BP BHEAD INT H

AN ACT Relating to quality assurance health insurance coverage; adding new sections to chapter 48.43 RCW; adding a new section to Title 18 RCW; and creating a new section.

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

NEW SECTION. Sec. 1. A new section is added to chapter 48.43 RCW to read as follows:

The legislature finds that controlling the cost of health care services is of great importance; however, unless quality assurance standards are maintained, cost control strategies may fail. Further, cost control efforts should not impede the patient's prudent choice of health care provider or the provider's clinical sovereignty regarding appropriate patient care. The legislature further finds that although the appropriate response to the concerns regarding quality assurance should be ultimately addressed through uniform standards of care, the present concern regarding appropriate health care services for mothers and their newly born children is of paramount importance and requires immediate attention. It is the intent of the legislature to establish immediate provisional remedies to the problems of appropriate mother and newborn care, while providing a framework for a more comprehensive solution to concerns of provider choice, clinical sovereignty, quality assurance, and cost-effectiveness for all health care services.

NEW SECTION. Sec. 2. A new section is added to chapter 48.43 RCW to read as follows:

Unless otherwise specifically provided, the definitions in this section apply throughout sections 3 and 4 of this act.

(1) "Attending provider" means a provider who has clinical hospital privileges consistent with RCW 70.43.020 and is a physician licensed under chapter 18.57 or 18.71 RCW, a certified nurse midwife or another advanced registered nurse practitioner licensed under chapter 18.79 RCW, or a midwife licensed under chapter 18.50 RCW.

(2) "Health carrier" or "carrier" means disability insurers regulated under chapter 48.20 or 48.21 RCW, health care services contractors regulated under chapter 48.44 RCW, health maintenance organizations regulated under chapter 48.46 RCW, plans operating under the health care authority under chapter 41.05 RCW, the state health insurance pool operating under chapter 48.41 RCW, and insuring entities regulated under this chapter.

(3) "Postbirth care" means services that include, but are not limited to, physical and emotional assessment of the mother and newly born child, parent education, assistance and training in breast or bottle feeding, follow-up lactation care, assessment of the home support system, and the performance of any medically necessary and appropriate clinical tests. Effective January 1, 1997, such services must be consistent with protocols and guidelines adopted by the state department of health after consideration of national pediatric, obstetric, and nursing professional organizations' guidelines for these services.

(4) "Postbirth care provider" means an attending provider or a registered nurse as defined by RCW 18.79.020 who has received specific training in the delivery of postbirth care.

NEW SECTION. Sec. 3. A new section is added to chapter 48.43 RCW to read as follows:

(1) Effective January 1, 1997, health carriers that provide coverage for maternity care services shall comply with the following requirements:

(a) Coverage for the newly born child must be no less than the coverage of the child's mother for no less than three weeks, even if there are separate hospital admissions.

(b) Coverage for inpatient maternity and postbirth care to a mother and her newly born child must be as follows:

(i) For vaginal deliveries without medical complications, no less than twenty-four hours from the time of birth;

(ii) For deliveries by cesarean section without medical complications, no less than ninety-six hours from the time of birth;

(iii) For labor and deliveries with medical complications, a period of time as determined by the attending provider, consistent with protocols and guidelines recommended by national pediatric and obstetric professional organizations.

(c) Decisions to shorten the length of inpatient stay to less than that provided under (b)(i) and (ii) of this subsection may be made only by the attending providers with the agreement of the mother.

(d) Mothers and newly born children who are discharged pursuant to (b) of this subsection must be covered for no less than one postbirth care visit to be made by a postbirth care provider on the third or fourth day after birth. Mothers and newly born children who are discharged pursuant to (c) of this subsection must be covered for no less than three postbirth care visits within fourteen days of discharge, however, the first visit must be made by a postbirth care provider on the third or fourth day after birth. All newly born children covered under this section must receive a postbirth care visit made by a pediatrician or family practitioner licensed under chapter 18.57 or 18.71 RCW prior to the thirty-fifth day of birth. Postbirth care visits may be made in a provider's office, clinic, hospital, or other appropriate alternative site.

(e) Deselection, termination of the coverage, requirements of additional documentation or utilization review, reduction in appropriate payment, or the imposition of financial disincentives to attending providers, postbirth care providers, or health care facilities who order care consistent with the provisions of this section is unlawful.

(2) Notice in writing regarding the availability of maternity and postbirth care coverage as set forth in sections 2 through 4 of this act must be transmitted at the earliest opportunity to all policyholders, but in no case later than January 1, 1997.

NEW SECTION. Sec. 4. A new section is added to chapter 48.43 RCW to read as follows:

Effective January 1, 1997, health carriers that provide coverage for maternity and postbirth shall provide identical coverage to an enrolled beneficiary's dependent child and her newly born child if the beneficiary's dependent child: Is nineteen years of age or younger or between the ages of twenty and twenty-three and registered and attending an accredited secondary school or institution of higher education; is the natural, step, or legally adopted child of the beneficiary; and qualifies as a dependent under the United States internal revenue code and is covered under the beneficiary policy. Coverage for the newly born child must be for a period of time no less than the period of time the beneficiary's dependent child is covered.

NEW SECTION. Sec. 5. A new section is added to Title 18 RCW to read as follows:

(1) Any quality assurance commission, professional regulatory board, committee, or professional association for professions subject to the secretary's authority under RCW 18.130.040 may recommend to the secretary the adoption of rules providing for standards of patient care with respect to the terms and conditions of a contract or agreement between a licensee and a payer of health services. The secretary shall consider recommendations only if the proposed rule would promote appropriate clinical sovereignty and foster compliance with standards of patient care, professional conduct, and scopes of practice; promote quality medical and health practice to improve the public's health status; prevent unreasonable interference with patient access to needed health services; or protect the public health and safety.

(2) The secretary is authorized to adopt rules based upon recommendations made in accordance with subsection (1) of this section. When practical and appropriate and with the approval of the appropriate commission, board, or committee, the secretary shall apply the rules to all licensees to promote consistent standards for the contracting process between licensees and payers of health services.

(3) Beginning one year after the promulgation of standards of patient care under subsection (1) of this section, the secretary may impose such standards of patient care as a condition of licensure, certification, or registration. Entering into a contract with a health carrier or other purchaser of health care services that does not meet such standards constitutes a violation of practice requirements.

NEW SECTION. Sec. 6. The insurance commissioner shall adopt rules to implement sections 1 through 4 of this act.