Haw. Rev. Stat. § 432E-10 — HI Code / Division 2 / Title 24 / Chapter 432E / Section 432E-10
Managed care plan performance measurement and data reporting standards.
Status: in_force

(a) It is the policy of this State that all managed care plans shall adopt and comply with nationally developed and promulgated standards for measuring quality, outcomes, access, satisfaction, and utilization of services. Every contract between a managed care plan and a participating provider of health care services shall require the participating provider to comply with the managed care plan's requests for any information necessary for the managed care plan to comply with the requirements of this chapter. The State shall require that:

(1) Consumers, providers, managed care plans, purchasers, and regulators shall be equitably represented in the development of standards; and

(2) Standards shall result in measurement and reporting that is purposeful, valid, and scientifically based, applied in a consistent and comparable manner, efficient and cost effective, and designed to minimize redundancy and duplication of effort.

(b) All managed care plans, no less than annually, shall report to the commissioner comparable information on performance, including measures of quality, outcomes, access, satisfaction, and utilization of services; provided that:

(1) Reporting shall be based upon a core data and information set that builds upon nationally recognized performance measurement systems. The core data and information set shall include standardized measures of:

(A) Effectiveness and appropriateness of care (the impact of care delivered to managed care plan enrollees, for example, results of the plan for childhood immunizations, cholesterol screening, mammography screening, cervical cancer screening, prenatal visits in the first trimester of pregnancy, and diabetic retinal examinations);

(B) Access and availability of care (the extent to which plan enrollees have access to the health care providers they need or desire to see, and receive appropriate services in a timely manner, without inappropriate barriers or inconvenience);

(C) Satisfaction with the experience of care (the results of the most recent enrollee satisfaction survey using standardized survey design and methods);

(D) Managed care plan stability (attributes of a managed care plan which affect its ability to deliver high-quality care and service on a sustained basis);

(E) Use of services (rates of service use per one thousand enrollees as well as percentages of enrollees who receive specified services);

(F) Cost of care (expenditures per enrollee per month, premium rates for selected membership categories, and rates of increases); and

(G) Managed care plan descriptive information (the plan name, location of headquarters, and number of years the plan has been in business; the model type of the plan; the counties in which the plan operates; the total number of participating physicians per one thousand enrollees and the number of primary care physicians per one thousand enrollees; the number of participating hospitals per ten thousand enrollees; the percentage of participating physicians who are board certified; and a list of wellness and health care education programs offered by the plan);

(2) Information shall be uniformly reported by managed care plans in a standardized format, as determined by rule;

(3) Information supplied by managed care plans shall be subject to independent audit by the appropriate regulatory agency or its designee to verify accuracy and protect against misrepresentation;

(4) Information reported by managed care plans shall be adjusted, based on standardized methods, to control for the effects of differences in health risk, severity of illness, or mix of services;

(5) A managed care plan shall ensure confidentiality of records and shall not disclose individually identifiable data or information pertaining to the diagnosis, treatment, or health of any enrollee, except as provided under law; and

(6) A managed care plan shall disclose to its enrollees the quality and satisfaction assessments used, including the current results of the assessments. [L 1998, c 178, pt of §2; am L 1999, c 137, §8]
Haw. Rev. Stat. § 432D-7 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-7
Investments.
Status: in_force

All investments permitted under section 432D-3(a)(1) may be considered admitted assets in determination of net worth; provided that these investments are in compliance with article 6 of chapter 431.
Haw. Rev. Stat. § 431N-2 — HI Code / Division 2 / Title 24 / Chapter 431N / Section 431N-2
Definitions.
Status: in_force

As used in this chapter unless otherwise indicated by the context:

"Gap group individuals" means medically uninsured persons who are residents of the State.

"Health care contractor" means any medical group or organization which undertakes, under a prepaid health care program, to provide health care, or any nonprofit organization or insurer who undertakes, under a prepaid health care program, to defray or reimburse in whole or part, the expenses of health care.

"Health care coverage" means contractually arranged medical, personal, or other services, including preventive services, education, case management, and outreach, provided to an eligible member.

"Medical indigence" means the status of a person who is uninsured or lacks medical insurance. [L 1989, c 378, pt of §1]
Haw. Rev. Stat. § 435E-17 — HI Code / Division 2 / Title 24 / Chapter 435E / Section 435E-17
Minimum indemnity level.
Status: in_force

Each participating member shall be covered by such interindemnity arrangement for not less than $100,000 for each claim and not less than $300,000 annual aggregate of professional negligence, with the terms and conditions of such coverage to be specified in the trust agreement.
Haw. Rev. Stat. § 432D-26.3 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-26.3
Nondiscrimination on the basis of actual gender identity or perceived gender identity; coverage for services.
Status: in_force

(a) No health maintenance organization policy, contract, plan, or agreement shall discriminate with respect to participation and coverage under the policy, contract, plan, or agreement against any person on the basis of actual gender identity or perceived gender identity.

(b) Discrimination under this section includes the following:

(1) Denying, canceling, limiting, or refusing to issue or renew an insurance policy, contract, plan, or agreement on the basis of a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity;

(2) Demanding or requiring a payment or premium that is based on a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity;

(3) Designating a transgender person's or a person's transgender family member's actual gender identity or perceived gender identity as a preexisting condition to deny, cancel, or limit coverage; and

(4) Denying, canceling, or limiting coverage for services on the basis of actual gender identity or perceived gender identity, including but not limited to the following:

(A) Health care services related to gender transition; provided that there is coverage under the policy, contract, plan, or agreement for the services when the services are not related to gender transition; and

(B) Health care services that are ordinarily or exclusively available to individuals of any sex.

(c) The medical necessity of any treatment for a transgender person, or any person, on the basis of actual gender identity or perceived gender identity shall be determined pursuant to the health maintenance organization policy, contract, plan, or agreement and shall be defined in accordance with applicable law. In the event of an appeal of a claim denied on the basis of medical necessity of the treatment, such appeal shall be decided in a manner consistent with applicable law and in consultation with a health care provider with experience in prescribing or delivering gender affirming treatment who shall provide input on the appropriateness of the denial of the claim.

(d) A health maintenance organization shall not apply categorical cosmetic or blanket exclusions to gender affirming treatments or procedures, or any combination of services or procedures or revisions to prior treatments, when determined to be medically necessary pursuant to applicable law, only if the policy, contract, plan, or agreement also provides coverage for those services when the services are offered for purposes other than gender transition. These services may include but are not limited to:

(1) Hormone therapies;

(2) Hysterectomies;

(3) Mastectomies;

(4) Vocal training;

(5) Feminizing vaginoplasties;

(6) Masculinizing phalloplasties;

(7) Metaoidioplasties;

(8) Breast augmentations;

(9) Masculinizing chest surgeries;

(10) Facial feminization surgeries;

(11) Reduction thyroid chondroplasties;

(12) Voice surgeries and therapies; and

(13) Electrolysis or laser hair removal.

(e) Each health maintenance organization policy, contract, plan, or agreement shall provide applicants and subscribers with clear information about the coverage of gender transition services and the requirements for determining medically necessary treatments related to these services, including the process for appealing a claim denied on the basis of medical necessity.

(f) Any coverage provided shall be subject to copayment, deductible, and coinsurance provisions of a health maintenance organization policy, contract, plan, or agreement that are no less favorable than the copayment, deductible, and coinsurance provisions for substantially all other medical services covered by the policy, contract, plan, or agreement.

(g) Nothing in this section shall be construed to mandate coverage of a service that is not medically necessary.

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

"Actual gender identity" means a person's internal sense of being male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female.

"Gender transition" means the process of a person changing the person's outward appearance or sex characteristics to accord with the person's actual gender identity.

"Perceived gender identity" means an observer's impression of another person's actual gender identity or the observer's own impression that the person is male, female, a gender different from the gender assigned at birth, a transgender person, or neither male nor female.

"Transgender person" means a person who has gender dysphoria, has received health care services related to gender transition, or otherwise identifies as a gender different from the gender assigned to that person at birth. [L 2016, c 135, §4; am L 2019, c 70, §30; am L 2022, c 39, §5]
Haw. Rev. Stat. § 431K-7 — HI Code / Division 2 / Title 24 / Chapter 431K / Section 431K-7
Notice and registration requirements of purchasing groups.
Status: in_force

(a) A purchasing group that intends to do business in this State shall furnish, on forms prescribed by the National Association of Insurance Commissioners, notice to the commissioner that shall include the following:

(1) Identification of the state in which the group is domiciled;

(2) Specification of the lines and classifications of liability insurance that the purchasing group intends to purchase;

(3) Identification of the insurance company or risk retention group from which the group intends to purchase its insurance and the domicile of the company or risk retention group; and

(4) Identification of the principal place of business of the group.

(b) The commissioner may require a purchasing group to provide the following information:

(1) The method by which, and the person or persons through whom, insurance will be offered to its members whose risks are resident or located in this State;

(2) Identify all other states in which the group intends to do business; and

(3) Provision of other information to verify that the purchasing group qualifies as such under section 431K-1.

(c) The purchasing group shall register with and designate the commissioner or other appropriate authority as its agent solely for the purpose of receiving service of legal documents or process, except that these requirements shall not apply in the case of a purchasing group that:

(1) Was domiciled before April 1, 1986, and is domiciled on and after October 27, 1986, in any state of the United States;

(2) Before October 27, 1986, purchased insurance from an insurance carrier licensed in any state, and since October 27, 1986, purchased its insurance from an insurance carrier licensed in any state;

(3) Was a purchasing group under the requirements of the Product Liability Risk Retention Act of 1981, 15 U.S.C. §3901 et seq., before October 27, 1986; and

(4) Does not purchase insurance that was not authorized for purposes of an exemption under that Act, as in effect before October 27, 1986.

(d) Within ten days a purchasing group shall notify the commissioner of any changes in any of the items set forth in subsections (a) and (b). [L 1987, c 180, pt of §1; am L 1989, c 272, §6; am L 1993, c 321, §17; am L 1997, c 368, §9]
Haw. Rev. Stat. § 432D-15 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-15
Rehabilitation, liquidation, or conservation of health maintenance organizations.
Status: in_force

(a) Any rehabilitation, liquidation, or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation, or conservation of an insurance company and shall be conducted under the supervision of the commissioner pursuant to the law governing the rehabilitation, liquidation, or conservation of insurance companies. The commissioner may apply for an order directing the commissioner to rehabilitate, liquidate, or conserve a health maintenance organization upon any one or more grounds set out in article 15 of chapter 431, or when in the commissioner's opinion, the continued operation of the health maintenance organization would be hazardous either to the enrollees or to the general public. Enrollees shall have the same priority in the event of liquidation or rehabilitation as the law provides to policyholders of an insurer.

(b) For purpose of determining the priority of distribution of general assets, claims of enrollees and enrollees' beneficiaries shall have the same priority as established by article 15 of chapter 431, for policyholders and beneficiaries of insureds of insurance companies. If an enrollee is liable to any provider for services provided pursuant to and covered by the health care plan, that liability shall have the status of an enrollee claim for distribution of general assets. Any provider who is obligated by statute or agreement to hold enrollees harmless from liability for services provided pursuant to and covered by a health care plan shall have a priority of distribution of the general assets immediately following that of enrollees and enrollees' beneficiaries as described herein, and immediately preceding the priority of distribution described in article 15 of chapter 431. [L 1995, c 179, pt of §1]
Haw. Rev. Stat. § 432D-33 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-33
[ §432D-33] Prohibited discrimination in premiums or contributions.
Status: in_force

[ §432D-33] Prohibited discrimination in premiums or contributions. No individual or group policy, contract, plan, or agreement and no health maintenance organization offering group or individual policies, contracts, plans, or agreements issued or renewed in this State shall require an individual, as a condition of enrollment or continued enrollment under a policy, contract, plan, or agreement, to pay a premium or contribution based on the individual's gender that is greater than the premium or contribution for a similarly situated individual of the opposite gender who is covered under the same policy, contract, plan, or agreement or a substantially similar policy, contract, plan, or agreement offered by the same health maintenance organization.
Haw. Rev. Stat. § 432D-13 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-13
Examinations.
Status: in_force

(a) The commissioner may examine the affairs of any health maintenance organization or of any providers with whom such organization has contracts, agreements, or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this State but shall make such examination not fewer than once every five years for health maintenance organizations domiciled in this State.

(b) Every health maintenance organization and provider shall submit its books and records for examination and in every way facilitate the completion of the examination. In the event a health maintenance organization or the provider fails to comply with the directions of the commissioner, the commissioner may examine the affiliates of the health maintenance organization or provider to obtain the information. For the purpose of examinations, the commissioner may administer oaths to, and examine the officers and agents of, the health maintenance organization and the principals of providers concerning their business.

(c) The cost of examinations under this section shall be assessed against the health maintenance organization being examined and remitted to the commissioner for deposit into the compliance resolution fund.

(d) In lieu of such examination, the commissioner may accept the report of an examination made by the commissioner or director of the department of health of another state. [L 1995, c 179, pt of §1; am L 2004, c 122, §91; am L 2012, c 251, §12]
Haw. Rev. Stat. § 431P-8 — HI Code / Division 2 / Title 24 / Chapter 431P / Section 431P-8
Annual statements.
Status: in_force

(a) The fund shall submit to the commissioner each year, not later than one hundred twenty days after the end of the fund's fiscal year, a financial report in a form approved by the commissioner.

(b) The commissioner may require other reports concerning risks insured by the fund as the commissioner deems appropriate. [L 1993, c 339, pt of §2]
Haw. Rev. Stat. § 432G-2 — HI Code / Division 2 / Title 24 / Chapter 432G / Section 432G-2
Establishment of a dental insurer; certificate of authority.
Status: in_force

(a) Any person may apply to the commissioner for a certificate of authority to establish and operate a dental insurer in compliance with this chapter and chapter 423. No person shall establish or operate a dental insurer in this State without meeting the requirements of chapter 423 and obtaining a certificate of authority under this chapter. A foreign corporation may qualify under this chapter, subject to its registration to do business in this State in compliance with all provisions of this chapter and other applicable state laws, including chapter 423.

(b) Any dental service corporation formed and operating pursuant to chapter 423 as of July 1, 2013, shall submit an application for a certificate of authority under subsection (c) within ninety days of July 1, 2013. The applicant may continue to operate until the commissioner acts upon the application. In the event that an application made pursuant to this subsection is denied, the applicant shall thereafter be treated as a dental service corporation whose charter of incorporation has been revoked.

(c) Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant, shall be in a form prescribed by the commissioner, and shall set forth or be accompanied by the following:

(1) A copy of the organizational documents of the applicant, such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents, and all amendments thereto;

(2) A copy of the bylaws, rules and regulations, or similar document, if any, regulating the conduct of the internal affairs of the applicant;

(3) A list of the names, addresses, official positions, and biographical information on forms acceptable to the commissioner of the persons who are to be responsible for the conduct of the affairs and day-to-day operations of the applicant, including all members of the board of directors, board of trustees, executive committee or other governing board or committee, and the principal officers in the case of a corporation, or the partners or members in the case of a partnership or association;

(4) A copy of any contract form made or to be made between any class of providers and the applicant and a copy of any contract made or to be made between third party administrators, marketing consultants, or persons listed in paragraph (3) and the applicant;

(5) A copy of the form of evidence of coverage to be issued to the enrollees;

(6) A copy of the form of group contract, if any, which is to be issued to employers, unions, trustees, or other organizations;

(7) Financial statements showing the applicant's assets, liabilities, and sources of financial support, and both a copy of the applicant's most recent audited financial statement and an unaudited current financial statement;

(8) A financial feasibility plan which includes detailed enrollment projections, the methodology for determining premium rates to be charged during the first twelve months of operations certified by an actuary or other qualified person, a projection of balance sheets, cash flow statements showing any capital expenditures, purchase and sale of investments, deposits with the State, income and expense statements anticipated from the start of operations until the organization has had net income for at least one year, and a statement as to the sources of working capital as well as any other sources of funding;

(9) A power of attorney duly executed by the applicant, if not domiciled in this State, appointing the commissioner and the commissioner's successors in office, and duly authorized deputies, as the true and lawful attorney of the applicant in and for this State upon whom all lawful process in any legal action or proceeding against the applicant on a cause of action arising in this State may be served;

(10) A statement or map reasonably describing the geographic area or areas to be served;

(11) A description of the internal grievance procedures to be utilized for the investigation and resolution of enrollee complaints and grievances;

(12) A description of the proposed quality assurance program, including the formal organizational structure, methods for developing criteria, procedures for comprehensive evaluation of the quality of care rendered to enrollees, and processes to initiate corrective action and reevaluation when deficiencies in provider or organizational performance are identified;

(13) A description of the procedures to be implemented to meet the protection against insolvency requirements in section 432G‑6;

(14) A list of the names, addresses, and license numbers of all providers or groups of providers with which the applicant has agreements; and

(15) Such other information as the commissioner may require.

