S-2969.2

1957-S.E AMS HHS S2969.2

ESHB 1957 - S COMM AMD

By Committee on Health & Human Services

Strike everything after the enacting clause and insert the following:

"NEW SECTION. Sec. 1. Because uneven practices have developed in this state that are adverse to the public interest, it is the purpose and intent of the legislature to provide an impartial and expeditious mechanism to assist the insurance commissioner in determining whether coverage for particular health care procedures, treatments, or drugs may be denied by issuers of health care coverage under their contracts on the basis that the procedures, treatments, or drugs are experimental or investigational.

NEW SECTION. Sec. 2. Unless the contest clearly requires otherwise, the following definitions apply throughout this chapter:

(1) "Committee" means the medical health coverage benefit determination committee created in section 3 of this act.

(2) "Health coverage issuer" or "issuer" means:

(a) Every insurer, as defined in RCW 48.01.050, having a certificate of 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.

NEW SECTION. Sec. 3. (1)(a) There is hereby created in the office of the insurance commissioner, the medical health coverage benefit determination committee consisting of nine members appointed by the commissioner on the basis of their knowledge and experience in health care services. In appointing the members the commissioner shall seek to appoint persons exhibiting a balance of and having a wide breadth of experience and knowledge in the treatment, research, and public or private funding of health care services.

(b) Seven members of the committee shall be medical or health professionals, one member shall represent consumers, and one member shall represent issuers of health insurance coverage.

(2) Members of the committee shall be appointed for a term of four years and shall serve until their successors are appointed by the insurance commissioner. The terms of the original members of the committee shall be staggered so that two members shall be appointed to serve until June 1, 1994, two members until June 1, 1995, two members until June 1, 1996, and three members until June 1, 1997.

(3) The commissioner may remove a member of the committee only for inefficiency, malfeasance, or misfeasance.

(4) The committee shall meet at the request of the commissioner to:

(a) Consider, develop, and recommend criteria to guide future actions of issuers of health care coverage in determining whether a procedure, treatment, drug, or other health care service is no longer experimental or investigational for purposes of extending coverage;

(b) Consider and decide whether a procedure, treatment, drug, or other health care service is no longer experimental or investigational; and

(c) Consider actual specific denials of health coverage because the proposed medical procedure is considered by the issuer to be experimental or investigative and decide whether the denial was appropriate.

(5) Members of the committee shall receive reimbursement for expenses incurred in the discharge of their duties in accordance with RCW 43.03.050 and 43.03.060.

(6) The insurance commissioner shall provide the committee with administrative, material, and staff support necessary for the proper functioning of the committee and may adopt all rules necessary to implement the provisions of this chapter.

NEW SECTION. Sec. 4. (1) In making a recommendation as to whether a procedure, treatment, drug, or other health care service is no longer experimental or investigative and in reviewing denials of individual coverage, the committee shall:

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

(b) Consider whether treating physicians find the procedure, 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

(2) After considering all relevant information before it on each issue or denial of coverage, and recognizing that time is of the essence, the committee shall issue a written recommendation to the commissioner detailing its findings and conclusions.

(3) The commissioner shall publish at least once a year, and make available to the public and issuers of health care coverage, a summary of the committee's deliberations, recommendations, and conclusions.

NEW SECTION. Sec. 5. This chapter shall expire on July 1, 1998.

NEW SECTION. Sec. 6. 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. 7. Sections 1 through 6 of this act shall constitute a new chapter in Title 48 RCW."

ESHB 1957 - S COMM AMD

By Committee on Health & Human Services

On page 1, beginning on line 2 of the title, after "committee" strike the remainder of the title and insert "adding a new chapter to Title 48 RCW; and providing an expiration date."

EFFECT: The committee created by ESHB 1957 is advisory, and is made up of nine members: seven medical or health professionals, one consumer representative, and one representative of issuers of health care coverage. Members of the committee and its chairman are appointed by the commissioner to: (a) consider, develop, and recommend criteria to guide future actions of issuers of health care coverage in determining whether a procedure, treatment, drug or other health care service is no longer experimental or investigational for purposes of extending coverage; (b) consider and recommend whether a procedure, treatment, drug, or other health care service is no longer experimental or investigational; and (c) consider and decide actual specific denials of health coverage because the proposed medical procedure is considered by the issuer to be experimental or investigative. The committee reports its determinations promptly to the commissioner.

The commissioner provides staff support for the committee.

Members are reimbursed for travel and per diem, in accordance with chapter 43.03 RCW.

The commissioner may adopt rules necessary to effectuate the chapter.

The committee sunsets July 1, 1998, a date designated to coordinate with other health care reform legislation.