AN
ACT Relating to review of mandated health insurance benefits; amending RCW
48.42.060, 48.42.070, and 48.42.080; adding a new chapter to Title 48 RCW; and
recodifying RCW 48.42.060, 48.42.070, and 48.42.080.
BE IT
ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec.
1. RCW
48.42.060 and 1984 c 56 s 1 are each amended to read as follows:
The
legislature ((takes notice of the increasing number of proposals for the))
finds that there is a continued interest in mandating ((of))
certain health coverages or offering of health coverages by ((insurance))
health carriers((, health care service contractors, and health
maintenance organizations as a component of individual or group policies.));
and that improved access to these health care services to segments of the
population which desire them can provide beneficial social and health
consequences which may be in the public interest.
The
legislature finds further, however, that the cost ramifications of
expanding health coverages is ((resulting in a growing)) of
continuing concern((. The way that such coverages are structured and
the steps taken to create incentives to provide cost-effective services or to
take advantage of cost off-setting features of services can significantly
influence the cost impact of mandating particular coverages.)); and that
the merits of a particular ((coverage mandate)) mandated benefit
must be balanced against a variety of consequences which may go far beyond the
immediate impact upon the cost of insurance coverage. The legislature hereby
finds and declares that a systematic review of proposed mandated ((or
mandatorily offered health coverage)) benefits, which explores all
the ramifications of such proposed legislation, will assist the legislature in
determining whether mandating a particular coverage or offering is in the
public interest. ((This chapter provides for a set of guidelines which
should be addressed in the consideration of all such mandated coverage
proposals coming before the legislature.)) The purpose of this chapter
is to establish a procedure for the proposal, review, and determination of
mandated benefit necessity.
NEW
SECTION. Sec. 2.
Unless otherwise specifically provided, the definitions in this section apply
throughout this chapter.
(1)
"Appropriate committees of the legislature" or "committees"
means nonfiscal standing committees of the Washington state senate and house of
representatives that have jurisdiction over statutes that regulate health
carriers, health care facilities, health care providers, or health care
services.
(2)
"Department" means the Washington state department of health.
(3)
"Health care facility" or "facility" means hospices
licensed under chapter 70.127 RCW, hospitals licensed under chapter 70.41 RCW,
rural health care facilities as defined in RCW 70.175.020, psychiatric hospitals
licensed under chapter 71.12 RCW, nursing homes licensed under chapter 18.51
RCW, community mental health centers licensed under chapter 71.05 or 71.24 RCW,
kidney disease treatment centers licensed under chapter 70.41 RCW, ambulatory
diagnostic, treatment, or surgical facilities licensed under chapter 70.41 RCW,
drug and alcohol treatment facilities licensed under chapter 70.96A RCW, and
home health agencies licensed under chapter 70.127 RCW, and includes such
facilities if owned and operated by a political subdivision or instrumentality
of the state, and such other facilities as required by federal law and
implementing regulations.
(4)
"Health care provider" or "provider" means:
(a)
A person regulated under Title 18 or chapter 70.127 RCW, to practice health or
health-related services or otherwise practicing health care services in this
state consistent with state law; or
(b)
An employee or agent of a person described in (a) of this subsection, acting in
the course and scope of his or her employment.
(5)
"Health care service" or "service" means a service, drug,
or medical equipment offered or provided by a health care facility and a health
care provider relating to the prevention, cure, or treatment of illness,
injury, or disease.
(6)
"Health carrier" or "carrier" means a disability insurer
regulated under chapter 48.20 or 48.21 RCW, a health care service contractor as
defined in RCW 48.44.010, a health maintenance organization as defined in RCW
48.46.020, plans operating under the state health care authority under chapter
41.05 RCW, the state health insurance pool operating under chapter 48.41 RCW,
and insuring entities regulated in chapter 48.43 RCW.
(7)
"Mandated health benefit," "mandated benefit," or
"benefit" means coverage or offering required by law to be provided
by a health carrier to: (a) Cover a specific health care service or services;
(b) cover treatment of a specific condition or conditions; or (c) contract,
pay, or reimburse specific categories of health care providers for specific
services; however, it does not mean benefits established pursuant to chapter
74.09, 41.05, or 70.47 RCW, or scope of practice modifications pursuant to
chapter 18.120 RCW.
Sec.