(d) If the commissioner finds that the applicant has met the requirements for and is fully entitled thereto under the applicable insurance laws, the commissioner shall issue an appropriate certificate of authority to the applicant. If the commissioner does not so find, the commissioner shall deny the applicant the certificate of authority within a reasonable length of time following filing of the completed application by the applicant. A certificate of authority shall be denied only after the commissioner complies with the requirements of section 432G‑13. [L 2013, c 191, pt of §1]

Revision Note

Subsection (e) to this section enacted by L 2013, c 191, §1 was redesignated as §432G-22 pursuant to §23G-15.
Haw. Rev. Stat. § 431L-2 — HI Code / Division 2 / Title 24 / Chapter 431L / Section 431L-2
State's right to third party payments.
Status: in_force

To the extent that payment has been made under the state plan for medical assistance for health care items or services furnished to an individual in any case where another party has a legal liability to make payment for such assistance, the State is considered to have acquired the rights of the individual to payment by the other party for those health care items or services.
Haw. Rev. Stat. § 435C-10 — HI Code / Division 2 / Title 24 / Chapter 435C / Section 435C-10
Examinations.
Status: in_force

The insurance commissioner shall make an examination into the affairs of the plan at least annually. Such examination shall be conducted and the report thereon filed in the manner prescribed in section 431:2-302. The expenses of every such examination shall be borne and paid by the plan in the manner prescribed by section 431:2-306.

Revision Note

Sections 431:2-302 and 431:2-306 substituted for sections 431-54 and 431-59, respectively.
Haw. Rev. Stat. § 4 — HI Code / Division 2 / Title 24 / Chapter 431 / Section 4
31:3-413 Phase-in provision.
Status: in_force

(a) For risk-based capital reports required to be filed by life or health insurers with respect to 1994, the following requirements shall apply in lieu of sections 431:3-403, 431:3-404, 431:3-405, and 431:3-406:

(1) In the event of a company action level event with respect to a domestic insurer, the commissioner shall take no regulatory action hereunder;

(2) In the event of a regulatory action level event under section 431:3-404(a)(1), (2), or (3), the commissioner shall take the actions required under section 431:3-403;

(3) In the event of a regulatory action level event under section 431:3-404(a)(4), (5), (6), (7), (8), or (9), or an authorized control level event, the commissioner shall take the actions required under section 431:3-404 with respect to the insurer; and

(4) In the event of a mandatory control level event with respect to an insurer, the commissioner shall take the actions required under section 431:3-405 with respect to the insurer.

(b) For risk-based capital reports required to be filed by property and casualty insurers with respect to 1997, the following requirements shall apply in lieu of sections 431:3-403, 431:3-404, 431:3-405, and 431:3-406:

(1) In the event of a company action level event with respect to a domestic insurer, the commissioner shall take no regulatory action hereunder;

(2) In the event of a regulatory action level event under section 431:3-404(a)(1), (2), or (3), the commissioner shall take the actions required under section 431:3‑403;

(3) In the event of a regulatory action level event under section 431:3-404(a)(4), (5), (6), (7), (8), or (9), or an authorized control level event, the commissioner shall take the actions required under section 431:3-404 with respect to the insurer; and

(4) In the event of a mandatory control level event with respect to an insurer, the commissioner shall take the actions required under section 431:3-405 with respect to the insurer. [L 1994, c 190, pt of §1; am L 1995, c 61, §2 as superseded by c 232, §4; am L 1997, c 75, §14; am L 1999, c 128, §2]
Haw. Rev. Stat. § 431C-51 — HI Code / Division 2 / Title 24 / Chapter 431C / Section 431C-51
Unfair trade practices.
Status: in_force

A violation of this chapter shall be considered an unfair trade practice pursuant to section 480-2 and subject to the penalties under chapter 480.
Haw. Rev. Stat. § 432E-35 — HI Code / Division 2 / Title 24 / Chapter 432E / Section 432E-35
Expedited external review.
Status: in_force

(a) Except as provided in subsection (i), an enrollee or the enrollee's appointed representative may request an expedited external review with the commissioner if the enrollee receives:

(1) An adverse determination that involves a medical condition of the enrollee for which the time frame for completion of an expedited internal appeal would seriously jeopardize the enrollee's life, health, or ability to gain maximum functioning or would subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the adverse determination;

(2) A final adverse determination if the enrollee has a medical condition where the time frame for completion of a standard external review would seriously jeopardize the enrollee's ability to gain maximum functioning, or would subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the adverse determination; or

(3) A final adverse determination if the final adverse determination concerns an admission, availability of care, continued stay, or health care service for which the enrollee received emergency services; provided that the enrollee has not been discharged from a facility for health care services related to the emergency services.

(b) Upon receipt of a request for an expedited external review, the commissioner shall immediately send a copy of the request to the health carrier. Immediately upon receipt of the request, the health carrier shall determine whether the request meets the reviewability requirements set forth in section 432E-34(b). The health carrier shall immediately notify the enrollee or the enrollee's appointed representative of its determination of the enrollee's eligibility for expedited external review.

Notice of ineligibility for expedited external review shall include a statement informing the enrollee and the enrollee's appointed representative that a health carrier's initial determination that an external review request that is ineligible for review may be appealed to the commissioner by submission of a request to the commissioner.

(c)(1) The commissioner may determine that a request is eligible for expedited external review under section 432E-34(b) notwithstanding a health carrier's initial determination that the request is ineligible and require that it be referred for external review; and

(2) In making a determination under paragraph (1), the commissioner's decision shall be made in accordance with the terms of the enrollee's health benefit plan and shall be subject to all applicable provisions of this part.

(d) If the commissioner determines that an enrollee is eligible for expedited external review pursuant to subsection (c) and the request for expedited external review is based on an adverse determination as provided under subsection (a)(1), the health carrier shall not be required to proceed with its internal review process but may elect to proceed with its internal review process; provided that the internal review process shall not delay or terminate an expedited external review unless the health carrier decides to reverse its adverse determination and provide coverage or payment for the health care service that is the subject of the adverse determination. Immediately after making a decision to reverse its adverse determination, the health carrier shall notify the enrollee, the enrollee's authorized representative, the independent review organization assigned pursuant to subsection (e), and the commissioner in writing of its decision. The assigned independent review organization shall terminate the expedited external review upon receipt of notice from the health carrier pursuant to this subsection.

(e) Upon receipt of the notice pursuant to subsection (b) or a determination of the commissioner pursuant to subsection (c) that the enrollee meets the eligibility requirements for expedited external review, the commissioner shall immediately randomly assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations qualified to conduct the external review, based on the nature of the health care service that is the subject of the adverse action and other factors determined by the commissioner including conflicts of interest pursuant to section 432E-43, compiled and maintained by the commissioner to conduct the external review and immediately notify the health carrier of the name of the assigned independent review organization.

(f) Upon receipt of the notice from the commissioner of the name of the independent review organization assigned to conduct the expedited external review, the health carrier or its designated utilization review organization shall provide or transmit all documents and information it considered in making the adverse action that is the subject of the expedited external review, and any documents related to the request for expedited external review that have been received by the health carrier or its designated utilization review organization, to the assigned independent review organization electronically or by telephone, facsimile, or any other available expeditious method.

(g) In addition to the documents and information provided or transmitted pursuant to subsection (f), the assigned independent review organization shall consider the following in reaching a decision:

(1) The enrollee's pertinent medical records;

(2) The attending health care professional's recommendation;

(3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, enrollee, the enrollee's appointed representative, or the enrollee's treating provider;

(4) The application of medical necessity criteria as defined in section 432E-1;

(5) The most appropriate practice guidelines, which shall include evidence-based standards, and may include any other practice guidelines developed by the federal government, national or professional medical societies, boards, and associations;

(6) Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review organization in making adverse determinations; and

(7) The opinion of the independent review organization's clinical reviewer or reviewers pertaining to the information enumerated in paragraphs (1) through (5) to the extent the information and documents are available and the clinical reviewer or reviewers consider appropriate.

In reaching a decision, the assigned independent review organization shall not be bound by any decisions or conclusions reached during the health carrier's utilization review or internal appeals process; provided that the independent review organization's decision shall not contradict the terms of the enrollee's health benefit plan or this part.

(h) As expeditiously as the enrollee's medical condition or circumstances requires, but in no event more than seventy-two hours after the date of receipt of the request for an expedited external review that meets the reviewability requirements set forth in section 432E-34(b), the assigned independent review organization shall:

(1) Make a decision to uphold or reverse the adverse action; and

(2) Notify the enrollee, the enrollee's appointed representative, the health carrier, and the commissioner of the decision.

If the notice provided pursuant to this subsection was not in writing, within forty-eight hours after the date of providing that notice, the assigned independent review organization shall provide written confirmation of the decision to the enrollee, the enrollee's appointed representative, the health carrier, and the commissioner that includes the information provided in section 432E-34(j).

Upon receipt of the notice of a decision reversing the adverse action, the health carrier shall immediately approve the coverage that was the subject of the adverse action.

(i) An expedited external review shall not be provided for retrospective adverse or final adverse determinations. [L 2011, c 230, pt of §2; am L 2012, c 34, §12; am L 2023, c 103, §4; am L 2024, c 103, §4]
Haw. Rev. Stat. § 432E-36 — HI Code / Division 2 / Title 24 / Chapter 432E / Section 432E-36
External review of experimental or investigational treatment adverse determinations.
Status: in_force

(a) An enrollee or an enrollee's appointed representative may file a request for an external review with the commissioner within one hundred thirty days of receipt of notice of an adverse action that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational.

(b) An enrollee or the enrollee's appointed representative may make an oral request for an expedited external review of the adverse action if the enrollee's treating physician or advanced practice registered nurse certifies, in writing, that the health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated. A written request for an expedited external review pursuant to this subsection shall include, and oral request shall be promptly followed by, a certification signed by the enrollee's treating physician or treating advanced practice registered nurse and the authorization for release and disclosures required by section 432E-33. Upon receipt of all items required by this subsection, the commissioner shall immediately notify the health carrier.

(c) Upon notice of the request for expedited external review, the health carrier shall immediately determine whether the request meets the requirements of subsection (g). The health carrier shall immediately notify the commissioner, the enrollee, and the enrollee's appointed representative of its eligibility determination.

Notice of eligibility for expedited external review pursuant to this subsection shall include a statement informing the enrollee and, if applicable, the enrollee's appointed representative that a health carrier's initial determination that the external review request is ineligible for review may be appealed to the commissioner.

(d)(1) The commissioner may determine that a request is eligible for external review under subsection (g) notwithstanding a health carrier's initial determination that the request is ineligible and require that it be referred for external review; and

(2) In making a determination under paragraph (1), the commissioner's decision shall be made in accordance with the terms of the enrollee's health benefit plan and shall be subject to all applicable provisions of this part.

(e) Upon receipt of the notice pursuant to subsection (c) or a determination of the commissioner pursuant to subsection (d) that the enrollee meets the eligibility requirements for expedited external review, the commissioner shall immediately randomly assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations qualified to conduct the external review, based on the nature of the health care service that is the subject of the adverse action and other factors determined by the commissioner including conflicts of interest pursuant to section 432E-43, compiled and maintained by the commissioner to conduct the external review and immediately notify the health carrier of the name of the assigned independent review organization.

(f) Upon receipt of the notice from the commissioner of the name of the independent review organization assigned to conduct the expedited external review, the health carrier or its designated utilization review organization shall provide or transmit all documents and information it considered in making the adverse action that is the subject of the expedited external review, and any documents related to the request for expedited external review that have been received by the health carrier or its designated utilization review organization, to the assigned independent review organization electronically or by telephone, facsimile, or any other available expeditious method.

(g) Except for a request for an expedited external review made pursuant to subsection (b), within three business days after the date of receipt of the request, the commissioner shall notify the health carrier that the enrollee has requested an external review pursuant to this section. Within five business days following the date of receipt of notice, the health carrier shall determine whether:

(1) The individual is or was an enrollee in the health benefit plan at the time the health care service or treatment was recommended or requested or, in the case of a retrospective review, was an enrollee in the health benefit plan at the time the health care service or treatment was provided;

(2) The recommended or requested health care service or treatment that is the subject of the adverse action:

(A) Would be a covered benefit under the enrollee's health benefit plan but for the health carrier's determination that the service or treatment is experimental or investigational for the enrollee's particular medical condition; and

(B) Is not explicitly listed as an excluded benefit under the enrollee's health benefit plan;

(3) The enrollee's treating physician or treating advanced practice registered nurse has certified in writing that:

(A) Standard health care services or treatments have not been effective in improving the condition of the enrollee;

(B) Standard health care services or treatments are not medically appropriate for the enrollee; or

(C) There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the health care service or treatment that is the subject of the adverse action;

(4) The enrollee's treating physician or treating advanced practice registered nurse:

(A) Has recommended a health care service or treatment that the physician or advanced practice registered nurse certifies, in writing, is likely to be more beneficial to the enrollee, in the physician's or advanced practice registered nurse's opinion, than any available standard health care services or treatments; or

(B) Who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat the enrollee's condition, or who is an advanced practice registered nurse qualified to treat the enrollee's condition, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment that is the subject of the adverse action is likely to be more beneficial to the enrollee than any available standard health care services or treatments;

(5) The enrollee has exhausted the health carrier's internal appeals process or the enrollee is not required to exhaust the health carrier's internal appeals process pursuant to section 432E-33(b); and

(6) The enrollee has provided all the information and forms required by the commissioner that are necessary to process an external review, including the release form and disclosure of conflict of interest information as provided under section 432E ‑ 33(a).

(h) Within three business days after determining the enrollee's eligibility for external review pursuant to subsection (g), the health carrier shall notify the commissioner, the enrollee, and the enrollee's appointed representative in writing as to whether the request is complete and eligible for external review.

If the request is not complete, the health carrier shall inform the commissioner, the enrollee, and the enrollee's appointed representative in writing of the information or materials needed to complete the request.

If the enrollee is not eligible for external review pursuant to subsection (g), the health carrier shall inform the commissioner, the enrollee, and the enrollee's appointed representative in writing of the ineligibility and the reasons for ineligibility.

Notice of ineligibility pursuant to this subsection shall include a statement informing the enrollee and the enrollee's appointed representative that a health carrier's initial determination that the external review request is ineligible for review may be appealed to the commissioner by submitting a request to the commissioner.

If a request for external review is determined eligible for external review, the health carrier shall notify the commissioner and the enrollee and, if applicable, the enrollee's appointed representative.

(i)(1) The commissioner may determine that a request is eligible for external review under subsection (g) notwithstanding a health carrier's initial determination that the request is ineligible and require that it be referred for external review; and

(2) In making a determination under paragraph (1), the commissioner's decision shall be made in accordance with the terms of the enrollee's health benefit plan and shall be subject to all applicable provisions of this part.

(j) When the commissioner receives notice pursuant to subsection (h) or makes a determination pursuant to subsection (i) that an enrollee is eligible for external review, within three business days after receipt of the notice or determination of eligibility, the commissioner shall:

(1) Randomly assign an independent review organization from the list of approved independent review organizations qualified to conduct the external review, based on the nature of the health care service that is the subject of the adverse action and other factors determined by the commissioner including conflicts of interest pursuant to section 432E-43, compiled and maintained by the [commissioner to] conduct the external review and notify the health carrier of the name of the assigned independent review organization; and

(2) Notify the enrollee and the enrollee's appointed representative, in writing, of the enrollee's eligibility and acceptance for external review.

(k) An enrollee or an enrollee's appointed representative may submit additional information in writing to the assigned independent review organization for consideration in its external review. The independent review organization shall consider information submitted within five business days following the date of the enrollee's receipt of the notice provided pursuant to subsection (j). The independent review organization may accept and consider additional information submitted by an enrollee after five business days.

(l) Within five business days after the date of receipt of notice pursuant to subsection (j), the health carrier or its designated utilization review organization shall provide to the assigned independent review organization all documents and information it considered in issuing the adverse action that is the subject of external review and any documents related to the request for external review that have been received by the health carrier or its designated utilization review organization. Failure by the health carrier or its designated utilization review organization to provide the documents and information within five business days shall not delay the conduct of the external review; provided that the assigned independent review organization may terminate the external review and reverse the adverse action that is the subject of the external review. The independent review organization shall notify the enrollee, the enrollee's appointed representative, the health carrier, and the commissioner within three business days of the termination of an external review and reversal of an adverse action pursuant to this subsection.

