REPORT TITLE:
Dermatology; Direct Access


DESCRIPTION:
Requires health care plans that include dermatological coverage
to reimburse the plan participant or pay the provider regardless
of whether a referral or authorization has been obtained prior to
the delivery of services. (SD1)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        837
THE SENATE                              S.B. NO.           S.D.1
TWENTIETH LEGISLATURE, 1999                                
STATE OF HAWAII                                            
                                                             
________________________________________________________________
________________________________________________________________


                   A  BILL  FOR  AN  ACT

RELATING TO MANAGED HEALTH CARE.



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

 1      SECTION 1.  Chapter 432, article I, part VI, Hawaii Revised
 
 2 Statutes, is amended by adding a new section to be appropriately
 
 3 designated and to read as follows:
 
 4      "432:1-    Coverage for dermatological services.
 
 5 Notwithstanding any provision to the contrary, whenever any
 
 6 individual or group hospital or medical service plan contract
 
 7 provides for reimbursement or payment for dermatological
 
 8 services, the person entitled to benefits or the person
 
 9 performing the services shall be entitled to reimbursement or
 
10 payment with or without obtaining a referral or other
 
11 authorization before those services are performed.  As used in
 
12 this section, "dermatological services" means services ordinarily
 
13 and customarily rendered by a physician specializing in the
 
14 practice of dermatology."
 
15      SECTION 2.  Section 431:10A-116, Hawaii Revised Statutes, is
 
16 amended to read as follows:
 
17      "431:10A-116  Coverage for specific services.  Every person
 
18 insured under a policy of accident and sickness insurance
 
19 delivered or issued for delivery in this State shall be entitled
 
20 to the reimbursements and coverages specified below:
 

 
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                                     S.B. NO.           S.D.1
                                                        
                                                        

 
 1      (1)  Notwithstanding any provision to the contrary, whenever
 
 2           a policy, contract, plan, or agreement provides for
 
 3           reimbursement for any visual or optometric service
 
 4           which is within the lawful scope of practice of a duly
 
 5           licensed optometrist, the person entitled to benefits
 
 6           or the person performing the services shall be entitled
 
 7           to reimbursement whether the service is performed by a
 
 8           licensed physician or by a licensed optometrist.
 
 9           Visual or optometric services shall include eye or
 
10           visual examination, or both, or a correction of any
 
11           visual or muscular anomaly, and the supplying of
 
12           [opthalmic] ophthalmic  materials, lenses, contact
 
13           lenses, spectacles, eyeglasses, and appurtenances
 
14           thereto.
 
15      (2)  Notwithstanding any provision to the contrary, for all
 
16           policies, contracts, plans, or agreements issued on or
 
17           after May 30, 1974, whenever provision is made for
 
18           reimbursement or indemnity for any service related to
 
19           surgical or emergency procedures which is within the
 
20           lawful scope of practice of any practitioner licensed
 
21           to practice medicine in this State, reimbursement or
 
22           indemnification under such policy, contract, plan, or
 
23           agreement shall not be denied when such services are
 

 
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                                     S.B. NO.           S.D.1
                                                        
                                                        

 
 1           performed by a dentist acting within the lawful scope
 
 2           of the dentist's license.
 
 3      (3)  Notwithstanding any provision to the contrary, whenever
 
 4           the policy provides reimbursement or payment for any
 
 5           service which is within the lawful scope of practice of
 
 6           a psychologist licensed in this State, the person
 
 7           entitled to benefits or performing the service shall be
 
 8           entitled to reimbursement or payment, whether the
 
 9           service is performed by a licensed physician or
 
10           licensed psychologist.
 
11      (4)  Notwithstanding any provision to the contrary, each
 
12           policy, contract, plan, or agreement issued on or after
 
13           February 1, 1991, except for policies which only
 
14           provide coverage for specified diseases or other
 
15           limited benefit coverage, but including policies issued
 
16           by companies subject to chapter 431, article 10A, part
 
17           II and chapter 432, article 1 shall provide coverage
 
18           for screening by low-dose mammography for occult breast
 
19           cancer as follows:
 
20           (A)  For women thirty-five to thirty-nine years of age,
 
21                one baseline mammogram;
 
22           (B)  For women forty to forty-nine years of age, a
 
23                mammogram every two years;
 

 
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                                     S.B. NO.           S.D.1
                                                        
                                                        

 
 1           (C)  For women fifty years of age and older, an annual
 
 2                mammogram; and
 
 3           (D)  For a woman of any age with a history of breast
 
 4                cancer or whose mother or sister has had a history
 
 5                of breast cancer, a mammogram upon the
 
 6                recommendation of the woman's physician.
 
