§393-7  Required health carebenefits.  (a)  A prepaid health care plan shall qualify as a planproviding the mandatory health care benefits required under this chapter if itprovides for health care benefits equal to, or medically reasonablysubstitutable for, the benefits provided by prepaid health plans of the sametype, as specified in section 393-12(a)(1) or (2), which have the largestnumbers of subscribers in the State.  This applies to the types and quantity ofbenefits as well as to limitations on reimbursability, including deductibles,and to required amounts of co-insurance.

The director, after advice by the prepaidhealth care advisory council, shall determine whether benefits provided in aplan, other than the plan of the respective type having the largest numbers ofsubscribers in the State, comply with the standards specified in thissubsection.

(b)  A prepaid group health care plan shallalso qualify for the mandatory health care benefits required under this chapterif it is demonstrated by the health care plan contractor offering such coverageto the satisfaction of the director after advice by the prepaid health careadvisory council that the plan provides for sound basic hospital, surgical,medical, and other health care benefits at a premium commensurate with thebenefits included taking proper account of the limitations, co-insurancefeatures, and deductibles specified in such plan.  Coverage under a plan whichprovides aggregate benefits that are more limited than those provided by plansqualifying under subsection (a) shall be in compliance with section 393-11 onlyif the employer contributes at least half of the cost of the coverage ofdependents under such plan.

(c)  Subject to the provisions of subsections(a) and (b) without limiting the development of medically more desirablecombinations and the inclusion of new types of benefits, a prepaid health careplan qualifying under this chapter shall include at least the following benefittypes:

(1)  Hospital benefits:

(A)  In-patient care for a period of at leastone hundred twenty days of confinement in each calendar year covering:

(i)  Room accommodations;

(ii)  Regular and special diets;

(iii)  General nursing services;

(iv)  Use of operating room, surgical supplies,anesthesia services, and supplies;

(v)  Drugs, dressings, oxygen, antibiotics, andblood transfusion services.

(B)  Out-patient care:

(i)  Covering use of out-patient hospital;

(ii)  Facilities for surgical procedures ormedical care of an emergency and urgent nature.

(2)  Surgical benefits:

(A)  Surgical services performed by a licensedphysician, as determined by plans meeting the standards of subsections (a) and(b);

(B)  After-care visits for a reasonable period;

(C)  Anesthesiologist services.

(3)  Medical benefits:

(A)  Necessary home, office, and hospitalvisits by a licensed physician;

(B)  Intensive medical care while hospitalized;

(C)  Medical or surgical consultations whileconfined.

(4)  Diagnostic laboratory services, x-ray films, andradio- therapeutic services, necessary for diagnosis or treatment of injuriesor diseases.

(5)  Maternity benefits, at least if the employee hasbeen covered by the prepaid health care plan for nine consecutive months priorto the delivery.

(6)  Substance abuse benefits:

(A)  Alcoholism and drug addiction areillnesses and shall receive benefits as such.  In-patient and out-patientbenefits for the diagnosis and treatment of substance abuse, including but notlimited to alcoholism and drug addiction, shall be specifically stated andshall not be less than the benefits for any other illness, except as providedin this subsection.  Medical treatment of substance abuse shall not be limitedor reduced by restricting coverage to the mental health or psychiatric benefitsof a plan.  However, any psychiatric services received as a result of thetreatment of substance abuse may be limited to the psychiatric benefits of theplan.

(B)  Out-patient benefits provided by aphysician, psychiatrist, or psychologist, without restriction as to place ofservice; provided that health plans of the type specified in section 393-12(a)shall retain for the contractor the option of:

(i)  Providing the benefits in its own facilityand utilizing its own staff, or

(ii)  Contracting for the provision of thesebenefits, or

(iii)  Authorizing the patient to utilize outsideservices and defraying or reimbursing the expenses at a rate not to exceed thatfor provision of services utilizing the health contractor's own facilities andstaff.

(C)  Detoxification and acute care benefits ina hospital or any other public or private treatment facility, or portionthereof, providing services especially for the detoxification of intoxicatedpersons or drug addicts, which is appropriately licensed, certified, orapproved by the department of health in accordance with the standardsprescribed by the Joint Commission on Accreditation of Hospitals.  In-patientbenefits for detoxification and acute care shall be limited in the case ofalcohol abuse to three admissions per calendar year, not to exceed seven daysper admission, and shall be limited in the case of other substance abuse tothree admissions per calendar year, not to exceed twenty-one days peradmission.

(D)  Prepaid health plans shall not be requiredto make reimbursements for care furnished by government agencies and availableat no cost to a patient, or for which no charge would have been made if therewere no health plan coverage.

(d)  The prepaid health care advisory councilshall be appointed by the director and shall include representatives of themedical and public health professions, representatives of consumer interests,and persons experienced in prepaid health care protection; provided that aperson representing a health maintenance organization under chapter 432D, amutual benefit society issuing individual and group hospital or medical serviceplans under chapter 432, or any other health care organization shall not be amember.  The membership of the council shall not exceed seven individuals. [L1974, c 210, pt of §1; am L 1976, c 25, §2; am L 2003, c 206, §2]

 

Law Journals and Reviews

 

  Implementation of Hawai`i'sPrepaid Health Care Act:  Root Cause of a Health Care Monopoly.  VII HBJ No.13, at pg. 9.