3. RCW
48.42.070 and 1989 1st ex.s. c 9 s 221 are each amended to read as follows:
Mandated
health benefits shall be established as follows:
(1)
Every person who, or organization ((which)) that, seeks
((sponsorship of a legislative proposal which would mandate a health
coverage or offering of a health coverage by an insurance carrier, health care
service contractor, or health maintenance organization as a component of
individual or group policies, shall submit a report to the legislative
committees having jurisdiction, assessing both the social and financial impacts
of such coverage, including the efficacy of the treatment or service proposed,
according to the guidelines enumerated in RCW 48.42.080. Copies of the report
shall be sent to the state department of health for review and comment. The
state department of health shall make recommendations based on the report to
the extent requested by the legislative committees)) to establish a
mandated benefit shall, at least ninety days prior to a regular legislative
session, submit a mandated benefit proposal to the appropriate committees of
the legislature, assessing the social impact, financial impact, and evidence
of health care service efficacy of the benefit in strict adherence to the
criteria enumerated in RCW 48.42.080 (as recodified by this act).
(2)
The chair of a committee may request that the department examine the proposal
using the criteria set forth in RCW 48.42.080 (as recodified by this act),
however, such request must be made no later than nine months prior to a
subsequent regular legislative session.
(3)
To the extent that funds are appropriated for this purpose, the department
shall report to the appropriate committees of the legislature on the
appropriateness of adoption no later than thirty days prior to the legislative
session during which the proposal is to be considered.
(4)
Mandated benefits must be authorized by law.
Sec.
4. RCW
48.42.080 and 1984 c 56 s 3 are each amended to read as follows:
((Guidelines
for assessing the impact of proposed mandated or mandatorily offered health
coverage to the extent that information is available, shall include, but not be
limited to, the following:))
(1)
Based on the availability of relevant information, the following criteria
shall be used to assess the impact of proposed mandated benefits:
(a)
The social impact: (((a))) (i) To what extent is the ((treatment
or service)) benefit generally utilized by a significant portion of
the population? (((b))) (ii) To what extent is the ((insurance
coverage)) benefit already generally available? (((c))) (iii)
If ((coverage)) the benefit is not generally available, to what
extent ((does the lack of coverage result in persons avoiding necessary
health care treatments)) has its unavailability resulted in persons not
receiving needed services? (((d))) (iv) If the ((coverage))
benefit is not generally available, to what extent ((does the lack of
coverage result)) has its unavailability resulted in unreasonable
financial hardship? (((e))) (v) What is the level of public
demand for the ((treatment or service)) benefit? (((f) What
is the level of public demand for insurance coverage of treatment or service?
(g))) (vi) What is the level of interest of collective bargaining
agents in negotiating privately for inclusion of this ((coverage)) benefit
in group contracts?
(((2)))
(b) The financial impact: (((a))) (i) To what extent will
the ((coverage)) benefit increase or decrease the cost of
treatment or service? (((b))) (ii) To what extent will the
coverage increase the appropriate use of the ((treatment or service)) benefit?
(((c))) (iii) To what extent will the ((mandated treatment or
service)) benefit be a substitute for a more expensive ((treatment
or service)) benefit? (((d))) (iv) To what extent
will the ((coverage)) benefit increase or decrease the
administrative expenses of ((insurance companies)) health carriers
and the premium and administrative expenses of policyholders? (((e))) (v)
What will be the impact of this ((coverage)) benefit on the total
cost of health care services and on premiums for health coverage? (vi) What
will be the impact of this benefit on costs for state-purchased health care?
(vii) What will be the impact of this benefit on affordability and access to
coverage?
(c)
Evidence of health care service efficacy:
(i)
If a mandatory benefit of a specific service is sought, to what extent has
there been conducted professionally accepted controlled trials demonstrating
the health consequences of that service compared to no service or an
alternative service?
(ii)
If a mandated benefit of a category of health care provider is sought, to what
extent has there been conducted professionally accepted controlled trials
demonstrating the health consequences achieved by the mandated benefit of this
category of health care provider?
(iii)
To what extent will the mandated benefit enhance the general health status of
the state residents?
(2)
The department shall consider the availability of relevant information in
assessing the completeness of the proposal.
(3)
The department may supplement these criteria to reflect new relevant
information or additional significant issues.
(4)
The department shall establish, where appropriate, ad hoc panels composed of
related experts, and representatives of carriers, consumers, providers, and purchasers
to assist in the proposal review process. Ad hoc panel members shall serve
without compensation.
(5)
The health care authority shall evaluate the reasonableness and accuracy of
cost estimates associated with the proposed mandated benefit that are provided
to the department by the proposer or other interested parties, and shall
provide comment to the department. Interested parties may, in addition, submit
data directly to the department.
NEW
SECTION. Sec. 5.
Section 2 of this act shall constitute a new chapter in Title 48 RCW.
NEW
SECTION. Sec. 6. RCW
48.42.060, 48.42.070, and 48.42.080 are each recodified in the new chapter
created in section 5 of this act.
NEW
SECTION. Sec. 7. 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.
