§393-7 - Required health care benefits.

§393-7 Required health care
benefits. (a) A prepaid health care plan shall qualify as a plan
providing the mandatory health care benefits required under this chapter if it
provides for health care benefits equal to, or medically reasonably
substitutable for, the benefits provided by prepaid health plans of the same
type, as specified in section 393-12(a)(1) or (2), which have the largest
numbers of subscribers in the State. This applies to the types and quantity of
benefits as well as to limitations on reimbursability, including deductibles,
and to required amounts of co-insurance.

The director, after advice by the prepaid
health care advisory council, shall determine whether benefits provided in a
plan, other than the plan of the respective type having the largest numbers of
subscribers in the State, comply with the standards specified in this
subsection.

(b) A prepaid group health care plan shall
also qualify for the mandatory health care benefits required under this chapter
if it is demonstrated by the health care plan contractor offering such coverage
to the satisfaction of the director after advice by the prepaid health care
advisory council that the plan provides for sound basic hospital, surgical,
medical, and other health care benefits at a premium commensurate with the
benefits included taking proper account of the limitations, co-insurance
features, and deductibles specified in such plan. Coverage under a plan which
provides aggregate benefits that are more limited than those provided by plans
qualifying under subsection (a) shall be in compliance with section 393-11 only
if the employer contributes at least half of the cost of the coverage of
dependents under such plan.

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

(1) Hospital benefits:

(A) In-patient care for a period of at least
one 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, and
blood transfusion services.

(B) Out-patient care:

(i) Covering use of out-patient hospital;

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

(2) Surgical benefits:

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

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

(3) Medical benefits:

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

(B) Intensive medical care while hospitalized;

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

(5) Maternity benefits, at least if the employee has
been covered by the prepaid health care plan for nine consecutive months prior
to the delivery.

(6) Substance abuse benefits:

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

(B) Out-patient benefits provided by a
physician, psychiatrist, or psychologist, without restriction as to place of
service; 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 facility
and utilizing its own staff, or

(ii) Contracting for the provision of these
benefits, or

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

(C) Detoxification and acute care benefits in
a hospital or any other public or private treatment facility, or portion
thereof, providing services especially for the detoxification of intoxicated
persons or drug addicts, which is appropriately licensed, certified, or
approved by the department of health in accordance with the standards
prescribed by the Joint Commission on Accreditation of Hospitals. In-patient
benefits for detoxification and acute care shall be limited in the case of
alcohol abuse to three admissions per calendar year, not to exceed seven days
per admission, and shall be limited in the case of other substance abuse to
three admissions per calendar year, not to exceed twenty-one days per
admission.

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

(d) The prepaid health care advisory council
shall be appointed by the director and shall include representatives of the
medical and public health professions, representatives of consumer interests,
and persons experienced in prepaid health care protection; provided that a
person representing a health maintenance organization under chapter 432D, a
mutual benefit society issuing individual and group hospital or medical service
plans under chapter 432, or any other health care organization shall not be a
member. The membership of the council shall not exceed seven individuals. [L
1974, 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's
Prepaid Health Care Act: Root Cause of a Health Care Monopoly. VII HBJ No.
13, at pg. 9.