FINAL BILL REPORT

SHB 1216

C 168 L 13

Synopsis as Enacted

Brief Description: Concerning treatment of eosinophilia gastrointestinal associated disorders.

Sponsors: House Committee on Health Care & Wellness (originally sponsored by Representatives Habib, Clibborn, Jinkins, McCoy, Springer, Morrell, Goodman, Appleton, Tarleton, Ryu, Tharinger and Fey).

House Committee on Health Care & Wellness

Senate Committee on Health Care

Background:

I. Eosinophilia.

Eosinophils are a type of white blood cells that contain proteins designed to help the body fight infection. Eosinophilia is an abnormally high number of eosinphils in the blood or body tissues. In some cases, eosinophilia can lead to inflammation of the gastrointestinal tract or the esophagus. Treatments for eosinophilia include corticosteroids and amino acid-based elemental formulas.

II. Mandated Benefits under the Patient Protection and Affordable Care Act.

Beginning in 2014, the federal Patient Protection and Affordable Care Act (PPACA) will require most small group and individual health plans to offer a package of benefits known as the "essential health benefits." A state must defray the costs to consumers for state-mandated benefits that are not included in the state's essential health benefits package.

To determine the essential health benefits, federal law allows a state to choose a "benchmark" plan from a list of options and to supplement that plan to ensure it covers all of the essential health benefit categories specified in the PPACA. Washington has chosen the largest small group plan in the state as its benchmark, which means most of the state's existing benefit mandates are included in the state's essential health benefit package. The state may not change its benchmark until at least 2016, when the federal government will revisit its approach for designating the essential health benefits.

The Insurance Commissioner must submit to the Legislature a list of state-mandated health benefits, the enforcement of which would result in federally imposed costs to the state. The list must include the anticipated costs to the state of each benefit on the list. The Insurance Commissioner may enforce a benefit on the list only if funds are appropriated by the Legislature for that purpose.

III. Sunrise Reviews.

The Department of Health (DOH) performs "sunrise reviews" on proposals for new mandated insurance benefits when requested to do so by the Legislature. The DOH reviews proposals for new insurance mandates by weighing the benefits of the mandates against the costs, including the impact on the availability of insurance. When the DOH performs a sunrise review, the results must be reported back to the Legislature no later than 30 days prior to the start of the following legislative session.

IV. Grievance and Appeals Process.

Health carriers must have a fully operational, comprehensive grievance and appeal process. Decisions on appeals must be made within 30 days. An appeal must be expedited if the enrollee, the enrollee's provider, or the health carrier's medical director reasonably determines that following the appeal process response timelines could seriously jeopardize the enrollee's life, health, or ability to regain maximum function.

Summary:

The DOH must conduct a sunrise review of the proposal to require health carriers to cover formulas necessary for the treatment of eosinophilia gastrointestinal associated disorders, regardless of delivery method. The DOH must report the results of the review no later than 30 days prior to the 2014 legislative session.

A health carrier must apply a timely appeals process to ensure medically necessary treatment is available. Expedited appeals must be completed when a delay in the appeal process could jeopardize the enrollee's life, health, or ability to regain maximum function.

Votes on Final Passage: