AN ACT Relating to
health insurance benefits following the birth of a child; adding a new section
to chapter 48.43 RCW; and creating new sections.
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:
(1) The legislature
recognizes the role of health care providers as the appropriate authority to
determine and establish the delivery of quality health care services to
maternity patients and their newly born children. It is the intent of the
legislature to recognize patient preference and the clinical sovereignty of
providers as they make determinations regarding services provided and the
length of time individual patients may need to remain in a health care facility
after giving birth. It is not the intent of the legislature to diminish a
carrier's ability to utilize managed care strategies but to ensure the clinical
judgment of the provider is not undermined by restrictive carrier contracts or
utilization review criteria that fail to recognize individual postpartum needs.
(2) Unless otherwise
specifically provided, the following definitions apply throughout this section:
(a) "Attending
provider" means a provider who: Has clinical hospital privileges
consistent with RCW 70.43.020; is included in a provider network of the carrier
that is providing coverage; and is a physician licensed under chapter 18.57 or
18.71 RCW, a certified nurse midwife licensed under chapter 18.79 RCW, a midwife
licensed under chapter 18.50 RCW, a physician's assistant licensed under
chapter 18.57A or 18.71A RCW, or an advanced registered nurse practitioner
licensed under chapter 18.79 RCW.
(b) "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)(a) Every health
carrier that provides coverage for maternity services must permit the attending
provider, in consultation with the mother, to make decisions on the length of
inpatient stay, rather than making such decisions through contracts or
agreements between providers, hospitals, and insurers. These decisions must be
based on accepted medical practice.
(b) Covered eligible
services may not be denied for inpatient, postdelivery care to a mother and her
newly born child after a vaginal delivery or a cesarean section delivery for
such care as ordered by the attending provider in consultation with the mother.
(c) At the time of
discharge, determination of the type and location of follow-up care, including
in-person care, must be made by the attending provider in consultation with the
mother rather than by contract or agreement between the hospital and the
insurer. These decisions must be based on accepted medical practice.
(d) Covered eligible
services may not be denied for follow-up care as ordered by the attending
provider in consultation with the mother. Coverage for providers of follow‑up
services must include, but need not be limited to, attending providers as
defined in this section, home health agencies licensed under chapter 70.127
RCW, and registered nurses licensed under chapter 18.79 RCW.
(e) Nothing in this
section shall be construed to require attending providers to authorize care they
believe to be medically unnecessary.
(f) 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.
(4) No carrier that
provides coverage for maternity services may deselect, terminate the services
of, require additional documentation from, require additional utilization
review of, reduce payments to, or otherwise provide financial disincentives to
any attending provider or health care facility solely as a result of the
attending provider or health care facility ordering care consistent with the
provisions of this section. Nothing in this section shall be construed to
prevent any insurer from reimbursing an attending provider or health care facility
on a capitated, case rate, or other financial incentive basis.
(5) Every carrier that
provides coverage for maternity services must provide notice to policyholders
regarding the coverage required under this section. The notice must be in
writing and must be transmitted at the earliest of the next mailing to the policyholder,
the yearly summary of benefits sent to the policyholder, or January 1 of the
year following the effective date of this section.
(6) This section is not
intended to establish a standard of medical care.
(7) This section shall
apply to coverage for maternity services under a contract issued or renewed by
a health carrier after the effective date of this section and shall apply to
plans operating under the health care authority under chapter 41.05 RCW
beginning January 1, 1998.
NEW SECTION. Sec.
2. Consistent with funds
available for this purpose, the Washington health care policy board, created by
chapter 43.73 RCW, shall conduct an analysis of the effects of this act,
addressing: The financial impact on health carriers in the public and private
individual and group insurance markets; the impact on utilization of health
care services; and, to the extent possible, the impact on the health status of
mothers and their newly born children. The board shall submit a final report
to the appropriate committees of the legislature by December 15, 1998.
NEW SECTION. Sec.
3. This act shall be known
as "the Erin Act."
