BILL REQ. #:  S-4238.1 

Read first time 01/28/2004.   Referred to Committee on Health & Long-Term Care.

     AN ACT Relating to requiring the department of social and health services to establish an evidence-based medical necessity definition and decision-making process for its medical assistance programs; adding a new section to chapter 74.09 RCW; and declaring an emergency.

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

NEW SECTION.  Sec. 1   A new section is added to chapter 74.09 RCW to read as follows:
     (1) The legislature finds that: The robust development and availability of new drugs, treatments, and therapies requires greater efforts to assure that medical assistance clients will not be harmed or injured by inappropriate service utilization; the growing limitations on available resources require funds be spent in a cost-efficient and effective manner to improve the health of clients; the department's current definition of medical necessity for determining services under this chapter is outdated and inadequate; and certain orders in Washington state superior court cases unduly restrict the department from adopting necessary rule modifications, which results in inefficiencies and possible harm to clients.
     (2) It is the intent of the legislature that the department adopt a new definition and decision-making process for the term "medical necessity" for use in programs authorized under this chapter that, to the extent possible, improves health status and avoids harm to clients.
     (3) By September 1, 2004, the department shall establish, by rule, a medical necessity definition and decision-making process for all programs authorized under this chapter, conditioned as follows:
     (a) The department is the authority for all medical necessity service determinations;
     (b) The definition must be established on evidence-based standards establishing criteria for new and existing health services;
     (c) The definition must set forth complementary definitions to include, but not be limited to, "cost-effective," "effective," "efficacy," "evidence," "expert opinion," "medical condition," "purpose," "scientific evidence," and "scope";
     (d) In developing the medical necessity definition and decision-making process, the department should consider, to the extent practicable, model definitions developed by prominent academic health centers and under consideration nationally by publicly funded health programs or private health purchasing organizations; and
     (e) The department must endeavor to complement uniform policy directives set forth in RCW 41.05.013.
     (4) To the extent the new definition and decision-making process for medical necessity adopted by the department differs from the definitions, conditions, and processes provided in court orders, the department's new definition and procedures shall control.
     (5) The secretary shall report by letter to the health policy committees of the legislature on the implementation of this section by October 1, 2004.

NEW SECTION.  Sec. 2   This act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect immediately.