Hawaii: Bill introduced to lock in $0-out-of-pocket sexual & reproductive healthcare coverage

Hawaii House Bill 1179 was introduced in January by 16 Democratic state legislators.

The first section of the legislative text is about as frank and clear as I've ever seen:

The legislature finds that Hawaii has long been a leader in advancing reproductive rights and advocating for access to affordable and comprehensive sexual and reproductive health care without discrimination. However, gaps in coverage and care still exist, and Hawaii benefits and protections have been threatened for years by a hostile federal administration that has attempted to restrict and repeal the federal Patient Protection and Affordable Care Act and limit access to sexual and reproductive health care. The Trump administration made it increasingly difficult for insurers to cover abortion care and assembled a Supreme Court that restricted abortion access and that may eliminate the Patient Protection and Affordable Care Act in the near future.

The legislature further finds that a host of the Protection and Affordable Care Act provisions could soon be eliminated, including coverage of preventive care with no patient cost-sharing. These changes would force people in Hawaii to pay more health care costs out-of-pocket, delay or forego care, and risk their health and economic security. The COVID-19 pandemic has cost thousands of people their jobs and health insurance. Forcing Hawaii residents to pay more for preventive care would create a new public health crisis in the wake of a global pandemic.

This section is clearly referring to the Braidwood v. Becerra lawsuit, in which a final ruling by right-wing U.S. District Judge Reed O'Connor is still pending (but which could be released at any time).

The legislature further finds that access to sexual and reproductive health care is critical for the health and economic security of all people in Hawaii, particularly during a recession. Investing in no-cost preventive services will ultimately save Hawaii money because providing preventive care avoids the need for more expensive treatment and management in the future. No-cost preventive services would also support families in financial difficulty by helping people remain healthy and plan their families in a way that is appropriate for them. Ensuring that Hawaii's people receive comprehensive, client-centered, and culturally-competent sexual and reproductive health care is prudent economic policy that will improve the overall health of our State's communities.

In order to guarantee essential health benefits, safeguard access to abortion, limit out-of-pocket costs, and improve overall access to care, the legislature finds that it is vital to preserve certain aspects of the Patient Protection and Affordable Care Act and ensure access to health care for residents of Hawaii.

Accordingly, the purpose of this Act is to ensure comprehensive coverage for sexual and reproductive health care services, including family planning and abortion, for all people in Hawaii.

The rest of the legislative text is quite long and repetitive (since it has to bake the types of services which have to be covered at no out-of-pocket cost to the enrollees into several different statutes of state law), but here's the gist of it:

Chapter 431, Hawaii Revised Statutes, is amended by adding two new sections to part I of article 10A to be appropriately designated and to read as follows:

"§431:10A-A Preventive care; coverage; requirements.

(a) Every individual policy of accident and health or sickness insurance issued or renewed in this State shall provide coverage for all of the following services, drugs, devices, products, and procedures for the policyholder or any dependent of the policyholder who is covered by the policy:

  • (1) Well-woman preventive care visit annually for women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception care and services necessary for prenatal care. For the purposes of this section and where appropriate, a "well-woman visit" shall include other preventive services as listed in this section; provided that if several visits are needed to obtain all necessary recommended preventive services, depending upon a woman's health status, health needs, and other risk factors, coverage shall apply to each of the necessary visits;
  • (2) Counseling for sexually transmitted infections, including human immunodeficiency virus and acquired immune deficiency syndrome;
  • (3) Screening for: chlamydia; gonorrhea; hepatitis B; hepatitis C; human immunodeficiency virus and acquired immune deficiency syndrome; human papillomavirus; syphilis; anemia; urinary tract infection; pregnancy; Rh incompatibility; gestational diabetes; osteoporosis; breast cancer; and cervical cancer;
  • (4) Screening to determine whether counseling and testing related to the BRCAl or BRCA2 genetic mutation is indicated and genetic counseling and testing related to the BRCAl or BRCA2 genetic mutation, if indicated;
  • (5) Screening and appropriate counseling or interventions for:
    • (A) Substance abuse, including tobacco and electronic smoking devices, and alcohol; and
    • (B) Domestic and interpersonal violence;
  • (6) Screening and appropriate counseling or interventions for mental health screening and counseling, including depression;
  • (7) Folic acid supplements;
  • (8) Abortion;
  • (9) Breastfeeding comprehensive support, counseling, and supplies;
  • (10) Breast cancer chemoprevention counseling;
  • (11) Any contraceptive supplies, as specified in section 431:l0A-116.6;
  • (12) Voluntary sterilization, as a single claim or combined with the following other claims for covered services provided on the same day:
    • (A) Patient education and counseling on contraception and sterilization; and
    • (B) Services related to sterilization or the administration and monitoring of contraceptive supplies, including:
      • (i) Management of side effects;
      • (ii) Counseling for continued adherence to a prescribed regimen;
      • (iii) Device insertion and removal; and
      • (iv) Provision of alternative contraceptive supplies deemed medically appropriate in the judgment of the insured's health care provider;
  • (13) Pre-exposure prophylaxis, post-exposure prophylaxis, and human papillomavirus vaccination; and
  • (14) Any additional preventive services for women that must be covered without cost sharing under title 42 United States Code section 300gg-13, as identified by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services, as of January 1, 2019.