(m) Within three business days after the receipt of the notice of assignment to conduct the external review pursuant to subsection (j), the assigned independent review organization shall:

(1) Select one or more clinical reviewers who each shall be a physician or other health care professional who meets the minimum qualifications described in section 432E-39 and, through clinical experience in the past three years, is an expert in the treatment of the enrollee's condition and knowledgeable about the recommended or requested health care service or treatment to conduct the external review; provided that neither the enrollee, the enrollee's appointed representative, nor the health carrier shall choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review; and

(2) Based on the written opinion of the clinical reviewer, or opinions if more than one clinical reviewer has been selected, to the assigned independent review organization on whether the recommended or requested health care service or treatment should be covered, make a determination to uphold or reverse the adverse action.

In reaching an opinion, the clinical reviewers are not bound by any decisions or conclusions reached during the health carrier's utilization review process or internal appeals process.

Each clinical reviewer selected pursuant to this subsection shall review all of the information and documents received pursuant to subsection (l) and any other information submitted in writing by the enrollee or the enrollee's authorized representative pursuant to this subsection.

(n) The assigned independent review organization, within one business day of receipt by the independent review organization, shall forward all information received from the enrollee pursuant to subsection (k) to the health carrier. Upon receipt of information forwarded to it pursuant to this subsection, a health carrier may reconsider the adverse action that is the subject of the external review; provided that reconsideration by the health carrier shall not delay or terminate an external review unless the health carrier reverses its adverse action and provides coverage or payment for the health care service that is the subject of the adverse action. The health carrier shall notify the enrollee, the enrollee's appointed representative, the assigned independent review organization, and the commissioner in writing of its decision to reverse its adverse action and within three business days of making its decision to reverse the adverse action and provide coverage. The assigned independent review organization shall terminate its external review upon receipt of notice pursuant to this subsection from the health carrier.

(o) Except as provided in subsection (p), within twenty days after being selected to conduct the external review, a clinical reviewer shall provide an opinion to the assigned independent review organization pursuant to subsection (q) regarding whether the recommended or requested health care service or treatment subject to an appeal pursuant to this section shall be covered.

The clinical reviewer's opinion shall be in writing and shall include:

(1) A description of the enrollee's medical condition;

(2) A description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is more likely than not to be more beneficial to the enrollee than any available standard health care services or treatments and whether the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments;

(3) A description and analysis of any medical or scientific evidence, as that term is defined in section 432E-1.4, considered in reaching the opinion;

(4) A description and analysis of any medical necessity; and

(5) Information on whether the reviewer's rationale for the opinion is based on:

(A) Approval of the health care service or treatment by the federal Food and Drug Administration for the condition; or

(B) Medical or scientific evidence or evidence-based standards that demonstrate that the expected benefits of the recommended or requested health care service or treatment is likely to be more beneficial to the enrollee than any available standard health care services or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments.

(p) Notwithstanding the requirements of subsection (o), in an expedited external review, the clinical reviewer shall provide an opinion orally or in writing to the assigned independent review organization as expeditiously as the enrollee's medical condition or circumstances require, but in no event more than five calendar days after being selected in accordance with subsection (m).

If the opinion provided pursuant to this subsection was not in writing, within forty-eight hours following the date the opinion was provided, the clinical reviewer shall provide written confirmation of the opinion to the assigned independent review organization and include the information required under subsection (o).

(q) In addition to the documents and information provided pursuant to subsection (b) or (l), a clinical reviewer may consider the following in reaching an opinion pursuant to subsection (o):

(1) The enrollee's pertinent medical records;

(2) The attending physician's or health care professional's recommendation;

(3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, enrollee, the enrollee's appointed representative, or the enrollee's treating physician or health care professional; and

(4) Whether:

(A) The recommended health care service or treatment has been approved by the federal Food and Drug Administration, if applicable, for the condition; or

(B) Medical or scientific evidence or evidence-based standards demonstrate that the expected benefits of the recommended or requested health care service or treatment is more likely than not to be beneficial to the enrollee than any available standard health care service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments;

provided that the independent review organization's decision shall not contradict the terms of the enrollee's health benefit plan or the provisions of this chapter.

(r) Except as provided in subsection (s), within twenty days after the date it receives the opinion of the clinical reviewer pursuant to subsection (o), the assigned independent review organization, in accordance with subsection (t), shall determine whether the health care service at issue in an external review pursuant to this section shall be a covered benefit and shall notify the enrollee, the enrollee's appointed representative, the health carrier, and the commissioner of its determination. The independent review organization shall include in the notice of its decision:

(1) A general description of the reason for the request for external review;

(2) The written opinion of each clinical reviewer, including the recommendation of each clinical reviewer as to whether the recommended or requested health care service or treatment should be covered and the rationale for the reviewer's recommendation;

(3) The date the independent review organization was assigned by the commissioner to conduct the external review;

(4) The date the external review was conducted;

(5) The date the decision was issued;

(6) The principal reason or reasons for its decision; and

(7) The rationale for its decision.

Upon receipt of a notice of a decision reversing the adverse action, the health carrier immediately shall approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse action.

(s) For an expedited external review, within forty-eight hours after the date it receives the opinion of each clinical reviewer, the assigned independent review organization, in accordance with subsection (t), shall make a decision and provide notice of the decision orally or in writing to the enrollee, the enrollee's appointed representative, the health carrier, and the commissioner.

If the notice provided was not in writing, within forty-eight hours after the date of providing that notice, the assigned independent review organization shall provide written confirmation of the decision to the enrollee, the enrollee's appointed representative, the health carrier, and the commissioner.

(t) If a majority of the clinical reviewers recommends that the recommended or requested health care service or treatment should be covered, the independent review organization shall make a decision to reverse the health carrier's adverse determination or final adverse determination.

If a majority of the clinical reviewers recommends that the recommended or requested health care service or treatment should not be covered, the independent review organization shall make a decision to uphold the health carrier's adverse determination or final adverse determination.

If the clinical reviewers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the independent review organization shall obtain the opinion of an additional clinical reviewer in order for the independent review organization to make a decision based on the opinions of a majority of the clinical reviewers. The additional clinical reviewer shall use the same information to reach an opinion as the clinical reviewers who have already submitted their opinions. The selection of the additional clinical reviewer shall not extend the time within which the assigned independent review organization is required to make a decision based on the opinions of the clinical reviewers selected. [L 2011, c 230, pt of §2; am L 2014, c 45, §12; am L 2015, c 63, §19; am L 2024, c 103, §5]
Haw. Rev. Stat. § 432G-8 — HI Code / Division 2 / Title 24 / Chapter 432G / Section 432G-8
Reserve credit for reinsurance.
Status: in_force

Any dental insurer that takes credit for reserves on risks ceded to a reinsurer shall be subject to provisions of article 4A of chapter 431.
Haw. Rev. Stat. § 432D-17 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-17
Fees.
Status: in_force

(a) The commissioner shall collect, in advance, the following fees:

(1) Certificate of authority:

(A) Application for a certificate of authority: $900; and

(B) Issuance of certificate of authority: $600; and

(2) For all services subsequent to the issuance of certificate of authority, including extension of the certificate of authority: $600 per year.

The commissioner may, upon showing of good cause, waive or modify, in whole or part, all fees in this subsection by order.

(b) No certificate of authority shall contain an expiration date, but all certificates of authority shall be extended by the commissioner from time to time in order to continue to be valid. When the commissioner issues or extends a certificate of authority, the commissioner shall determine the date prior to which the certificate of authority shall be extended and shall so notify the insurer in writing. This date is called the extension date. The extension date shall be any date not less than one year and not more than three years after date of issue or extension of the certificate of authority. If the insurer qualifies, its certificate of authority shall be extended. The commissioner shall provide each holder of a certificate of authority at least thirty days' advance written notice of the applicable extension date. If the fee for the extension of the certificate of authority is not paid before or on the extension date, a penalty shall be imposed in the amount of fifty per cent of the fee. The commissioner shall provide notice in writing of the delinquency of extension and the imposition of the authorized penalty. If the fee and the penalty are not paid within thirty days immediately following the date of the notice of delinquency, the commissioner may revoke the certificate of authority and may not reinstate the certificate of authority until the fee and penalty have been paid.

(c) All fees and penalties collected pursuant to this section and penalties collected pursuant to section 432D-14 shall be deposited to the credit of the compliance resolution fund. [L 1995, c 179, pt of §1; am L 1999, c 247, §2; am L 2012, c 251, §13; am L 2015, c 63, §18; am L 2021, c 110, §21]
Haw. Rev. Stat. § 432E-37 — HI Code / Division 2 / Title 24 / Chapter 432E / Section 432E-37
[ §432E-37] Binding nature of external review decision.
Status: in_force

[ §432E-37] Binding nature of external review decision. (a) An external review decision shall be binding on the health carrier and the enrollee except to the extent that the health carrier or the enrollee has other remedies available under applicable federal or state law.

(b) An enrollee or the enrollee's appointed representative shall not file a subsequent request for external review involving the same adverse action for which the enrollee has already received an external review decision pursuant to this part. [L 2011, c 230, pt of §2]
Haw. Rev. Stat. § 435C-6 — HI Code / Division 2 / Title 24 / Chapter 435C / Section 435C-6
Directors.
Status: in_force

The plan shall be governed by a board of eleven directors, ten to be selected annually. Five directors shall be elected by cumulative voting by the members of the plan, whose votes in such election shall be weighted in accordance with each member's net direct premiums written during the preceding calendar year. Three directors shall be appointed by the insurance commissioner as representatives of the medical profession. Two directors shall be appointed by the insurance commissioner as representatives of the public. The five member companies serving on the first board shall be elected at a meeting of the members, or their authorized representatives, which shall be held at a time and place designated by the insurance commissioner. The insurance commissioner shall appoint the five directors serving on the first board on or before the date of such meeting. The insurance commissioner shall be the other member and shall be its chairperson.
Haw. Rev. Stat. § 435E-2 — HI Code / Division 2 / Title 24 / Chapter 435E / Section 435E-2
Cooperative indemnity.
Status: in_force

Physicians and surgeons may, any other law to the contrary notwithstanding, form cooperative corporations for the purposes of this chapter. The members of a cooperative corporation, which shall be limited to physicians and surgeons only, may enter into unincorporated interindemnity or reciprocal contracts among themselves; provided that such contracts indemnify solely in respect to medical malpractice claims against such members, and do not collect in advance of loss any moneys other than contributions by each member to a collective reserve trust fund or for necessary expenses of administration. In addition, each such interindemnity, reciprocal, or interinsurance contract shall meet the requirements of this chapter.
Haw. Rev. Stat. § 432G-17 — HI Code / Division 2 / Title 24 / Chapter 432G / Section 432G-17
Acquisition of control of or merger of a dental insurer.
Status: in_force

No person may make a tender for or a request or invitation for tenders of, enter into an agreement to exchange securities for, or acquire in the open market or otherwise, any voting security of a dental insurer or enter into any other agreement if, after the consummation thereof, that person, directly or indirectly, or by conversion or by exercise of any right to acquire, would be in control of the dental insurer, and no person may enter into an agreement to merge or consolidate with or otherwise to acquire control of a dental insurer, unless, at the time any offer, request, or invitation is made or any agreement is entered into, or prior to the acquisition of the securities if no offer or agreement is involved, the person has filed with the commissioner and has sent to the dental insurer information required by section 431:11-104 and the offer, request, invitation, agreement, or acquisition has been approved by the commissioner. Approval by the commissioner shall be governed by section 431:11-104(d); provided that if no action is taken by the commissioner within thirty days, the offer, request, invitation, agreement, or acquisition shall be deemed approved.
Haw. Rev. Stat. § 435E-29 — HI Code / Division 2 / Title 24 / Chapter 435E / Section 435E-29
Termination.
Status: in_force

The interindemnity arrangement, and the reserve trust fund incident thereto, shall be subject to termination at any time by the vote or written consent of not less than three-fourths of the participating members.
Haw. Rev. Stat. § 432D-16 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-16
Summary orders and supervision.
Status: in_force

(a) Whenever the commissioner determines that the financial condition of any health maintenance organization is such that its continued operation might be hazardous to its enrollees, creditors, or the general public, or that it has violated any provision of this chapter, the commissioner, after notice and hearing, may order the health maintenance organization to take such action as may be reasonably necessary to rectify such condition or violation, including but not limited to one or more of the following:

(1) Reducing the total amount of present and potential liability for benefits by reinsurance or other method acceptable to the commissioner;

(2) Reducing the volume of new business being accepted;

(3) Reducing expenses by specified methods;

(4) Suspending or limiting the writing of new business for a period of time;

(5) Increasing the health maintenance organization's capital and surplus by contribution; or

(6) Taking such other steps as the commissioner may deem appropriate under the circumstances.

(b) For purposes of this section, the violation by a health maintenance organization of any law of this State to which such health maintenance organization is subject shall be deemed a violation of this chapter.

(c) The commissioner is authorized, by rule, to set uniform standards and criteria for early warning that the continued operation of any health maintenance organization might be hazardous to its enrollees, creditors, or the general public and to set standards for evaluating the financial condition of any health maintenance organization, which standards shall be consistent with the purposes expressed in subsection (a).

(d) The remedies and measures available to the commissioner under this section shall be in addition to, and not in lieu of, the remedies and measures available to the commissioner under the provisions of article 15 of chapter 431. [L 1995, c 179, pt of §1]
Haw. Rev. Stat. § 431M-2 — HI Code / Division 2 / Title 24 / Chapter 431M / Section 431M-2
Policy coverage.
Status: in_force

(a) All individual and group accident and health or sickness insurance policies issued in this State, individual or group hospital or medical service plan contracts, and nonprofit mutual benefit society , fraternal benefit society, and health maintenance organization health plan contracts shall include within their hospital and medical coverage the benefits of alcohol use disorder, substance use disorder, and mental health treatment services, including services for alcohol dependence and drug dependence, except that this section shall not apply to insurance policies that are issued solely for single diseases, or otherwise limited, specialized coverage.

(b) The policies and contracts set forth in subsection (a) shall not impose any financial requirements or treatment limitations on mental health or substance use disorder benefits that are more restrictive than the predominant financial requirements and treatment limitations, either quantitative or nonquantitative, imposed on medical and surgical benefits in accordance with the Mental Health Parity and Addiction Equity Act of 2008. [L 1988, c 202, pt of §1, §3; am L 1994, c 111, §4; am L 1998, c 78, §3; am L 2002, c 239, §1; am L 2003, c 212, §120; am L 2004, c 122, §82; am L 2014, c 186, §10]
Haw. Rev. Stat. § 432G-7 — HI Code / Division 2 / Title 24 / Chapter 432G / Section 432G-7
Uncovered expenditures insolvency deposit.
Status: in_force

(a) If, at any time, uncovered expenditures exceed ten per cent of total dental care expenditures, a dental insurer shall place with the commissioner or with any organization or trustee acceptable to the commissioner through which a custodial or controlled account is maintained, an uncovered expenditures insolvency deposit consisting of cash or securities that are acceptable to the commissioner. Such deposit shall have, at all times, a fair market value in an amount of one-hundred-twenty per cent of the dental insurer's outstanding liability for uncovered expenditures for enrollees in this State, including incurred but not reported claims, and shall be calculated as of the first day of the month and maintained for the remainder of the month. If a dental insurer is not otherwise required to file a quarterly report, it shall file a report within forty-five days of the end of the calendar quarter with information sufficient to demonstrate compliance with this section.

(b) The deposit required under this section is in addition to the deposit required under section 432G‑6 and is an asset of the dental insurer in the determination of net worth. All income from the deposits or trust accounts subject to this section shall be an asset of the dental insurer and may be withdrawn from the deposit or trust account quarterly with the approval of the commissioner.

(c) A dental insurer that has made a deposit may withdraw that deposit or any part of the deposit if:

(1) A substitute deposit of cash or securities of equal amount and value is made;

(2) The fair market value exceeds the amount of the required deposit; or

(3) The required deposit under subsection (a) is reduced or eliminated.

Deposits, substitutions, or withdrawals may be made only with the prior written approval of the commissioner.

