Hawaii-2014-HB2522-Introduced

SECTION 1. The rate of children with orofacial anomalies such as cleft lip or cleft palate in the State is estimated to be one in five hundred births. Orthodontic services for the treatment of orofacial anomalies are not included as a benefit of commercial health plans. Without orthodontic treatment, appropriate care and reconstructive surgical outcomes are compromised and result in functional deficiencies in chewing, swallowing, respiration, speech, unstable or malpositioned oral structures, premature tooth loss, and adverse psychosocial effects.

Orthodontic services has for several years been a covered medical benefit of the Hawaii medicaid program and is the benchmark plan for pediatric oral health for the essential health benefits package for the State.

The purpose of this Act is to promote quality health care procedures in the State by requiring insurance coverage of medically necessary orthodontic treatment of orofacial anomalies.

SECTION 2. Chapter 431, Hawaii Revised Statutes, is amended by adding a new section to article 10A to be appropriately designated and to read as follows:

"§431:10A- Orthodontic services for orofacial anomalies; benefits and coverage; notice. (a) Each health insurance policy, contract, plan, or agreement issued or renewed in this State after December 31, 2014, shall provide to the policyholder and individuals under twenty-six years of age covered under the policy, contract, plan, or agreement, coverage of medically necessary orthodontic services for the treatment of orofacial anomalies.

(b) Every insurer shall provide written notice to its

policy holders regarding the coverage required by this section.

The notice shall be in writing and prominently positioned in any literature or correspondence sent to policyholders and shall be transmitted to policyholders within calendar year 2015 when annual information is made available to members or in any other mailing to members, but in no case later than December 31, 2015.

(c) Orthodontic services for treatment of orofacial anomalies provided under this section shall be subject to a maximum benefit of $5,000 per treatment phase, but shall not be subject to limits on the number of visits to an orthodontist. After December 31, 2016, the insurance commissioner, on an annual basis, shall adjust the maximum benefit for inflation using the medical care component of the United States Department of Labor Consumer Price Index for all urban consumers. The commissioner shall publish the adjusted maximum benefit annually no later than April 1 the following calendar year to health insurance policies subject to this section. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, or service other than orthodontic services, shall not be applied toward any maximum benefit established under this subsection.

(d) Coverage under this section may be subject to copayment, deductible, and coinsurance provisions of a health insurance policy that are no less favorable than the copayment, deductible, and coinsurance provisions for other medical services covered by the policy.

(e) This section shall not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy.

(f) Coverage for treatment under this section shall not be denied on the basis that the treatment is habilitative or non-restorative in nature.

(g) As of January 1, 2016, to the extent that this section requires benefits that exceed the essential health benefits specified under section 1302(b) of the Patient Protection and

Affordable Care Act of 2010 (P.L. 111-148), the specific benefits that exceed the specified essential health benefits shall not be required of a qualified health plan when the plan is offered in this State through the Hawaii health insurance exchange by a health carrier. Nothing in this subsection shall nullify the application of this section to plans offered outside the exchange.

(h) As used in this section, unless the context clearly requires otherwise:

"Health insurance policy" means an individual or group or accident and health or sickness insurance policy or subscriber contract or certificate issued by an insurance entity subject to this section.

"Orofacial anomalies" means cleft lip or cleft palate and other birth defects of the mouth and face affecting functions such as eating, chewing, speech, and respiration.

"Orthodontic services" mean direct or consultative services provided by a licensed orthodontist.

"Treatment for orofacial anomalies" includes the care prescribed, provided, or ordered for an individual diagnosed with an orofacial anomaly by a craniofacial team that includes a licensed dentist, orthodontist, oral surgeon, and physician, and is coordinated between specialists and providers."

SECTION 3. Chapter 432, Hawaii Revised Statutes, is amended by adding a new section to article 1 to be appropriately designated and to read as follows:

"§432:1- Orthodontic services for orofacial anomalies, benefits and coverage; notice. (a) Notwithstanding any law to the contrary, each health insurance policy, contract, or agreement issued or renewed in this State after December 31, 2014, shall provide to the member and individuals under twenty-six years of age covered under the service plan, policy, contract, or agreement, coverage for medically necessary orthodontic services for the treatment of orofacial anomalies.

(b) Every mutual benefit society shall provide written notice to its members regarding the coverage required by this section. The notice shall be in writing and prominently positioned in any literature or correspondence sent to members and shall be transmitted to members within calendar year 2015 when annual information is made available to members or in any other mailing to members, but in no case later than December 31,

2015.

(c) Coverage provided under this section shall be subject to a maximum benefit of $5,000 per treatment phase but shall not be subject to any limits on the number of visits to an orthodontist. After December 31, 2016, the insurance commissioner, on an annual basis, shall adjust the maximum benefit for inflation, using the medical care component of the United States Department of Labor Consumer Price Index for all urban consumers. The commissioner shall publish the adjusted maximum benefit annually no later than April 1 of each calendar year, which shall apply during the following calendar year to health insurance policies subject to this section. Payments made by a mutual benefit society on behalf of a covered individual for any care, treatment, intervention, service, or item, the provision of which was for the treatment of a health condition unrelated to the covered individual's orofacial anomaly, shall not be applied toward any maximum benefit established under this subsection.

(d) Coverage under this section shall be subject to copayment, deductible, and coinsurance provisions of a health insurance policy to the extent that other medical services covered by the policy are subject to these provisions.

(e) This section shall not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy.

(f) As used in this section, unless the context clearly requires otherwise:

"Health insurance policy" means an individual or group accident and health or sickness insurance policy or subscriber contract or certificate issued by a mutual benefit society subject to this section.

"Orofacial anomalies" means cleft lip or cleft palate and other congenital anomalies of the mouth and face affecting functions such as eating, chewing, speech, and respiration.

"Orthodontic services" means direct or consultative services provided by a licensed orthodontist.

SECTION 4. Section 432D-23, Hawaii Revised Statutes, is amended to read as follows:

"§432D-23 Required provisions and benefits. Notwithstanding any provision of law to the contrary, each policy, contract, plan, or agreement issued in the State after January 1, 1995, by health maintenance organizations pursuant to this chapter, shall include benefits provided in sections 431:10-212, 431:10A-115, 431:10A-115.5, 431:10A-116, 431:10A-116.5, 431:10A-116.6, 431:10A-119, 431:10A-120, 431:10A-121, 431:10A-125, 431:10A-126, 431:10A-122, [~~and~~] 431:10A-116.2, and 431:10A- , and chapter 431M."

SECTION 5. The coverage and benefit to be provided by a health maintenance organization under section 4 of this Act shall begin for all policies, contracts, plans, or agreements issued in this State by a health maintenance organization after December 31, 2014.

SECTION 6. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 7. This Act shall take effect upon its approval.

INTRODUCED BY:

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HOUSE OF REPRESENTATIVES	H.B. NO.	2522
TWENTY-SEVENTH LEGISLATURE, 2014
STATE OF HAWAII