(b) An insurer shall not impose any cost-sharing requirements, including copayments, coinsurance, or deductibles, on a policyholder or an individual covered by the policy with respect to the coverage and benefits required by this section, except to the extent that coverage of particular services without cost-sharing would disqualify a high-deductible health plan from eligibility for a health savings account pursuant to title 26 United States Code section 223. For a qualifying high-deductible health plan, the insurer shall establish the plan's cost-sharing for the coverage provided pursuant to this section at the minimum level necessary to preserve the insured's ability to claim tax-exempt contributions and withdrawals from the insured's health savings account under title 26 United States Code section 223.

If I'm reading this correctly, this would be a bigger deal than it appears at first. To my knowledge, there's only 6 states which currently mandate abortion coverage for all private major medical insurance policies (CA, IL, ME, NY, OR & WA)...and of those, I think this would make Hawaii the only one which requires that abortion be covered with no deductible, co-pay, coinsurance or other out-of-pocket cost*, though I could be wrong about that.

*(Technically there would still be a $12/year cost in the form of the ACA's infamous "$1/mo abortion premium" requirement, but that isn't really the same thing since it applies to everyone enrolled in those policies whether they ever have an abortion or not.)

(c) A health care provider shall be reimbursed for providing the services pursuant to this section without any deduction for coinsurance, copayments, or any other cost-sharing amounts.

(d) Except as otherwise authorized under this section, an insurer shall not impose any restrictions or delays on the coverage required under this section.

(e) This section shall not require a policy of accident and health or sickness insurance to cover:

  • (1) Experimental or investigational treatments;
  • (2) Clinical trials or demonstration projects;
  • (3) Treatments that do not conform to acceptable and customary standards of medical practice; or
  • (4) Treatments for which there is insufficient data to determine efficacy.

(f) If services, drugs, devices, products, or procedures required by this section are provided by an out-of-network provider, the insurer shall cover the services, drugs, devices, products, or procedures without imposing any cost-sharing requirement on the policyholder if:

  • (1) There is no in-network provider to furnish the service, drug, device, product, or procedure that meets the requirements for network adequacy under section 431:26-103; or
  • (2) An in-network provider is unable or unwilling to provide the service, drug, device, product, or procedure in a timely manner.

(g) Every insurer shall provide written notice to its policyholders 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 beginning with calendar year 2024 when annual information is made available to policyholders or in any other mailing to policyholders, but in no case later than December 31, 2024.

(h) This section shall not apply to policies that provide coverage for specified diseases or other limited benefit health insurance coverage, as provided pursuant to section 431:l0A-607.

(i) If the commissioner concludes that enforcement of this section may adversely affect the allocation of federal funds to the State, the commissioner may grant an exemption to the requirements, but only to the minimum extent necessary to ensure the continued receipt of federal funds.

(j) A bill or statement for services from any health care provider or insurer shall be sent directly to the person receiving the services.

(k) For purposes of this section, "contraceptive supplies" shall have the same meaning as in section 431:l0A-116.6.

§431:l0A-B Nondiscrimination; reproductive health care; coverage.

(a) An individual, on the basis of actual or perceived race, color, national origin, sex, gender identity, sexual orientation, age, or disability, shall not be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination in the coverage of, or payment for, the services, drugs, devices, products, and procedures covered by section 431:l0A-A or 431:l0A-116.6.

(b) Violation of this section shall be considered a violation pursuant to chapter 489.

(c) Nothing in this section shall be construed to limit any cause of action based upon any unfair or discriminatory practices for which a remedy is available under state or federal law."