(d) The deposit required under this section shall be held in trust and shall be used only as provided in this section. The commissioner may use the deposit of an insolvent dental insurer for administrative costs associated with administering the deposit and payment of claims of enrollees of this State for uncovered expenditures in this State. Claims for uncovered expenditures shall be paid on a pro rata basis based on assets available to pay such ultimate liability for incurred expenditures. Partial distribution may be made pending final distribution. Any amount of the deposit remaining shall be paid into the liquidation or receivership of the dental insurer.

(e) The commissioner may prescribe the time, manner, and form for filing claims under subsection (d).

(f) The commissioner may require dental insurers to file annual, quarterly, or more frequent reports as the commissioner deems necessary to demonstrate compliance with this section. The commissioner may require that the reports include liability for uncovered expenditures as well as an audit opinion. [L 2013, c 191, pt of §1]
Haw. Rev. Stat. § 431C-4 — HI Code / Division 2 / Title 24 / Chapter 431C / Section 431C-4
License suspension, revocation, or refusal to renew.
Status: in_force

(a) The commissioner may suspend, revoke, or refuse to renew the license of any licensee if the commissioner finds that:

(1) There was any material misrepresentation in the application for the license;

(2) The licensee or any officer, partner, member, or director has been guilty of fraudulent or dishonest practices, is subject to a final administrative action, or is otherwise shown to be untrustworthy or incompetent to act as a licensee;

(3) The provider demonstrates a pattern of unreasonably withholding payments to policy owners;

(4) The licensee no longer meets the requirements for initial licensure;

(5) The licensee or any officer, partner, member, or director has been convicted of a felony, or of any misdemeanor of which criminal fraud is an element or has pleaded guilty or nolo contendere with respect to any felony or any misdemeanor of which criminal fraud or moral turpitude is an element, regardless of whether a judgment of conviction has been entered by the court;

(6) The provider has entered into any life settlement contract that has not been approved pursuant to this chapter;

(7) The provider has failed to honor contractual obligations set out in a life settlement contract;

(8) The provider has assigned, transferred, or pledged a settled policy to a person other than a provider licensed in this State, a purchaser, an accredited investor or qualified institutional buyer as defined respectively in Rule 501 of Regulation D or Rule 144A of the federal Securities Act of 1933, as amended, a financing entity, a special purpose entity, or a related provider trust; or

(9) The licensee or any officer, partner, member, or key management personnel has violated this chapter.

(b) Before the commissioner may deny a license application or suspend, revoke, or refuse to renew the license of any licensee under this chapter, the commissioner shall conduct a hearing in accordance with chapter 91. [L 2012, c 256, pt of §1]
Haw. Rev. Stat. § 432D-11 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-11
Replacement coverage.
Status: in_force

(a) For purposes of this chapter, "discontinuance" means the termination of the contract between the group contract holder and a health maintenance organization due to the insolvency of the health maintenance organization, and does not refer to the termination of any agreement between any individual enrollee and the health maintenance organization.

(b) Any carrier providing replacement coverage with respect to group hospital, medical, or surgical expense or service benefits within a period of sixty days from the date of discontinuance of a prior health maintenance organization contract or policy providing such hospital, medical, or surgical expense or service benefits shall immediately cover all enrollees who were validly covered under the previous health maintenance organization contract or policy at the date of discontinuance and who would otherwise be eligible for coverage under the succeeding carrier's contract, regardless of any provisions of the contract relating to active employment or hospital confinement or pregnancy.

(c) Except to the extent benefits for the condition would have been reduced or excluded under the prior carrier's contract or policy, no provision in a succeeding carrier's contract of replacement coverage which would operate to reduce or exclude benefits on the basis that the condition giving rise to benefits preexisted the effective date of the succeeding carrier's contract shall be applied with respect to those enrollees validly covered under the prior carrier's contract or policy on the date of discontinuance. [L 1995, c 179, pt of §1]
Haw. Rev. Stat. § 432D-8 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-8
Protection against insolvency.
Status: in_force

(a) Net worth requirements are as follows:

(1) Before issuing any certificate of authority, the commissioner shall require that the health maintenance organization has an initial net worth of $2,000,000 and shall thereafter maintain the minimum net worth required under paragraph (2);

(2) Except as provided in paragraphs (3) and (4), every health maintenance organization shall maintain a minimum net worth equal to the greater of:

(A) $2,000,000;

(B) Two per cent of annual premium revenues as reported on the most recent annual financial statement filed with the commissioner on the first $150,000,000 of premium revenues and one per cent of annual premium revenues on the premium revenues in excess of $150,000,000;

(C) An amount equal to the sum of three months uncovered health care expenditures as reported on the most recent financial statement filed with the commissioner; or

(D) An amount equal to the sum of:

(i) Eight per cent of annual health care expenditures except those paid on a capitated basis or managed hospital payment basis as reported on the most recent financial statement filed with the commissioner; and

(ii) Four per cent of annual hospital expenditures paid on a managed hospital payment basis as reported on the most recent financial statement filed with the commissioner;

(3) The minimum net worth requirement set forth in paragraph (2)(A) shall be phased in as follows:

(A) Seventy-five per cent of the required amount by January 1, 2001; and

(B) One hundred per cent of the required amount by December 31, 2002; and

(4) The following shall apply in determining compliance with the requirements of this subsection:

(A) In determining net worth, no debt shall be considered fully subordinated unless the subordination clause is in a form acceptable to the commissioner. Any interest obligation relating to the repayment of any subordinated debt shall be similarly subordinated;

(B) The interest expenses relating to the repayment of any fully subordinated debt shall be considered covered expenses; and

(C) Any debt incurred by a note meeting the requirements of this section, and otherwise acceptable to the commissioner, shall not be considered a liability and shall be recorded as equity.

(b) Deposit requirements are as follows:

(1) Unless otherwise provided below, each health maintenance organization shall deposit with the commissioner or, at the discretion of the commissioner, with any organization or trustee acceptable to the commissioner through which a custodial or controlled account is utilized, cash, securities, or any combination of these or other measures that are acceptable to the commissioner which at all times shall have a value of not less than $300,000;

(2) A health maintenance organization that is in operation on January 1, 1996, shall make a deposit equal to $150,000. Within one year after January 1, 1996, a health maintenance organization that is in operation on January 1, 1996, shall make an additional deposit of $150,000 for a total of $300,000;

(3) Deposits shall be an admitted asset of the health maintenance organization in the determination of net worth;

(4) All income from deposits shall be an asset of the health maintenance organization. A health maintenance organization that has made a securities deposit may withdraw that deposit or any part thereof after making a substitute deposit of cash, securities, or any combination of these or other measures of equal amount and value. Any securities shall be approved by the commissioner before being deposited or substituted;

(5) The deposit shall be used to protect the interests of the health maintenance organization's enrollees and to assure continuation of health care services to enrollees of a health maintenance organization which is in rehabilitation or conservation. The commissioner may use the deposit for administrative costs directly attributable to a receivership or liquidation. If the health maintenance organization is placed in receivership or liquidation, the deposit shall be an asset subject to the provisions of article 15 of chapter 431; and

(6) The commissioner may reduce or eliminate the deposit requirement if the health maintenance organization deposits with the director of finance of this State, or the insurance commissioner, or other official body of the state or jurisdiction of domicile of such health maintenance organization, for the protection of all subscribers and enrollees, wherever located, cash, acceptable securities, or surety, and delivers to the commissioner a certificate to such effect, duly authenticated by the appropriate state official holding the deposit.

(c) Every health maintenance organization, when determining liabilities, shall include an amount estimated in the aggregate to provide for any unearned premium and for the payment of all claims for health care expenditures which have been incurred, whether reported or unreported, which are unpaid and for which the organization is or may be liable, and to provide for the expense of adjustment or settlement of claims. Such liabilities shall be computed in accordance with rules adopted by the commissioner upon reasonable consideration of the ascertained experience and character of the health maintenance organization.

(d) Every contract between a health maintenance organization and a participating provider of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the contract, the subscriber or enrollee shall not be liable to the provider for any sums owed by the health maintenance organization. In the event that a contract with a participating provider has not been reduced to writing as required by this subsection or that a contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from the subscriber or enrollee sums owed by the health maintenance organization. No participating provider, or agent, trustee, or assignee thereof, may maintain any action at law against a subscriber or enrollee to collect sums owed by the health maintenance organization.

(e) The commissioner shall require that each health maintenance organization have a plan for handling insolvency which allows for continuation of benefits for the duration of the contract period for which premiums have been paid and continuation of benefits to members who are confined on the date of insolvency in an inpatient facility until their discharge or expiration of benefits. In considering such a plan, the commissioner may require:

(1) Insurance to cover the expenses to be paid for continued benefits after an insolvency;

(2) Provisions in provider contracts that obligate the provider to provide services for the duration of the period after the health maintenance organization's insolvency for which premium payment has been made and until the enrollees' discharge from inpatient facilities;

(3) Insolvency reserves;

(4) Acceptable letters of credit; or

(5) Any other arrangements acceptable to the commissioner to assure that benefits are continued as specified above.

(f) An agreement to provide health care services between a provider and a health maintenance organization shall require that a provider shall give the organization at least sixty days' advance notice in the event of termination.

(g) Each health maintenance organization shall prepare and submit for review by the commissioner on or before the forty-fifth day after each of the first three calendar quarters, and for the fourth calendar quarter ending December 31, on or before the next March 1, a copy of its quarterly net solvency report verified by at least two principal officers. The commissioner may prescribe the forms on which the reports are to be prepared. Every health maintenance organization shall maintain a copy of its current net solvency report on the premises of its primary place of business. The commissioner may order an examination, subject to article 2 of chapter 431, to determine whether a health maintenance organization is in compliance with this section. Any health maintenance organization that fails or refuses to prepare or submit for review the quarterly net solvency report as required by this subsection shall be liable for a penalty in an amount no less than $100 and no more than $500 per day. [L 1995, c 179, pt of §1; am L 2001, c 185, §2; am L 2025, c 61, §2]
Haw. Rev. Stat. § 431L-4 — HI Code / Division 2 / Title 24 / Chapter 431L / Section 431L-4
Employer obligations.
Status: in_force

Where a parent is required by a court or administrative order to provide health coverage, which is available through an employer doing business in this State, the employer is required:

(1) To permit the parent to enroll under family coverage, as defined in section 431:10A-103 or reciprocal beneficiary family coverage, as defined in section 431:10A-601, any child who is otherwise eligible for coverage without regard to any enrollment season restrictions;

(2) If the parent is enrolled but fails to make application to obtain coverage of the child, to enroll the child under family coverage or reciprocal beneficiary family coverage upon application by the child's other parent, by the state agency administering the medicaid program, or by the state agency administering the child support enforcement program;

(3) Not to disenroll (or eliminate coverage of) any such child unless the employer is provided satisfactory written evidence that:

(A) The court or administrative order is no longer in effect;

(B) The child is or will be enrolled in comparable coverage which will take effect no later than the effective date of disenrollment; or

(C) The employer has eliminated family health coverage or reciprocal beneficiary family coverage for all of its employees; and

(4) To withhold from the employee's compensation the employee's share (if any) of premiums for health coverage and to pay this amount to the insurer. [L 1995, c 83, pt of §2; am L 1997, c 383, §9]
Haw. Rev. Stat. § 431C-46 — HI Code / Division 2 / Title 24 / Chapter 431C / Section 431C-46
Confidentiality.
Status: in_force

(a) The documents and evidence provided pursuant to section 431C-45 or obtained by the commissioner in an investigation of suspected or actual fraudulent life settlement acts shall be privileged and confidential and shall not be a public record and shall not be subject to discovery or subpoena in a civil or criminal action.

(b) Subsection (a) does not prohibit release by the commissioner of documents and evidence obtained in an investigation of suspected or actual fraudulent life settlement acts:

(1) In administrative or judicial proceedings to enforce laws administered by the commissioner;

(2) To federal, state, or local law enforcement or regulatory agencies, to an organization established for the purpose of detecting and preventing fraudulent life settlement acts, or to the National Association of Insurance Commissioners; or

(3) At the discretion of the commissioner, to a person in the business of life settlements that is aggrieved by a fraudulent life settlement act.

(c) Release of documents and evidence under subsection (b) does not abrogate or modify the privilege granted in subsection (a). [L 2012, c 256, pt of §1]
Haw. Rev. Stat. § 431K-2 — HI Code / Division 2 / Title 24 / Chapter 431K / Section 431K-2
Risk retention groups chartered in this State.
Status: in_force

(a) A risk retention group seeking to be chartered in this State shall be chartered and licensed as a liability insurance company authorized by the insurance laws of this State and, except as provided elsewhere in this chapter, shall comply with all of the laws, rules, and requirements applicable to these insurers chartered and licensed in this State and with section 431K-3, to the extent these requirements are not a limitation on the laws, rules, or requirements of this State. Prior to offering insurance in any state, each risk retention group shall also submit for approval to the commissioner a plan of operation or feasibility study and revisions of such plan or study if the group intends to offer any additional lines of liability insurance. Immediately upon receipt of an application for charter, the commissioner shall provide summary information concerning the filing to the National Association of Insurance Commissioners, including:

(1) The name of the risk retention group;

(2) The identity of the initial members of the group;

(3) The identity of those individuals who organized the group or who will provide administrative services or otherwise influence or control the activities of the group;

(4) The amount and nature of initial capitalization;

(5) The coverages to be afforded; and

(6) The states in which the group intends to operate.

Providing notification to the National Association of Insurance Commissioners is in addition to and shall not be sufficient to satisfy the requirements of section 431K-3 or any other sections of this chapter.

(b) New risk retention groups established on or after July 1, 2016, shall be in compliance with the governance standards set forth in subsection (c).

(c) By July 1, 2017, existing risk retention groups shall be in compliance with the following:

(1) The board shall have a majority of independent directors. The board of directors shall: determine whether a director is independent and has no material relationship with the risk retention group; review such determination annually; and maintain a record of the determinations, which shall be provided to the commissioner annually. If the risk retention group is reciprocal, then the attorney-in-fact shall be required to adhere to the same standards regarding independence of operation and governance as imposed on the risk retention group's board of directors and subscribers advisory committee[;]

(2) The term of any material service provider contract entered into with a risk retention group shall not exceed five years. The contract or its renewal requires approval of a majority of the risk retention group's independent directors. The board of directors has the right to terminate a contract at any time for cause after providing adequate notice as defined in the terms of the contract. Service providers of a reciprocal risk retention group shall contract with the risk retention group[;]

(3) A risk retention group shall not enter into a material service provider contract without the prior written approval of the commissioner[;]

(4) A risk retention group's plan of operation shall include written policies approved by its board of directors requiring the board to:

(A) Provide evidence of ownership interest to each risk retention group member;

(B) Develop governance standards applicable to the risk retention group;

(C) Oversee the evaluation of the risk retention group's management, including the performance of its captive manager, managing general underwriter, or any other person responsible for underwriting, rate determination, premium collection, claims adjustment and settlement, or preparation of financial statements;

(D) Review and approve the amount to be paid under a material service provider contract; and

(E) Review and approve at least annually:

(i) The risk retention group's goals and objectives relevant to the compensation of officers and service providers;

(ii) The performance of officers and service providers as measured against the risk retention group's goals and objectives; and

(iii) The continued engagement of officers and material service providers[;]

(5) A risk retention group shall have an audit committee composed of at least three independent board members. A nonindependent board member may participate in the committee's activities if invited to do so by the audit committee, but a nonindependent board member shall not serve as a committee member. The commissioner may waive the requirement of an audit committee if the risk retention group demonstrates to the commissioner's satisfaction that having such committee is impracticable and that the board of directors itself is able to sufficiently perform the committee's responsibilities. The audit committee shall have a written charter defining its responsibilities, which shall include:

(A) Assisting board oversight of the integrity of financial statements, compliance with legal and regulatory requirements, and qualifications, independence, and performance of the independent auditor or actuary;

(B) Reviewing annual audited financial statements and quarterly financial statements with management;

(C) Reviewing annual audited financial statements with its independent auditor and, if deemed advisable, the risk retention group's quarterly financial statements;

(D) Reviewing risk assessment and risk management policies;

(E) Meeting with management, either directly or through a designated representative of the committee;

(F) Meeting with independent auditors, either directly or through a designated representative of the committee;

(G) Reviewing with the independent auditor any audit problems and management's response;

(H) Establishing clear hiring policies applicable to the hiring of employees or former employees of the independent auditor by the risk retention group;

(I) Requiring the independent auditor to rotate the lead audit partner having primary responsibility for the risk retention group's audit, as well as the audit partner responsible for reviewing that audit, so that neither individual performs audit services for the risk retention group for more than five consecutive fiscal years; and

(J) Reporting regularly to the board of directors[;]

(6) The board of directors shall adopt governance standards, which shall be available to risk retention group members through electronic or other means and, upon request, provided to risk retention group members. The governance standards shall include:

(A) A process by which risk retention group members elect directors;

(B) Director qualifications, responsibilities, and compensation;

(C) Director orientation and continuing education requirements;

(D) A process allowing the board access to management and, as necessary and appropriate, independent advisors;

(E) Policies and procedures for management succession; and

(F) Policies and procedures providing for an annual performance evaluation of the board[;]

(7) The board of directors shall adopt a code of business conduct and ethics applicable to directors, officers, and employees of the risk retention group and disclose criteria for waivers of code provisions to the board of directors, which shall be available to risk retention group members through electronic or other means and, upon request, provided to risk retention group members. Provisions of the code shall address:

(A) Conflicts of interest;

(B) Matters covered under the Hawaii corporate opportunities doctrine;

(C) Confidentiality;

(D) Fair dealing;

(E) Protection and proper use of risk retention group assets;

(F) Standards for complying with applicable laws, rules, and regulations; and

(G) Mandatory reporting of illegal or unethical behavior affecting the operation of the risk retention group[;]

(8) The captive manager, president, or chief executive officer of a risk retention group shall promptly notify the commissioner in writing of any known noncompliance with the governance standards established in this subsection.

