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This page lists some of the action toward parity compliance undertaken by Hawaii regulatory agencies since 2008.

Are we missing any actions taken by state regulatory agencies? Let us know at info@paritytrack.org.

Action in the Regulatory Arena

The Hawaii Insurance Division has this FAQ section for small employers in regards to small employer fully-insured plans they may purchase on the insurance marketplace. Among other things, it informs them that any new plans sold (excluding transitional plans) must cover essential health benefits and comply with the Federal Parity Law.

12/2014

The Hawaii Insurance Division issued a report (pdf | Get Adobe® Reader®) on the ramifications of requiring insurance plans to cover autism services, as required by SB 2054 from the 2014 Legislative Session. This report was prepared by Wakely Consulting Group, Inc. The report was to specifically include information about the prevalence of autism spectrum disorders (ASD), the intensity and frequency of treatments based on the severity of the ASD, and a tiered delivery model for applied behavior analysis (ABA). Some of the significant findings of the report are (there is much greater detail and analysis in the report itself in terms of how these broad figures were reached):

  • 1 in 103 children have ASD, with 1 in 211 being classified as mild, 1 in 292 being classified as moderate, and 1 in 629 being classified as severe
  • The estimate for yearly hours per child for ABA is 600, with an average of 499 for mild cases, an average of 518 for moderate cases, and an average of 731 for severe cases
  • Overall utilization rates for ABA, as classified by ASD intensity and utilization type (look at the table on page 5 of the report for these percentages)
  • The average ABA cost per hour: $108 for high utilization; $90 for middle utilization; $72 for low utilization
  • The average estimate for the impact on insurance premiums of requiring autism coverage was $28 per year, per plan member

Hawaii Parity Law

There are several sections of the state insurance law relevant to parity. There are a few sections about behavioral health coverage, there are a few sections about behavioral health utilization review agents, and there are a few about autism coverage. These will be summarized in 3 sections:

  • Behavioral Health Coverage
  • Behavioral Health Utilization Review Agents
  • Autism Coverage

Behavioral Health Coverage

This section requires individual plans, small employer fully-insured plans, large employer fully-insured plans to cover behavioral health conditions, with no exclusions listed. Plans are forbidden from using any financial requirements, quantitative treatment limitations, and non-quantitative treatment limitations for behavioral health services that are “more restrictive” than those in place for other medical services. It explicitly requires plans to comply with the Federal Parity Law.

This section requires the following for substance use disorder services and mental health services:

This section requires the Insurance Commissioner to issue regulations regarding the linked sections above, and this section defines many terms related to behavioral health. It also requires these regulations to specifically address medical necessity criteria for behavioral health coverage.

Behavioral Health Utilization Review Agents

This section lists a number of requirements for utilization review agents who perform behavioral health service reviews. Some of the most significant requirements for these agents are:

  • Must disclose review criteria to patients and providers
  • Cannot deny or limit coverage for medical necessity without first consulting with another similarly-qualified professional
  • Written explanations about why coverage was denied
  • Instructions as to how the patient can start the appeals process
  • Agents must be “accessible” to patients and providers at least 5 days a week
  • Agents are forbidden from having contracts with plans or other payors that could be interpreted as a “conflict of interest”

This section requires an annual report to be filed detailing complaints against behavioral health review agents.

This section defines some of the terms in the section of the law about behavioral health utilization review agents.

Autism Coverage

The link to the section of the law is actually a link to the passed legislation from 2015 that added that section of the law because because Hawaii’s online statutes page has not yet been updated to include this section.

This section requires individual plans, small employer fully-insured plans, and large employer fully-insured plans to cover autism services through age 13.

There is a $25,000 annual maximum for applied behavior analysis (can be adjusted for inflation), but plans are not allowed to limit outpatient visits in any other way.

Financial requirements for autism services must be the same as those used for other medical services.

Plans can review a child’s treatment plan and perform medical necessity reviews as often as they want.

Plans can require that any child who was diagnosed with autism according to criteria in an earlier version of the DSM can be reevaluated to see if he or she meets the diagnostic criteria for autism in the current version of the DSM.

Autism is defined as the autism spectrum disorder from the DSM.

Autism treatment is listed as (these are all defined in the law):

  • Behavioral health treatment (includes applied behavior analysis)
  • Pharmacy care
  • Psychiatric care
  • Psychological care
  • Therapeutic care

Get Support

Hawaii Insurance Division

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

Definition

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