, or registered health professional regulated under chapter 18.130 RCW;

(ii) An employee or agent of a person described in (b)(i) of this subsection, acting in the course and scope of his or her employment; or

(iii) An entity, facility, or institution, whether or not incorporated, employing one or more persons described in (b)(i) of this subsection, including, but not limited to, a hospital, clinic, or nursing home; or an officer, director, employee, or agent thereof acting in the course and scope of his or her employment.

(i) 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;

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

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

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

(v) The Washington state health care authority, as defined in chapter 41.05 RCW.

(d) "Patient" means an insured, subscriber, or enrolled participant of a health coverage provider.

(2) The insurance commissioner shall appoint a medical health coverage benefit determination committee composed of representatives of the health services community having a broad perspective of the relevant issues.

(a) Members of the committee shall be appointed by the insurance commissioner. The committee shall be composed of:

(i) Two physicians, selected from a list of six names recommended by the Washington medical association;

(ii) One representative of the University of Washington school of medicine;

(iii) One representative of a medical research center;

(iv) The administrator of the Washington state health care authority;

(v) The administrator of the Washington basic health plan;

(vi) The administrator of the Washington state health insurance pool, also known as the "high risk health pool";

(vii) One representative of Washington hospitals;

(viii) Three representatives of health coverage providers, one each representing an insurer, a health care service contractor, and a health maintenance organization;

(ix) A medical ethicist; and

(x) Three consumer representatives.

(b) The insurance commissioner shall designate one member of the committee to serve as chairperson.

(3) The committee shall meet upon the call of the insurance commissioner, or upon request of either a patient or a health coverage provider. The committee shall:

(a) Develop and approve criteria that will guide future actions of the health care providers of this state in deciding whether a procedure or drug is no longer experimental or investigative;

(b) Develop a process designed to consider actual or potential specific denials of health coverage because the proposed medical procedure is considered by the health coverage provider to be experimental or investigative. In making such a determination the committee shall:

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

(ii) Consider whether the federal food and drug administration, national institutes of health, including the national cancer institute, or other similar research institutes are conducting or sponsoring assessment procedures to determine the safety and efficacy of a drug or procedure, or substantially similar drugs or procedures, or any part of the drugs or procedures;

(iii) 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

(iv) Consider other relevant information.

(d) Make decisions by a simple majority of the members by a preponderance of the evidence brought before it, and when necessary, both a majority and minority report may be made to the insurance commissioner; and

(e) Report to the insurance commissioner if a majority of the committee finds that a health coverage provider acted in bad faith in denying a treatment or drug because it is experimental or investigative.

(4) Great weight should be afforded to the determinations made by the committee.

(5) If the patient prevails and has incurred costs by submitting the question of the denial of coverage for his or her medical procedure or drug to the committee, the patient may petition the committee to assess costs from the health coverage provider and the committee may impose the costs if it determines that they are reasonable.

(6) The committee shall publish at least once a year, and the insurance commissioner shall disseminate to the public and all health care and health coverage providers, a summary of its review and the decisions for each individual, drug, or procedure considered. The committee shall prepare a report each time there is a consensus of the committee that a drug or procedure is no longer experimental or investigative.

(7) The members of the committee shall be immune from liability in a civil action or suit arising from their performance, unless actual malice, fraud, or bad faith is shown.

(8) Members of the committee may be removed by the insurance commissioner for a cause that unreasonably interferes with the proper discharge of the responsibilities of the committee or a member thereof. The insurance commissioner shall fill a vacancy by appointing a new committee member within ninety days of the occurrence of the vacancy.

(9) Appointed members of the committee shall be reimbursed for their travel expenses incurred in the actual performance of their duties in accordance with RCW 43.03.050 and 43.03.060.

(10) The insurance commissioner shall adopt rules, in consultation with the committee, as are necessary to implement this section.

(11) This section shall expire July 1, 1996.