(d) For the purposes of this section:

"Independent director" means a director who does not have a material relationship with the risk retention group. A person who is a direct or an indirect owner of or subscriber in the risk retention group, as referenced in the definition of "risk retention group" in section 431K-1, or who is an officer, a director, or an employee of the owner and insured unless some other position of the officer, director, or employee constitutes a "material relationship", is considered independent. The commissioner shall have the authority to determine whether or not a director is independent.

A director has a "material relationship" with a risk retention group if the director or a member of the director's immediate family:

(1) Receives in any twelve-month period from the risk retention group or a consultant or service provider to the risk retention group compensation or other item of value in an amount equal to or greater than five per cent of the risk retention group's gross written premium or two per cent of the risk retention group's surplus as measured at the end of any fiscal quarter falling in the twelve-month period, whichever is greater. This provision also applies to compensation or items of value received by any business with which the director or a member of the director's immediate family is affiliated. The material relationship shall be deemed to exist for one year after the item of value is received or the compensation ceases or falls below the threshold established in this paragraph, as applicable;

(2) Is affiliated with or employed in a professional capacity by a current or former internal or external auditor of the risk retention group. The material relationship shall be deemed to exist for one year after the affiliation, employment, or audit ends; or

(3) Is employed as an executive officer of another company whose board of directors includes executive officers of the risk retention group unless a majority of the membership of the other company's board of directors is the same as the membership of the board of directors of the risk retention group. The material relationship shall be deemed to exist for one year after the employment or service ends.

"Material service provider" includes a captive manager, auditor, accountant, actuary, investment advisor, attorney, managing general underwriter, or other person responsible for underwriting, determination of rates, premium collection, claims adjustment or settlement, or preparation of financial statements, whose aggregate annual contract fees are equal to or greater than five per cent of the risk retention group's annual gross written premium or two per cent of its surplus, whichever is greater. "Material service provider" does not mean defense counsel retained by a risk retention group unless the counsel's annual fees are equal to or greater than five per cent of a risk retention group's annual gross written premium or two per cent of its surplus, whichever is greater. [L 1987, c 180, pt of §1; am L 2016, c 140, §4]
Haw. Rev. Stat. § 432D-1.5 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-1.5
Bona fide trade associations.
Status: in_force

(a) At the option of a bona fide trade association, or its designated agent, a health maintenance organization that sells health insurance to the bona fide trade association shall treat the bona fide trade association and its members as a group for the purpose of issuing a group contract; provided that:

(1) The bona fide trade association shall have been formed for purposes other than obtaining insurance;

(2) The health maintenance organization shall be prohibited from restricting, in any manner, the number or types of health plans issued by another insurance entity that the bona fide trade association may offer to its members, including but not limited to such restrictions as clauses that reduce competition between insurers or clauses that require a bona fide trade association to allow an insurer to match the price or terms offered by another insurer; and

(3) Each member of the bona fide trade association shall not be required to be insured under the group policy;

and provided further that this section shall be inapplicable if less than two persons from the bona fide trade association seek to be insured under the group policy.

(b) As used in this section:

"Bona fide trade association" means an association of persons organized to promote common interests and comprised of persons engaged in a business, trade, or profession that:

(1) Has been actively in existence for five years;

(2) Has been formed and maintained in good faith for purposes other than obtaining insurance;

(3) Does not condition membership in the association on any health status related factor pertaining to an individual (including an employee of an employer or a dependent of an employee);

(4) Makes health insurance coverage offered through the association available to all members regardless of any health status related factor pertaining to such members (or individuals eligible for coverage through a member);

(5) Does not make health insurance coverage offered through the association available other than in connection with a member of the association; and

(6) Meets such additional requirements as may be imposed under state law. [L 2004, c 118, §§3, 5; am L 2006, c 41, §2]
Haw. Rev. Stat. § 432G-13 — HI Code / Division 2 / Title 24 / Chapter 432G / Section 432G-13
Suspension, revocation, or denial of certificate of authority.
Status: in_force

(a) The commissioner may suspend, revoke, or refuse to extend any certificate of authority issued under this chapter and may deny any application for a certificate of authority if the commissioner finds that:

(1) The dental insurer is operating significantly in contravention of its basic organizational document or in a manner contrary to that described in any other information submitted under section 432G‑2, unless amendments to such submissions have been filed with and approved by the commissioner;

(2) The dental insurer or applicant does not provide or arrange for basic dental care services;

(3) The dental insurer or applicant is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;

(4) The dental insurer has failed to correct, within the time prescribed by subsection (b), any deficiency occurring due to the impairment of the dental insurer's prescribed minimum net worth;

(5) The dental insurer, applicant, or any person acting on its behalf has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive, or unfair manner;

(6) The dental insurer, applicant, or any person acting on its behalf fails or refuses to produce or submit any of the documents required under sections 432G‑4 and 432G‑6;

(7) The operation or continued operation of the dental insurer would be hazardous to its enrollees; or

(8) The dental insurer or applicant has otherwise failed to substantially comply with this chapter.

(b) The following shall pertain when insufficient net worth is maintained:

(1) Whenever the commissioner finds that the net worth maintained by any dental insurer subject to this chapter is less than the minimum net worth required, the commissioner shall give written notice to the dental insurer of the amount of the deficiency and shall require the dental insurer to:

(A) File with the commissioner a plan for correction of the deficiency acceptable to the commissioner; and

(B) Correct the deficiency within a reasonable time, not to exceed sixty days, unless an extension of time, not to exceed sixty additional days, is granted by the commissioner. A deficiency in net worth shall be deemed an impairment. Failure to correct an impairment within the prescribed time shall be grounds for suspension or revocation of the certificate of authority or for placing the dental insurer in conservation, rehabilitation, or liquidation; and

(2) Unless allowed by the commissioner, no dental insurer or person acting on its behalf, directly or indirectly, may renew, issue, or deliver any certificate, agreement, or contract of coverage in this State, for which a premium is charged or collected, while the dental insurer is impaired and the fact of the impairment is known to the dental insurer or person. The existence of an impairment shall not prevent the issuance or renewal of a certificate, agreement, or contract if an enrollee exercises an option granted under the plan to obtain new, renewed, or converted coverage.

(c) A certificate of authority shall be suspended, revoked, or not extended, or an application for a certificate of authority denied, or an administrative fine imposed, only after compliance with the following requirements:

(1) Suspension or revocation of a certificate of authority, refusal to extend a certificate of authority, denial of an application, or imposition of an administrative fine pursuant to section 432G‑15(a) shall be by written order of the commissioner, which shall be sent to the dental insurer or applicant by certified or registered mail. The written order shall state the grounds, charges, or conduct on which suspension, revocation, refusal to extend, denial, or administrative fine is based. The insurer or applicant may request in writing a hearing pursuant to section 431:2-308; and

(2) If the dental insurer or applicant requests a hearing pursuant to this section, the commissioner shall issue a written notice of hearing stating a specific time for the hearing, which may not be less than twenty nor more than thirty days after mailing of the notice of hearing and a specific place for the hearing. Notice of hearing shall be delivered to the insurer or applicant by certified or registered mail.

(d) When the certificate of authority of a dental insurer is suspended, the dental insurer shall not, during the period of suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing subscribers, and shall not engage in any advertising or solicitation whatsoever.

(e) When the certificate of authority of a dental insurer is revoked, the insurer, immediately following the effective date of the order of revocation, shall proceed to wind up its affairs, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the insurer. It shall engage in no further advertising or solicitation whatsoever. The commissioner, by written order, may permit any further operation of the insurer as the commissioner may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing dental care coverage. [L 2013, c 191, pt of §1]
Haw. Rev. Stat. § 432G-6 — HI Code / Division 2 / Title 24 / Chapter 432G / Section 432G-6
Protection against insolvency; net solvency report.
Status: in_force

(a) Net worth requirements are as follows:

(1) Before issuing any certificate of authority, the commissioner shall require that the dental insurer has an initial net worth of $2,000,000 and shall thereafter maintain the minimum net worth required under paragraph (2);

(2) Except as provided in paragraphs (3) and (4), every dental insurer shall maintain a minimum net worth equal to the greater of:

(A) $2,000,000;

(B) Two per cent of annual premium revenues as reported on the most recent annual financial statement filed with the commissioner on the first $150,000,000 of premium revenues and one per cent of annual premium revenues on the premium revenues in excess of $150,000,000;

(C) An amount equal to the sum of three months uncovered dental care expenditures as reported on the most recent financial statement filed with the commissioner; or

(D) An amount equal to eight per cent of annual dental care expenditures except those paid on a capitated basis as reported on the most recent financial statement filed with the commissioner;

(3) The minimum net worth requirement set forth in paragraph (2)(A) shall be phased in as follows:

(A) Seventy-five per cent of the required amount by January 1, 2016; and

(B) One hundred per cent of the required amount by December 31, 2017; and

(4) The following shall apply in determining compliance with the requirements of this subsection:

(A) In determining net worth, no debt shall be considered fully subordinated unless the subordination clause is in a form acceptable to the commissioner. Any interest obligation relating to the repayment of any subordinated debt shall be similarly subordinated;

(B) The interest expenses relating to the repayment of any fully subordinated debt shall be considered covered expenses; and

(C) Any debt incurred by a note meeting the requirements of this section, and otherwise acceptable to the commissioner, shall not be considered a liability and shall be recorded as equity.

(b) Deposit requirements are as follows:

(1) Unless otherwise provided in this subsection, each dental insurer shall deposit with the commissioner or, at the discretion of the commissioner, with any organization or trustee acceptable to the commissioner through which a custodial or controlled account is utilized, cash, securities, or any combination of these or other measures that are acceptable to the commissioner which at all times shall have a value of not less than $300,000;

(2) A dental service corporation formed and operating pursuant to chapter 423 that is in operation on July 1, 2013, shall make a deposit equal to $150,000. Within one year after January 1, 2014, a dental service corporation originally formed pursuant to chapter 423 that is reconstituted under this chapter and in operation on January 1, 2014, shall make an additional deposit of $150,000 for a total of $300,000;

(3) Deposits shall be an asset of the dental insurer in the determination of net worth;

(4) All income from deposits shall be an asset of the dental insurer. A dental insurer that has made a securities deposit may withdraw that deposit or any part thereof after making a substitute deposit of cash, securities, or any combination of these or other measures of equal amount and value. Any securities shall be approved by the commissioner before being deposited or substituted;

(5) The deposit shall be used to protect the interests of the dental insurer's enrollees and to assure continuation of dental care services to enrollees of a dental insurer which is in rehabilitation or conservation. The commissioner may use the deposit for administrative costs directly attributable to a receivership or liquidation. If the dental insurer is placed in receivership or liquidation, the deposit shall be an asset subject to the provisions of article 15 of chapter 431; and

(6) The commissioner may reduce or eliminate the deposit requirement if the dental insurer deposits with the director of finance of this State, or the commissioner, or other official body of the state or jurisdiction of domicile of such dental insurer, for the protection of all subscribers and enrollees, wherever located, cash, acceptable securities, or surety, and delivers to the commissioner a certificate to such effect, duly authenticated by the appropriate state official holding the deposit.

(c) Every dental insurer, when determining liabilities, shall include an amount estimated in the aggregate to provide for any unearned premium and for the payment of all claims for dental care expenditures which have been incurred, whether reported or unreported, which are unpaid and for which the organization is or may be liable, and to provide for the expense of adjustment or settlement of claims. These liabilities shall be computed in accordance with rules adopted by the commissioner upon reasonable consideration of the ascertained experience and character of the dental insurer.

(d) Every contract between a dental insurer and a participating provider shall be in writing and shall set forth that in the event the dental insurer fails to pay for dental care services as set forth in the contract, the subscriber or enrollee shall not be liable to the provider for any sums owed by the dental insurer. In the event that a contract with a participating provider has not been reduced to writing as required by this subsection or that a contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from the subscriber or enrollee sums owed by the dental insurer. No participating provider, or agent, trustee, or assignee thereof, may maintain any action at law against a subscriber or enrollee to collect sums owed by the dental insurer.

(e) The commissioner shall require that each dental insurer have a plan for handling insolvency which allows for continuation of benefits for the duration of the contract period for which premiums have been paid. In considering such a plan, the commissioner may require:

(1) Insurance to cover the expenses to be paid for continued benefits after an insolvency;

(2) Provisions in participating provider contracts that obligate the provider to provide dental care services for the duration of the period after the dental insurer's insolvency for which premium payment has been made;

(3) Insolvency reserves;

(4) Acceptable letters of credit; or

(5) Any other arrangements acceptable to the commissioner to assure that benefits are continued as specified in this subsection.

(f) An agreement to provide dental care services between a participating provider and a dental insurer shall require that a participating provider shall give the dental insurer at least sixty days' advance notice in the event of termination.

(g) Each dental insurer shall prepare and submit for review by the commissioner on or before the forty-fifth day after each of the first three calendar quarters, and for the fourth calendar quarter ending December 31, on or before the next March 1, a copy of its quarterly net solvency report verified by at least two principal officers. The commissioner may prescribe the forms on which the reports are to be prepared. Every dental insurer shall maintain a copy of its current net solvency report on the premises of its primary place of business.

(h) The commissioner may order an examination, subject to article 2 of chapter 431, to determine whether a dental insurer is in compliance with this section. Any dental insurer that fails or refuses to prepare or submit for review the quarterly net solvency report or any of the documents as required by this section shall be liable for a penalty pursuant to section 432G-4(c). [L 2013, c 191, pt of §1; am L 2025, c 61, §3]
Haw. Rev. Stat. § 431K-9 — HI Code / Division 2 / Title 24 / Chapter 431K / Section 431K-9
Administrative and procedural authority regarding risk retention groups and purchasing groups.
Status: in_force

The commissioner is authorized to make use of any of the powers established under chapter 431 to enforce the laws of this State as long as those powers are not specifically preempted by the Product Liability Risk Retention Act of 1981, 15 U.S.C. §3901 et seq., as amended by the Risk Retention Amendments of 1986, P.L. 99-563. This includes, but is not limited to, the commissioner's administrative authority to investigate, issue subpoenas, conduct depositions and hearings, issue orders, and impose penalties. With regard to any investigation, administrative proceedings, or litigation, the commissioner may rely on the procedural law and rules of this State. The injunctive authority of the commissioner in regard to risk retention groups shall be restricted by the requirement that any injunction be issued by a court of competent jurisdiction. All penalties collected under this section and section 431K-7.1 shall be deposited to the credit of the compliance resolution fund.
Haw. Rev. Stat. § 431C-42 — HI Code / Division 2 / Title 24 / Chapter 431C / Section 431C-42
Fraudulent life settlement acts prohibited.
Status: in_force

It is a violation of this chapter for any person, provider, broker, or any other party related to the business of life settlements, to commit a fraudulent life settlement act.

