48.47.030 - Mandated health benefit proposal -- Guidelines for assessing impact -- Inclusion of ad hoc review panels -- Health care authority. - Washington Statutes

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.

[1997 c 412 § 4; 1984 c 56 § 3. Formerly RCW 48.42.080.]