Hawaii

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

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:

• Detoxification for substance use disorders
• Inpatient care, residential treatment, and day treatment services for substance use disorder treatment (but not if it is court ordered)
• Inpatient care, residential treatment, and partial hospitalization for 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.

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.

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 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