For the purposes of this part, "fraudulent life settlement act" includes:

(1) Acts or omissions committed by any person who, knowingly and with intent to defraud, for the purpose of depriving another of property or for pecuniary gain, commits or permits its employees or agents to engage in acts, including but not limited to:

(A) Presenting, causing to be presented, or preparing with knowledge and belief that it will be presented to or by a provider, premium finance lender, broker, insurer, insurance producer, or any other person, false material information, or concealing material information, as part of, in support of, or concerning a fact material to one or more of the following:

(i) An application for the issuance of a policy or life settlement contract;

(ii) The underwriting of a policy or life settlement contract;

(iii) A claim for payment or benefit pursuant to a policy or life settlement contract;

(iv) Premiums paid on a policy;

(v) Payments and changes in ownership or beneficiary made in accordance with the terms of a policy or life settlement contract;

(vi) The reinstatement or conversion of a policy;

(vii) The solicitation, offer to enter into, or effectuation of a policy or life settlement contract;

(viii) The issuance of written evidence of a policy or life settlement contract;

(ix) Any application for or the existence of or any payments related to a loan secured directly or indirectly by any interest in a policy; or

(x) Entering into any practice or plan that involves stranger-originated life insurance;

(B) Failing to disclose to the insurer, where the insurer requests such disclosure, that the prospective insured has undergone a life expectancy evaluation by any person or entity other than the insurer or its authorized representatives in connection with the issuance of the policy;

(C) Employing any device, scheme, or artifice to defraud in the business of life settlements; or

(D) In the solicitation, application, or issuance of a policy, employing any device, scheme, or artifice in violation of state insurable interest laws;

(2) Acts or omissions committed by any person who, in the furtherance of a fraud or to prevent the detection of a fraud, commits or permits its employees or its agents to engage in to:

(A) Remove, conceal, alter, destroy, or sequester from the commissioner the assets or records of a licensee or other person engaged in the business of life settlements;

(B) Misrepresent or conceal the financial condition of a licensee, financing entity, insurer, or other person;

(C) Transact the business of life settlements in violation of laws requiring a license, certificate of authority, or other legal authority for the transaction of the business of life settlements;

(D) File with the commissioner or the chief insurance regulatory official of another jurisdiction a document containing false information or otherwise concealing information about a material fact from the commissioner;

(E) Engage in embezzlement, theft, misappropriation, or conversion of moneys, funds, premiums, credits, or other property of a provider, insurer, insured, owner, insurance, policy owner, or any other person engaged in the business of life settlements or insurance;

(F) Knowingly and with intent to defraud, enter into, broker, or otherwise deal in a life settlement contract, the subject of which is a policy that was obtained by presenting false information concerning any fact material to the policy or by concealing, for the purpose of misleading another, information concerning any fact material to the policy, where the owner or the owner's agent intended to defraud the policy's issuer;

(G) Attempt to commit, assist, aid, or abet in the commission of, or conspire to commit the acts or omissions specified in this section; or

(H) Misrepresent the state of residence of an owner to be a state or jurisdiction that does not have a law substantially similar to this chapter for the purpose of evading or avoiding the provisions of this chapter. [L 2012, c 256, pt of §1]
Haw. Rev. Stat. § 432D — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D
‑28] Federal law compliance.
Status: in_force

[§432D‑28] Federal law compliance. A health maintenance organization shall comply with applicable federal law. The commissioner shall enforce the consumer protections and market reforms relating to insurance as set forth in the federal Patient Protection and Affordable Care Act, Public Law 111-148.
Haw. Rev. Stat. § 432D-10 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-10
Enrollment period.
Status: in_force

(a) In the event of an insolvency of a health maintenance organization, upon order of the commissioner, all other carriers offered as alternatives to the insolvent health maintenance organization at a group's last regular enrollment period shall offer to those members of the group who enrolled in the insolvent health maintenance organization a thirty-day enrollment period commencing upon the date of insolvency. Each carrier shall offer the enrollees of the insolvent health maintenance organization the same coverages and rates that it had offered to the enrollees of the group at its last regular enrollment period.

(b) If no other carrier had been offered to some groups enrolled in the insolvent health maintenance organization, or if the commissioner determines that the other health benefit plans lack sufficient health care delivery resources to assure that health care services will be available and accessible to all of the group's enrollees of the insolvent health maintenance organization, then the commissioner shall equitably allocate the insolvent health maintenance organization's group contracts for such groups among all health maintenance organizations that operate within a portion of the insolvent health maintenance organization's service area, taking into consideration the health care delivery resources of each health maintenance organization. Each health maintenance organization to which a group is so allocated shall offer the group the health maintenance organization's existing coverage that is most similar to each group's coverage with the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization's existing rating methodology.

(c) The commissioner also shall allocate equitably the insolvent health maintenance organization's nongroup enrollees who are unable to obtain other coverage among all health maintenance organizations which operate within a portion of the insolvent health maintenance organization's service area, taking into consideration the health care delivery resources of each health maintenance organization. Each health maintenance organization to which nongroup enrollees are allocated shall offer such nongroup enrollees the health maintenance organization's existing coverage for individual or conversion coverage as determined by the enrollee's type of coverage in the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization's existing rating methodology. Successor health maintenance organizations that do not offer direct nongroup enrollment may aggregate all of the allocated nongroup enrollees into one group for rating and coverage purposes. [L 1995, c 179, pt of §1]
Haw. Rev. Stat. § 432E-34 — HI Code / Division 2 / Title 24 / Chapter 432E / Section 432E-34
Standard external review.
Status: in_force

(a) An enrollee or the enrollee's appointed representative may file a request for an external review with the commissioner within one hundred thirty days of receipt of notice of an adverse action. Within three business days after the receipt of a request for external review pursuant to this section, the commissioner shall send a copy of the request to the health carrier.

(b) Within five business days following the date of receipt of the copy of the external review request from the commissioner pursuant to subsection (a), the health carrier shall determine whether:

(1) The individual is or was an enrollee in the health benefit plan at the time the health care service was requested or, in the case of a retrospective review, was an enrollee in the health benefit plan at the time the health care service was provided;

(2) The health care service that is the subject of the adverse determination or the final adverse determination would be a covered service under the enrollee's health benefit plan but for a determination by the health carrier that the health care service does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness;

(3) The enrollee has exhausted the health carrier's internal appeals process or the enrollee is not required to exhaust the health carrier's internal appeals process pursuant to section 432E-33(b); and

(4) The enrollee has provided all the information and forms required to process an external review, including a completed release form and disclosure form as required by section 432E-33(a).

(c) Within three business days after a determination of an enrollee's eligibility for external review pursuant to subsection (b), the health carrier shall notify the commissioner, the enrollee, and the enrollee's appointed representative in writing as to whether the request is complete and whether the enrollee is eligible for external review.

If the request for external review submitted pursuant to this section is not complete, the health carrier shall inform the commissioner, the enrollee, and the enrollee's appointed representative in writing that the request is incomplete and shall specify the information or materials required to complete the request.

If the enrollee is not eligible for external review pursuant to subsection (b), the health carrier shall inform the commissioner, the enrollee, and the enrollee's appointed representative in writing that the enrollee is not eligible for external review and the reasons for ineligibility.

Notice of ineligibility for external review pursuant to this section shall include a statement informing the enrollee and the enrollee's appointed representative that a health carrier's initial determination that the external review request is ineligible for review may be appealed to the commissioner by submission of a request to the commissioner.

(d) (1) The commissioner may determine that a request is eligible for external review under subsection (b) notwithstanding a health carrier's initial determination that the request is ineligible and require that it be referred for external review; and

(2) In making a determination under paragraph (1), the commissioner's decision shall be made in accordance with the terms of the enrollee's health benefit plan and shall be subject to all applicable provisions of this part.

(e) When the commissioner receives notice pursuant to subsection (c) or makes a determination pursuant to subsection (d) that an enrollee is eligible for external review, within three business days after receipt of the notice or determination of eligibility, the commissioner shall:

(1) Randomly assign an independent review organization from the list of approved independent review organizations qualified to conduct the external review, based on the nature of the health care service that is the subject of the adverse action and other factors determined by the commissioner including conflicts of interest pursuant to section 432E-43, compiled and maintained by the commissioner to conduct the external review and notify the health carrier of the name of the assigned independent review organization; and

(2) Notify the enrollee and the enrollee's appointed representative, in writing, of the enrollee's eligibility and acceptance for external review.

(f) An enrollee or an enrollee's appointed representative may submit additional information in writing to the assigned independent review organization for consideration in its external review. The independent review organization shall consider information submitted within five business days following the date of the enrollee's receipt of the notice provided pursuant to subsection (e). The independent review organization may accept and consider additional information submitted by an enrollee or an enrollee's appointed representative after five business days.

(g) Within five business days after the date of receipt of notice pursuant to subsection (e), the health carrier or its designated utilization review organization shall provide to the assigned independent review organization all documents and information it considered in issuing the adverse action that is the subject of external review and any documents related to the request for external review that have been received by the health carrier or its designated utilization review organization . Failure by the health carrier or its utilization review organization to provide the documents and information within five business days shall not delay the conduct of the external review; provided that the assigned independent review organization may terminate the external review and reverse the adverse action that is the subject of the external review. The independent review organization shall notify the enrollee, the enrollee's appointed representative, the health carrier, and the commissioner within three business days of the termination of an external review and reversal of an adverse action pursuant to this subsection.

(h) The assigned independent review organization shall, within one business day of receipt by the independent review organization, forward all information received from the enrollee pursuant to subsection (f) to the health carrier. Upon receipt of information forwarded to it pursuant to this subsection, a health carrier may reconsider the adverse action that is the subject of the external review; provided that reconsideration by the health carrier shall not delay or terminate an external review unless the health carrier reverses its adverse action and provides coverage or payment for the health care service that is the subject of the adverse action. The health carrier shall notify the enrollee, the enrollee's appointed representative, the assigned independent review organization, and the commissioner in writing of its decision to reverse its adverse action within three business days of making its decision to reverse the adverse action and provide coverage. The assigned independent review organization shall terminate its external review upon receipt of notice pursuant to this subsection from the health carrier.

(i) In addition to the documents and information provided pursuant to subsections (f) and (g), the assigned independent review organization shall consider the following in reaching a decision:

(1) The enrollee's medical records;

(2) The attending health care professional's recommendation;

(3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, enrollee, enrollee's appointed representatives, or enrollee's treating provider;

(4) The application of medical necessity as defined in section 432E-1;

(5) The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any practice guidelines developed by the federal government or national or professional medical societies, boards, and associations;

(6) Any applicable clinical review criteria developed and used by the health carrier or its designated utilization review organization; and

(7) The opinion of the independent review organization's clinical reviewer or reviewers pertaining to the information enumerated in paragraphs (1) through (5) to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.

In reaching a decision, the assigned independent review organization shall not be bound by any decisions or conclusions reached during the health carrier's utilization review or internal appeals process; provided that the independent review organization's decision shall not contradict the terms of the enrollee's health benefit plan or this part.

(j) Within forty-five days after it receives a request for an external review pursuant to subsection (e), the assigned independent review organization shall notify the enrollee, the enrollee's appointed representative, the health carrier, and the commissioner of its decision to uphold or reverse the adverse action that is the subject of the internal review. The independent review organization shall include in the notice of its decision:

(1) A general description of the reason for the request for external review;

(2) The date the independent review organization received the assignment from the commissioner to conduct the external review;

(3) The date the external review was conducted;

(4) The date the decision was issued; and

(5) The basis for the independent review organization's decision, including its reasoning, rationale, and the supporting evidence or documentation, including evidence-based standards, that the independent review organization considered in reaching its decision.

Upon receipt of a notice of a decision reversing the adverse action, the health carrier shall immediately approve the coverage that was the subject of the adverse action. [L 2011, c 230, pt of §2; am L 2024, c 103, §3]
Haw. Rev. Stat. § 431C-43 — HI Code / Division 2 / Title 24 / Chapter 431C / Section 431C-43
Fraud warning required.
Status: in_force

(a) Life settlement contracts and applications for life settlement contracts, regardless of the form of transmission, shall contain the following statement or a substantially similar statement: "Any person who knowingly presents false information in an application for insurance or life settlement contract is guilty of a crime and may be subject to fines and confinement in prison."

(b) The lack of a statement as required in subsection (a) shall not constitute a defense in any prosecution for a fraudulent life settlement act. [L 2012, c 256, pt of §1]
Haw. Rev. Stat. § 431M-4 — HI Code / Division 2 / Title 24 / Chapter 431M / Section 431M-4
Mental illness, alcohol and drug dependence benefits.
Status: in_force

(a) Alcohol and drug dependence benefits shall be as follows:

(1) Detoxification services as a covered benefit under this chapter shall be provided either in a hospital or in a nonhospital facility that has a written affiliation agreement with a hospital for emergency, medical, and mental health support services. The following services shall be covered under detoxification services:

(A) Room and board;

(B) Diagnostic x-rays;

(C) Laboratory testing; and

(D) Drugs, equipment use, special therapies, and supplies.

Detoxification services shall be included as part of the covered in-hospital services;

(2) Alcohol or drug dependence treatment through in-hospital, nonhospital residential, or day treatment substance abuse services as a covered benefit under this chapter shall be provided in a hospital or nonhospital facility. Before a person qualifies to receive benefits under this subsection, a qualified physician, psychologist, licensed clinical social worker, licensed marriage and family therapist, licensed mental health counselor, or advanced practice registered nurse shall determine that the person suffers from alcohol or drug dependence, or both; provided that the substance abuse services covered under this paragraph shall include those services that are required for licensure and accreditation. Excluded from alcohol or drug dependence treatment under this subsection are detoxification services and educational programs to which drinking or drugged drivers are referred by the judicial system and services performed by mutual self-help groups;

(3) Alcohol or drug dependence outpatient services as a covered benefit under this chapter shall be provided under an individualized treatment plan approved by a qualified physician, psychologist, licensed clinical social worker, licensed marriage and family therapist, licensed mental health counselor, or advanced practice registered nurse and shall be services reasonably expected to produce remission of the patient's condition. An individualized treatment plan approved by a licensed marriage and family therapist, licensed mental health counselor, licensed clinical social worker, or an advanced practice registered nurse for a patient already under the care or treatment of a physician or psychologist shall be done in consultation with the physician or psychologist; and

(4) Substance abuse assessments for alcohol or drug dependence as a covered benefit under this section for a child facing disciplinary action under section 302A-1134.6 shall be provided by a qualified physician, psychologist, licensed clinical social worker, advanced practice registered nurse, or certified substance abuse counselor. The certified substance abuse counselor shall be employed by a hospital or nonhospital facility providing substance abuse services. The substance abuse assessment shall evaluate the suitability for substance abuse treatment and placement in an appropriate treatment setting.

(b) Mental illness benefits.

(1) Covered benefits for mental health services set forth in this subsection shall be limited to coverage for diagnosis and treatment of mental disorders. All mental health services shall be provided under an individualized treatment plan approved by a physician, psychologist, licensed clinical social worker, licensed marriage and family therapist, licensed mental health counselor, advanced practice registered nurse, or licensed dietitian treating eating disorders, and must be reasonably expected to improve the patient's condition. An individualized treatment plan approved by a licensed clinical social worker, licensed marriage and family therapist, licensed mental health counselor, advanced practice registered nurse, or a licensed dietitian treating eating disorders, for a patient already under the care or treatment of a physician or psychologist shall be done in consultation with the physician or psychologist;

(2) In-hospital and nonhospital residential mental health services as a covered benefit under this chapter shall be provided in a hospital or a nonhospital residential facility. The services to be covered shall include those services required for licensure and accreditation;

(3) Mental health partial hospitalization as a covered benefit under this chapter shall be provided by a hospital or a mental health outpatient facility. The services to be covered under this paragraph shall include those services required for licensure and accreditation; and

(4) Mental health outpatient services shall be a covered benefit under this chapter. [L 1988, c 202, pt of §1, §3; am L 1994, c 111, §§2, 4; am L 1997, c 247, §3 and c 273, §3; am L 1998, c 78, §§2, 3; am L 1999, c 121, §§2, 6; am L 2000, c 243, §8(2); am L 2001, c 111, §3; am L 2002, c 167, §5 and c 239, §1; am L 2003, c 197, §3; am L 2006, c 205, §3; am L 2007, c 38, §3; am L 2008, c 206, §4; am L 2014, c 186, §11; am L 2016, c 29, §3 and c 141, §13]
Haw. Rev. Stat. § 431C-16 — HI Code / Division 2 / Title 24 / Chapter 431C / Section 431C-16
Immunity from liability.
Status: in_force

(a) No cause of action shall arise nor shall any liability be imposed against the commissioner, the commissioner's authorized representatives, or any examiner appointed by the commissioner for any statements made or conduct performed in good faith while carrying out the provisions of this chapter.

(b) No cause of action shall arise, nor shall any liability be imposed against any person for the act of communicating or delivering information or data to the commissioner or the commissioner's authorized representative or examiner pursuant to an examination made under this chapter, if the act of communication or delivery was performed in good faith and without fraudulent intent or the intent to deceive. This subsection does not abrogate or modify in any way any common law or statutory privilege or immunity heretofore enjoyed by any person identified in subsection (a).

