The legislature finds that there is a continued interest in mandating certain health coverages or offering of health coverages by health carriers; 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 of continuing concern; and that the merits of a particular 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 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. The purpose of this chapter is to establish a procedure for the proposal, review, and determination of mandated benefit necessity.
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
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
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
(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
Submission of mandated health benefit proposal—Review—Benefit must be authorized by law.
Mandated health benefits shall be established as follows:
(1) Every person who, or organization that, seeks 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 48.47.030
(2) The chair of a committee may request that the department examine the proposal using the criteria set forth in RCW 48.47.030
, 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.
Mandated health benefit proposal—Guidelines for assessing impact—Inclusion of ad hoc review panels—Health care authority.
(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: (i) To what extent is the benefit generally utilized by a significant portion of the population? (ii) To what extent is the benefit already generally available? (iii) If the benefit is not generally available, to what extent has its unavailability resulted in persons not receiving needed services? (iv) If the benefit is not generally available, to what extent has its unavailability resulted in unreasonable financial hardship? (v) What is the level of public demand for the benefit? (vi) What is the level of interest of collective bargaining agents in negotiating privately for inclusion of this benefit in group contracts?
(b) The financial impact: (i) To what extent will the benefit increase or decrease the cost of treatment or service? (ii) To what extent will the coverage increase the appropriate use of the benefit? (iii) To what extent will the benefit be a substitute for a more expensive benefit? (iv) To what extent will the benefit increase or decrease the administrative expenses of health carriers and the premium and administrative expenses of policyholders? (v) What will be the impact of this 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.
Severability—1997 c 412.
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.