 7                The services provided in this paragraph are
 
 8           subject to any coinsurance provisions which may be in
 
 9           force in these policies, contracts, plans, or
 
10           agreements.  The commissioner shall annually review the
 
11           age and frequency guidelines for mammographic screening
 
12           recommended by the American Cancer Society, and shall
 
13           accordingly adjust the age and frequency requirements
 
14           under subparagraphs (A) to (C) by rule, if necessary.
 
15                For the purpose of this paragraph, the term "low-
 
16           dose mammography" means the x-ray examination of the
 
17           breast using equipment dedicated specifically for
 
18           mammography, including but not limited to the x-ray
 
19           tube, filter, compression device, screens, films, and
 
20           cassettes, with an average radiation exposure delivery
 
21           of less than one rad mid-breast, with two views for
 
22           each breast.  An insurer may provide the services
 
23           required by this paragraph through contracts with
 

 
Page 5                                                     837
                                     S.B. NO.           S.D.1
                                                        
                                                        

 
 1           providers; provided that the contract is determined to
 
 2           be a cost-effective means of delivering the services
 
 3           without sacrifice of quality and meets the approval of
 
 4           the director of health.
 
 5      (5)  (A)  (i)  Notwithstanding any provision to the
 
 6                     contrary, whenever a policy, contract, plan,
 
 7                     or agreement provides coverage for the
 
 8                     children of the insured, that coverage shall
 
 9                     also extend to the date of birth of any
 
10                     newborn child to be adopted by the insured;
 
11                     provided that the insured gives written
 
12                     notice to the insurer of the insured's
 
13                     intent to adopt the child prior to the
 
14                     child's date of birth or within thirty days
 
15                     after the child's birth or within the time
 
16                     period required for enrollment of a natural
 
17                     born child under the policy, contract plan,
 
18                     or agreement of the insured, whichever period
 
19                     is longer; provided, however, if the adoption
 
20                     proceedings are not successful, the insured
 
21                     shall reimburse the insurer for any expenses
 
22                     paid for the child.
 

 
 
 
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                                     S.B. NO.           S.D.1
                                                        
                                                        

 
 1               (ii)  Where notification has not been received by
 
 2                     the insurer prior to the child's birth or
 
 3                     within the specified period following the
 
 4                     child's birth, insurance coverage shall be
 
 5                     effective from the first day following the
 
 6                     insurer's receipt of legal notification of
 
 7                     the insured's ability to consent for
 
 8                     treatment of the infant for whom coverage is
 
 9                     sought.
 
10           (B)  When the insured is a member of a health
 
11                maintenance organization (HMO), coverage of an
 
12                adopted newborn is effective:
 
13                (i)  From the date of birth of the adopted newborn
 
14                     when the newborn is treated from birth
 
15                     pursuant to a provider contract with the
 
16                     health maintenance organization, and written
 
17                     notice of enrollment in accord with the
 
18                     health maintenance organization's usual
 
19                     enrollment process is provided within thirty
 
20                     days of the date the insured notifies the
 
21                     health maintenance organization of the
 
22                     insured's intent to adopt the infant for whom
 
23                     coverage is sought; or
 

 
Page 7                                                     837
                                     S.B. NO.           S.D.1
                                                        
                                                        

 
 1               (ii)  From the first day following receipt by the
 
 2                     health maintenance organization of written
 
 3                     notice of the insured's ability to consent
 
 4                     for treatment of the infant for whom coverage
 
 5                     is sought and enrollment of the adopted
 
 6                     newborn in accord with the health maintenance
 
 7                     organization's usual enrollment process if
 
 8                     the newborn has been treated from birth by a
 
 9                     provider not contracting or affiliated with
 
10                     the health maintenance organization.
 
11      (6)  Notwithstanding any provision to the contrary, whenever
 
12           a policy, contract, plan, or agreement provides for
 
13           reimbursement or payment for dermatological services,
 
14           the person entitled to benefits or the person
 
15           performing the services shall be entitled to
 
16           reimbursement or payment with or without obtaining a
 
17           referral or other authorization before those services
 
18           are performed.  As used in this section,
 
19           "dermatological services" means services ordinarily and
 
20           customarily rendered by a physician specializing in the
 
21           practice of dermatology."
 
22      SECTION 3.  Statutory material to be repealed is bracketed.
 
23 New statutory material is underscored.
 

 
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                                     S.B. NO.           S.D.1
                                                        
                                                        

 
 1      SECTION 4.  This Act shall take effect upon its approval.
 
 2