(c) A person identified in subsection (a) or (b) shall be entitled to an award of attorney's fees and costs if the person is the prevailing party in a civil cause of action for libel, slander, or any other relevant tort arising out of activities in carrying out the provisions of this chapter and the party bringing the action was not substantially justified in doing so. For purposes of this section, a proceeding is "substantially justified" if it had a reasonable basis in law or fact at the time that it was initiated. [L 2012, c 256, pt of §1]
Haw. Rev. Stat. § 431C-47 — HI Code / Division 2 / Title 24 / Chapter 431C / Section 431C-47
Other law enforcement or regulatory authority.
Status: in_force

This chapter shall not:

(1) Preempt the authority or relieve the duty of other law enforcement or regulatory agencies to investigate, examine, and prosecute suspected violations of law;

(2) Preempt, supersede, or limit any provision of any state securities law or any rule, order, or notice issued thereunder;

(3) Prevent or prohibit a person from voluntarily disclosing information concerning life settlement fraud to a law enforcement or regulatory agency other than the insurance division; or

(4) Limit the powers granted elsewhere by the laws of this State to the commissioner or the insurance fraud investigations unit to investigate and examine possible violations of law and to take appropriate action against wrongdoers. [L 2012, c 256, pt of §1]
Haw. Rev. Stat. § 431P-13 — HI Code / Division 2 / Title 24 / Chapter 431P / Section 431P-13
Appeals.
Status: in_force

(a) Any applicant or policyholder adversely affected by a decision of the fund shall have the right to appeal to the fund's board within thirty days after the decision. The application for an appeal shall specify how the person making the appeal was aggrieved and the grounds upon which relief is demanded. The decision of the board shall be deemed final.

(b) Any final action, decision, or order of the board under this chapter shall be subject to judicial review by the circuit court. [L 1993, c 339, pt of §2]
Haw. Rev. Stat. § 432D-2 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-2
Establishment of health maintenance organizations.
Status: in_force

(a) Any person may apply to the commissioner for a certificate of authority to establish and operate a health maintenance organization in compliance with this chapter. No person shall establish or operate a health maintenance organization in this State without obtaining a certificate of authority under this chapter. A foreign corporation may qualify under this chapter, subject to its registration to do business in this State in compliance with all provisions of this chapter and other applicable state laws.

(b) Any health maintenance organization which has not previously received a certificate of authority to operate as a health maintenance organization as of January 1, 1996, shall submit an application for a certificate of authority under subsection (c) within one-hundred-eighty days of January 1, 1996. Each applicant may continue to operate until the commissioner acts upon the application. In the event that an application is denied under this chapter, the applicant shall thereafter be treated as a health maintenance organization whose certificate of authority has been revoked.

(c) Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant, shall be in a form prescribed by the commissioner, and shall set forth or be accompanied by the following:

(1) A copy of the organizational documents of the applicant, such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents, and all amendments thereto;

(2) A copy of the bylaws, rules and regulations, or similar document, if any, regulating the conduct of the internal affairs of the applicant;

(3) A list of the names, addresses, official positions, and biographical information on forms acceptable to the commissioner of the persons who are to be responsible for the conduct of the affairs and day-to-day operations of the applicant, including all members of the board of directors, board of trustees, executive committee or other governing board or committee, and the principal officers in the case of a corporation, or the partners or members in the case of a partnership or association;

(4) A copy of any contract form made or to be made between any class of providers and the health maintenance organization and a copy of any contract made or to be made between third party administrators, marketing consultants, or persons listed in paragraph (3) and the health maintenance organization;

(5) A copy of the form of evidence of coverage to be issued to the enrollees;

(6) A copy of the form of group contract, if any, which is to be issued to employers, unions, trustees, or other organizations;

(7) Financial statements showing the applicant's assets, liabilities, and sources of financial support, and both a copy of the applicant's most recent certified financial statement and an unaudited current financial statement;

(8) A financial feasibility plan which includes detailed enrollment projections, the methodology for determining premium rates to be charged during the first twelve months of operations certified by an actuary or other qualified person, a projection of balance sheets, cash flow statements showing any capital expenditures, purchase and sale of investments, deposits with the State, income and expense statements anticipated from the start of operations until the organization has had net income for at least one year, and a statement as to the sources of working capital as well as any other sources of funding;

(9) A power of attorney duly executed by such applicant, if not domiciled in this State, appointing the commissioner and the commissioner's successors in office, and duly authorized deputies, as the true and lawful attorney of such applicant in and for this State upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this State may be served;

(10) A statement or map reasonably describing the geographic area or areas to be served;

(11) A description of the internal grievance procedures to be utilized for the investigation and resolution of enrollee complaints and grievances;

(12) A description of the proposed quality assurance program, including the formal organizational structure, methods for developing criteria, procedures for comprehensive evaluation of the quality of care rendered to enrollees, and processes to initiate corrective action and reevaluation when deficiencies in provider or organizational performance are identified;

(13) A description of the procedures to be implemented to meet the protection against insolvency requirements in section 432D-8;

(14) A list of the names, addresses, and license numbers of all providers or groups of providers with which the health maintenance organization has agreements; and

(15) Such other information as the commissioner may require.

(d) If the commissioner finds that the applicant has met the requirements for and is fully entitled thereto under the applicable insurance laws, the commissioner shall issue an appropriate certificate of authority to the applicant. If the commissioner does not so find, the commissioner shall deny the applicant the certificate of authority within a reasonable length of time following filing of the application by the applicant. A certificate of authority shall be denied only after the commissioner complies with the requirements of section 432D-14.

(e) The commissioner may adopt rules under chapter 91 for the implementation and administration of this chapter. [L 1995, c 179, pt of §1]

Revision Note

"January 1, 1996" substituted for "the effective date of this chapter" pursuant to § 23G-15.
Haw. Rev. Stat. § 431C-48 — HI Code / Division 2 / Title 24 / Chapter 431C / Section 431C-48
Life settlement anti-fraud initiatives.
Status: in_force

(a) Providers and brokers shall have in place anti-fraud initiatives reasonably calculated to detect, prosecute, and prevent fraudulent life settlement acts. At the discretion of the commissioner, the commissioner may order, or a licensee may request and the commissioner may grant, such modifications of the following required initiatives as necessary to ensure an effective anti-fraud program. The modifications may be more or less restrictive than the required initiatives so long as the modifications may reasonably be expected to accomplish the purpose of this section. Anti-fraud initiatives shall include:

(1) Fraud investigators, who may be provider or broker employees or independent contractors; and

(2) An anti-fraud plan that shall be submitted to the commissioner. The anti-fraud plan shall include but not be limited to:

(A) A description of the procedures for detecting and investigating possible fraudulent life settlement acts and procedures for resolving material inconsistencies between medical records and insurance applications;

(B) A description of the procedures for reporting possible fraudulent life settlement acts to the commissioner;

(C) A description of the plan for anti-fraud education and training of underwriters and other personnel; and

(D) A description or chart outlining the organizational arrangement of the anti-fraud personnel who are responsible for the investigation and reporting of possible fraudulent life settlement acts and investigating unresolved material inconsistencies between medical records and insurance applications.

(b) Anti-fraud plans submitted to the commissioner shall be privileged and confidential and shall not be a public record and shall not be subject to discovery or subpoena in a civil or criminal action. [L 2012, c 256, pt of §1]
Haw. Rev. Stat. § 435E-23 — HI Code / Division 2 / Title 24 / Chapter 435E / Section 435E-23
Member failure to pay.
Status: in_force

In the event a participating member fails to pay any assessment when the same is due, the board of trustees may terminate such person's membership status if such failure to pay is not cured within thirty days from the date the assessment was due. Upon termination the former participating member shall not be entitled to the return of all or any part of his or her initial contribution, and the indemnity coverage shall thereupon terminate as to all claims then pending against such person and in respect to all occurrences prior to the date of such termination of membership. However, in the event the interindemnity arrangement is then providing legal defense services to such person, the interindemnity arrangement shall continue to provide those services for a period of ten days following such termination.
Haw. Rev. Stat. § 432C-4 — HI Code / Division 2 / Title 24 / Chapter 432C / Section 432C-4
Directors, officers of nonprofit entity; prohibition.
Status: in_force

(a) Directors or officers of a nonprofit entity are prohibited from directly benefiting from the conversion.

(b) No officer of the nonprofit entity who is employed by the nonprofit entity at the time the conversion application is submitted, at the time of conversion, or for a one-year period after conversion shall be employed by the for-profit entity. [L 1998, c 260, pt of §2]
Haw. Rev. Stat. § 432D-30 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-30
Medication synchronization; proration; dispensing fees.
Status: in_force

(a) Each health maintenance organization policy, contract, plan, or agreement that provides prescription drug coverage in the State shall apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a network pharmacy for less than a thirty-day supply for the purpose of medication synchronization; provided that the enrollee patient requests or agrees to less than a thirty-day supply.

(b) For the purposes of medication synchronization under this section, the health maintenance organization that provides prescription drug coverage shall:

(1) Not deny coverage for the dispensing of a maintenance medication that is dispensed by a network pharmacy on the basis that the dispensed amount is a partial supply and the enrollee patient requests or agrees to a partial supply; and

(2) Authorize a network pharmacy to override any denial codes indicating that a prescription is being refilled too soon.

(c) No policy, contract, plan, or agreement providing prescription drug coverage shall use payment structures incorporating prorated dispensing fees. Dispensing fees for partially filled or refilled prescriptions shall be paid in full for each prescription dispensed, regardless of any prorated copayment for the beneficiary or fee paid for medication synchronization services.

(d) A network pharmacy shall identify an anchor prescription to which all other prescriptions may be subject to medication synchronization; provided that any medication dispensed in an unbreakable package shall not be considered the anchor prescription for purposes of this section.

(e) No schedule II narcotic controlled substance listed in section 329-16 shall be eligible for medication synchronization.

(f) For purposes of this section:

"Medication synchronization" means the coordination of medication refills that are being dispensed by a single contracted pharmacy to an enrollee patient taking two or more medications for one or more chronic conditions so that the patient's medications are refilled on the same schedule for a given time period.

"Unbreakable package" means a medication form or package that is to be dispensed in its original container. The term "unbreakable package" includes but is not limited to eye drops, inhalers, creams, and ointments. [L 2018, c 197, §4]
Haw. Rev. Stat. § 431P-7 — HI Code / Division 2 / Title 24 / Chapter 431P / Section 431P-7
Plan of operation.
Status: in_force

(a) The fund shall adopt a plan of operation and a manual of rules and rates necessary or suitable to ensure both the solvency and the reasonable and equitable administration of the fund. The adoption of or amendments to the plan of operation and manual of rules and rates shall not be subject to chapter 91, except that the policy forms for policies of hurricane property insurance shall be adopted pursuant to chapter 91.

(b) If the fund fails to adopt a plan of operation, or the fund fails to adopt amendments to the plan of operation, the commissioner shall adopt a plan of operation or make amendments necessary to carry out the purposes of this chapter. Any plan of operation, or amendment, adopted by rule of the commissioner, shall continue in full force and effect until the rule is superseded by a plan of operation, or amendment, adopted by a majority vote of all members of the fund's board, and approved by the commissioner.

(c) The plan of operation:

(1) Shall establish procedures for performance of all powers and duties of the fund;

(2) Shall establish procedures for providing notice to all persons with interests insurable by the fund in the State of the type of insurance available from the fund if the fund offers insurance;

(3) Shall provide for and adopt all necessary forms, including insurance policies to be used by and on behalf of the fund, for use by the fund and servicing facilities;

(4) Shall adopt actuarially sound rates, based on reasonable assumptions relative to expectations of hurricane frequency and severity, to be charged for insurance provided by the fund, in accordance with article 14 of chapter 431;

(5) Shall publish manuals of rules, rates, and rating and classification plans, which shall address mandatory deductibles, limits of coverage, and the classification of risks and rate modifications based on the exposure of insureds, subject to the approval of the commissioner;

(6) Shall establish procedures for receiving and servicing applications to the fund;

(7) Shall establish procedures for processing and maintaining records of the fund relating to its financial transactions, its agents, its employees, its operations, and all transactions with any servicing facility;

(8) Shall establish procedures for the collection and remittance of the premiums and return of unearned premiums where applicable;

(9) Shall establish procedures for the payment of valid claims;

(10) Shall establish procedures for prorating available funds pursuant to section 431P-15;

(11) Shall establish procedures for obtaining reinsurance;

(12) Shall establish procedures to borrow funds;

(13) Shall develop a plan for the investment of moneys held by the fund;

(14) Shall require, prior to issuance or renewal of coverage, the applicant for condominium insurance coverage or renewal to:

(A) Cause to be completed an inspection of the applicable condominium; provided that the inspection shall be consistent with any inspection and reporting standards established by the board and incorporated into the plan of operation; and

(B) Satisfy any relevant requirements established by the board and incorporated into the plan of operation; and

(15) May prohibit coverage under this chapter for any high-rise condominium for which the fund or its servicing entities or any agents thereof have identified maintenance issues materially affecting the insurability of the high-rise condominium for hurricane property insurance. [L 1993, c 339, pt of §2; am L Sp 1995, c 17, §3; am L 2025, c 296, §13]
Haw. Rev. Stat. § 432C-6 — HI Code / Division 2 / Title 24 / Chapter 432C / Section 432C-6
For-profit entity; after conversion.
Status: in_force

After conversion, the for-profit entity shall not be subject to this chapter, but if a stock insurance company, shall be in conformance with title 24.
Haw. Rev. Stat. § 432D-26 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-26
Genetic information nondiscrimination in health insurance coverage.
Status: in_force

(a) No health maintenance organization may:

(1) Use an individual's or a family member's genetic information, or request for genetic services, to deny or limit any coverage or establish eligibility, continuation, enrollment, or premium payments;

(2) Request or require collection or disclosure of an individual's or a family member's genetic information; or

(3) Disclose an individual's or a family member's genetic information without the written consent of the person affected, the person's legal guardian, or a person with power of attorney for health care for the person affected. This consent shall be required for each disclosure and shall include the name of each person or organization to whom the disclosure will be made.

(b) As used in this section:

"Family member" means, with respect to the individual, another individual related by blood to that individual.

"Genetic information" means information about genes, gene products, hereditary susceptibility to disease, or inherited characteristics that may derive from the individual or family member.

"Genetic services" means health services to obtain, assess, or interpret genetic information for diagnosis, therapy, and genetic counseling. [L 1997, c 91, §3]
Haw. Rev. Stat. § 432E-8 — HI Code / Division 2 / Title 24 / Chapter 432E / Section 432E-8
Enforcement.
Status: in_force

All remedies, penalties, and proceedings in articles 2 and 13 of chapter 431 made applicable hereby to managed care plans shall be invoked and enforced solely and exclusively by the commissioner.
Haw. Rev. Stat. § 431P-10 — HI Code / Division 2 / Title 24 / Chapter 431P / Section 431P-10
Coverage available from the fund; deductible.
Status: in_force

Coverage limits and deductibles for policies issued by the fund covering eligible property shall be established in the plan of operation, subject to approval by the commissioner.
Haw. Rev. Stat. § 432D-32 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-32
[ §432D-32] Prohibition of preexisting condition exclusions.
Status: in_force

[ §432D-32] Prohibition of preexisting condition exclusions. (a) No individual or group health maintenance organization policy, contract, plan, or agreement issued or renewed in this State shall impose any preexisting condition exclusion.

(b) For purposes of this section, a "preexisting condition exclusion" means a limitation or exclusion of benefits, including a denial of coverage, based on the fact that the condition was present before the effective date of coverage (or if coverage is denied, the date of the denial) under an individual or group health maintenance organization policy, contract, plan, or agreement, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that day and includes any condition.

The term "preexisting condition exclusion" includes any limitation or exclusion of benefits, including a denial of coverage, applicable to an individual as a result of information relating to an individual's health status before the individual's effective date of coverage (or if coverage is denied, the date of the denial) under an individual or group health maintenance organization policy, contract, plan, or agreement, such as a condition identified as a result of a pre-enrollment questionnaire or physical examination given to the individual, or review of medical records relating to the pre-enrollment period. [L 2018, c 111, pt of §5]
Haw. Rev. Stat. § 431P-19 — HI Code / Division 2 / Title 24 / Chapter 431P / Section 431P-19
Recoupment of assessments paid.
Status: in_force

(a) Subject to the approval of the commissioner, each licensed property and casualty insurer shall annually recoup assessments paid by the licensed property and casualty insurer under sections 431P-5(b)(8)(A) and (B) and 431P-16(d). The recoupment shall be recovered by means of a surcharge on premiums charged by the licensed property and casualty insurer for policies on which the assessment was made. Any excess recovery by a licensed property and casualty insurer shall be credited pro rata to that insurer's policyholders' premiums in the succeeding year unless there has been a subsequent assessment, in which case the excess shall be used to pay the amount of the subsequent assessment. A licensed property and casualty insurer may continue to collect a surcharge on premiums until the full assessments are recouped.

(b) The surcharge required under subsection (a) shall be the same percentage of the total premiums charged for each policy assessed under sections 431P-5(b)(8)(A) and (B) and 431P-16(d).

(c) Each licensed property and casualty insurer shall provide to the fund an accounting of its recoupments. The fund shall compile the licensed property and casualty insurers' accountings and submit the accountings as part of the fund's annual report to the commissioner.

(d) The amount of and reason for any surcharge shall be separately stated on any billing sent to an insured. The surcharge shall not be considered a premium for any other purpose, including the computation of gross premium tax or the determination of producer commissions. [L 2025, c 296, pt of §8]
Haw. Rev. Stat. § 431N-4 — HI Code / Division 2 / Title 24 / Chapter 431N / Section 431N-4
Transfer of funds.
Status: in_force

The department of health shall have the authority to utilize funds appropriated under this chapter to directly purchase services in accordance with chapter 103F when it is determined that such a purchase is more effective and cost efficient in meeting the goals of this chapter. The department of health shall also have the authority to transfer funds appropriated under this chapter to the department of human services. The department of human services may receive and apply such funds for the purpose of maximizing medical care services to gap group individuals under the medicaid program contained in the medicaid state plan. The departments of health and human services shall develop and implement an interagency working agreement necessary to carry out the purpose of this section.
Haw. Rev. Stat. § 432E-6.5 — HI Code / Division 2 / Title 24 / Chapter 432E / Section 432E-6.5
Expedited internal appeal, when authorized; standard for decision.
Status: in_force

(a) An enrollee may request that the internal appeal under section 432E-5 be conducted as an expedited appeal. If a request for expedited appeal is approved by the health carrier, the appropriate internal appeal shall be completed within seventy-two hours of receipt of the request for expedited appeal.

(b) An expedited appeal shall be authorized if the application of the sixty day standard review time frame may:

(1) Seriously jeopardize the life or health of the enrollee;

(2) Seriously jeopardize the enrollee's ability to gain maximum functioning; or

(3) Subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the expedited appeal.

(c) The decision as to whether an enrollee's complaint is an expedited appeal shall be made by applying the standard of a reasonable individual who is not a trained health professional. The decision may be made for the managed care plan by an individual acting on behalf of the managed care plan. If a licensed health care provider with knowledge of a claimant's medical condition requests an expedited appeal on behalf of an enrollee, the request shall be treated as an expedited appeal. [L 2000, c 250, §2; am L 2004, c 27, §2; am L 2011, c 230, §§8, 9]
Haw. Rev. Stat. § 431K-7.1 — HI Code / Division 2 / Title 24 / Chapter 431K / Section 431K-7.1
Registration fees and service fees of purchasing groups.
Status: in_force

(a) A purchasing group that intends to do business in this State shall pay an initial registration fee of $300 to the commissioner and shall thereafter pay annually a service fee of $150 on or before the extension date of the certificate of authority, as established pursuant to section 431:3-214. The commissioner may, upon showing of good cause, waive or modify, in whole or part, all fees in this subsection by order.

(b) If the service fee is not paid on or before August 16 of the year in which payment is due, a penalty shall be imposed in the amount of fifty per cent of the service fee. The commissioner shall provide written notice of the delinquency of payment and the imposition of the authorized penalty. If the service fee and the penalty are not paid within thirty days immediately following the date of the notice of delinquency, the commissioner may revoke the registration of the purchasing group and may not reinstate the registration until the service fee and the penalty have been paid. [L 2015, c 63, pt of §1; am L 2021, c 110, §16]
Haw. Rev. Stat. § 431K-1 — HI Code / Division 2 / Title 24 / Chapter 431K / Section 431K-1
Definitions.
Status: in_force

As used in this chapter:

"Board of directors" or "board" means the governing body of the risk retention group elected by the shareholders or members to establish policy, elect or appoint officers and committees, and make other governing decisions.

"Commissioner" means the insurance commissioner of this State.

"Completed operations liability" means liability arising out of the installation, maintenance, or repair of any product at a site which is not owned or controlled by any person who:

(1) Performs that work; or

(2) Hires an independent contractor to perform that work; but shall include liability for activities which are completed or abandoned before the date of the occurrence giving rise to the liability.

"Director" means a natural person designated in the articles of the risk retention group or designated, elected, or appointed by any other manner, name, or title to act as a director.

"Domicile", for purposes of determining the state in which a purchasing group is domiciled, means:

(1) For a corporation, the state in which the purchasing group is incorporated; or

(2) For an unincorporated entity, the state of its principal place of business.

"Financially impaired" means that a risk retention group:

(1) Has admitted assets that are less than the sum of its aggregate liabilities and the amount of surplus to policyholders required to be maintained by a risk retention group chartered in this State and authorized to do the same kind or kinds of insurance; or

(2) Has admitted assets that are less than the sum of its aggregate liabilities and outstanding capital stock; or

(3) Is insolvent.

"Hazardous financial condition" means that, based on its present or reasonably anticipated financial condition, a risk retention group, although not yet financially impaired or insolvent, is unlikely to be able to:

(1) Meet obligations to policyholders with respect to known claims and reasonably anticipated claims; or

(2) Pay other obligations in the normal course of business.

"Insolvent" means that a risk retention group has admitted assets that are less than the aggregate amount of its liabilities.

"Insurance" means primary insurance, excess insurance, reinsurance, surplus lines insurance, and any other arrangement for shifting and distributing risk which is determined to be insurance under the laws of this State.

"Liability" means legal liability for damages, including costs of defense, legal costs and fees, and other claims expenses because of injuries to other persons, damage to their property, or other damage or loss to those other persons resulting from or arising out of:

(1) Any business, whether for profit or nonprofit, trade, product, services, including professional services, premises, or operations; or

(2) Any activity of any state or county government, or any agency or political subdivision;

but does not include personal risk liability and an employer's liability with respect to its employees other than legal liability under the Federal Employers' Liability Act, 45 U.S.C. §51 et seq.

"Personal risk liability" means liability for damages because of injury to any person, damage to property, or other loss or damage resulting from any personal, familial, or household responsibilities or activities, rather than from responsibilities or activities referred to in paragraphs (1) and (2) in the definition of "liability".

"Plan of operation" or "feasibility study" means an analysis which presents the expected activities and results of a risk retention group including, not less than the following:

(1) The coverages, deductibles, coverage limits, rates, and rating classification systems for each line of insurance the group intends to offer;

(2) Historical and expected loss experience of the proposed members and national experience of similar exposures to the extent that this experience is reasonably available;

(3) Pro forma financial statements and projections;

(4) Appropriate opinions by a qualified, independent casualty actuary, including a determination of minimum premiums or participation levels required to commence operations and to prevent a hazardous financial condition;

(5) Identification of management, underwriting procedures, managerial oversight methods, investment policies;

(6) Identification of each state in which the risk retention group has obtained, or sought to obtain, a charter and license, and a description of its status in each state; and

(7) Other matters as may be prescribed by the commissioner for liability insurance companies authorized by the insurance laws of the state in which the risk retention group is chartered.

"Product liability" means liability for damages because of any personal injury, death, emotional harm, consequential economic damage, or property damage, including damages resulting from the loss of use of property, arising out of the manufacture, design, importation, distribution, packaging, labeling, lease, or sale of a product, but does not include the liability of any person for those damages if the product involved was in the possession of the person when the incident giving rise to the claim occurred.

"Purchasing group" means any group which:

(1) Has as one of its purposes the purchase of liability insurance on a group basis;

(2) Purchases this insurance only for its group members and only to cover their similar or related liability exposure, as described in [paragraph (3)];

(3) Is composed of members whose businesses or activities are similar or related with respect to the liability to which members are exposed by virtue of any related, similar, or common business, trade, product, services, premises, or operations; and

(4) Is domiciled in any state.

"Risk retention group" means any corporation or other limited liability association formed under the laws of any state, Bermuda, or the Cayman Islands:

(1) Whose primary activity consists of assuming and spreading all, or any portion, of the liability exposure of its group members;

(2) Which is organized for the primary purpose of conducting the activity described under paragraph (1);

(3) Which:

(A) Is chartered and licensed as a liability insurance company and authorized to engage in the business of insurance under the laws of any state; or

(B) Before January 1, 1985, was chartered or licensed and authorized to engage in the business of insurance under the laws of Bermuda or the Cayman Islands and, before this date, had certified to the insurance commissioner of at least one state that it satisfied the capitalization requirements of that state, except that any group shall be considered to be a risk retention group only if the group has been engaged in business continuously since this date and only for the purpose of continuing to provide insurance to cover product liability or completed operations liability, as defined in the Product Liability Risk Retention Act of 1981, 15 U.S.C. §3901 et seq., before the date of the enactment of the Liability Risk Retention Act of 1986, P.L. 99-563;

(4) Which does not exclude any person from membership in the group solely to provide for members of the group a competitive advantage over the person;

(5) Which has as its:

(A) Members only persons who have an ownership interest in the group and that has as its owners only persons who are members who are provided insurance by the risk retention group; or

(B) Sole member and sole owner an organization that is owned by persons who are provided insurance by the risk retention group;

(6) Whose members are engaged in business or activities similar or related to the liability of which these members are exposed by virtue of any related, similar, or common business trade, product, services, premises, or operations;

(7) Whose activities do not include the provision of insurance other than:

(A) Liability insurance for assuming and spreading all or any portion of the liability for its group members; and

(B) Reinsurance with respect to the liability of any other risk retention group, or any members of another group, which is engaged in businesses or activities so that this group or member meets the requirement described in paragraph (6) for membership in the risk retention group that provides this reinsurance; and

(8) The name of which includes the phrase "risk retention group".

"State" means any state of the United States or the District of Columbia. [L 1987, c 180, pt of §1; am L 1989, c 272, §§2, 3; am L 1997, c 368, §8; am L 2004, c 122, §80; am L 2016, c 140, §3]
Haw. Rev. Stat. § 432D-1 — HI Code / Division 2 / Title 24 / Chapter 432D / Section 432D-1
Definitions.
Status: in_force

For purposes of this chapter:

"Basic health care services" means the following medical services: preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory services, and diagnostic and therapeutic radiological services. It does not include mental health services, services for alcohol or drug abuse, dental or vision services, or long-term rehabilitation treatment, except as provided in chapter 431M.

"Capitated basis" means fixed per member per month payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value, or frequency of services provided. For purposes of this definition, capitated basis includes the cost associated with operating staff model facilities.

"Carrier" means a health maintenance organization, an insurer, a nonprofit hospital and medical service corporation, a mutual benefit society, or other entity responsible for the payment of benefits or provision of services under a group contract.

"Commissioner" means the insurance commissioner.

"Copayment" means an amount an enrollee must pay to receive a specific service which is not fully prepaid.

"Deductible" means the amount an enrollee is responsible to pay out-of-pocket before the health maintenance organization begins to pay the costs associated with treatment.

"Enrollee" means an individual who is covered by a health maintenance organization.

"Evidence of coverage" means a statement of the essential features and services of the health maintenance organization coverage that is given to the subscriber by the health maintenance organization or by the group contract holder.

"Extension of benefits" means the continuation of coverage under a particular benefit provided under a contract following termination with respect to an enrollee who is totally disabled on the date of termination.

"Grievance" means a written complaint submitted in accordance with the health maintenance organization's formal grievance procedure by or on behalf of the enrollee regarding any aspect of the health maintenance organization relative to the enrollee.

"Group contract" means a contract for health care services which by its terms limits eligibility to members of a specified group. The group contract may include coverage for dependents.

"Group contract holder" means the person to which a group contract has been issued.

"Health maintenance organization" means any person that undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments, deductibles, or both.

"Individual contract" means a contract for health care services issued to and covering an individual. The individual contract may include dependents of the subscriber.

"Insolvent" or "insolvency" means that the health maintenance organization has been declared insolvent and placed under an order of supervision, rehabilitation, or liquidation by a court of competent jurisdiction.

"Managed hospital payment basis" means agreements wherein the financial risk is primarily related to the degree of utilization rather than to the cost of services.

"Net worth" means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt.

"Participating provider" means a provider as defined in this section, who, under an express or implied contract with the health maintenance organization or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment or deductible, directly or indirectly from the health maintenance organization.

"Person" means any natural or artificial person including but not limited to individuals, partnerships, associations, trusts, or corporations.

"Provider" means any physician, hospital, or other person licensed or otherwise authorized to furnish health care services.

"Replacement coverage" means the benefits provided by a succeeding carrier.

"Subscriber" means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the health maintenance organization, or in the case of an individual contract, the person in whose name the contract is issued.

"Uncovered expenditures" means the costs to the health maintenance organization for health care services that are the obligation of the health maintenance organization, for which an enrollee may also be liable in the event of the health maintenance organization's insolvency, and for which no alternative arrangements have been made that are acceptable to the commissioner. Uncovered expenditures include but are not limited to out-of-area services, referral services, and hospital services. Uncovered expenditures do not include expenditures for services when a provider has agreed not to bill the enrollee even though the provider is not paid by the health maintenance organization, or for services that are guaranteed, insured, or assumed by a person or organization other than the health maintenance organization. [L 1995, c 179, pt of §1; am L 2014, c 186, §15]
Haw. Rev. Stat. § 435E-21 — HI Code / Division 2 / Title 24 / Chapter 435E / Section 435E-21
Retirement of member.
Status: in_force

A participating member who is then in full compliance with the trust agreement and who has reached the age of sixty-five and who has retired completely from the practice of medicine may elect to retire from the interindemnity arrangement, in which case the member shall not be responsible for assessments levied following the date notice of retirement is given to the trust. Following retirement, the indemnity coverage shall continue for the benefit of the member in respect of occurrences prior to the time the member retired from the interindemnity arrangement. The retired member's initial contribution shall be repaid ten years from the date the notice of retirement is received by the trust, or such earlier date as specified in the trust agreement.
Haw. Rev. Stat. § 431C-3 — HI Code / Division 2 / Title 24 / Chapter 431C / Section 431C-3
Licensing requirements.
Status: in_force

(a) No person, wherever located, shall act as a provider or broker with an owner who is a resident of this State, without first having obtained a license from the commissioner.

(b) Application for a provider or broker license shall be made to the commissioner by the applicant on a form prescribed by the commissioner, and the application shall be accompanied by a fee in the amount provided by section 431:7-101.

(c) A person, wherever located, may act as a broker with an owner who is a resident of this State, if the person is a life insurance producer who has been duly licensed as a resident insurance producer with a life line of authority in this State or the producer's home state for at least one year and is issued a broker license in this State.

(d) Not later than thirty days from the first day of operating as a broker, the life insurance producer shall notify the commissioner that the life insurance producer is acting as a broker on a form prescribed by the commissioner, and shall pay a fee in the amount provided by section 431:7-101. Notification shall include an acknowledgment by the life insurance producer that the life insurance producer will operate as a broker in accordance with this chapter.

(e) The insurer that issued the policy that is the subject of a life settlement contract shall not be responsible for any act or omission of a broker, provider, or purchaser, arising out of or in connection with the life settlement transaction, unless the insurer receives compensation for the placement of a life settlement contract from the provider, purchaser, or broker in connection with the life settlement contract.

(f) A person licensed as an attorney, certified public accountant, or financial planner accredited by a nationally recognized accreditation agency, who is retained to represent the owner in the type of practice customarily performed in the person's professional capacity, and whose compensation is not paid directly or indirectly by the provider or purchaser, may negotiate life settlement contracts on behalf of the owner without obtaining a license as a broker.

(g) Licenses are issued and renewed in accordance with article 9A of chapter 431 upon payment of fees in the amounts required under section 431:7-101. Failure to pay the fees within the terms prescribed shall result in the automatic inactivation of the license.

(h) The applicant shall provide such information as the commissioner may require on forms prepared by the commissioner. The commissioner shall have authority, at any time, to require such applicant to fully disclose the identity of its stockholders, other than stockholders owning fewer than ten per cent of the shares of an applicant whose shares are publicly traded, and the identity of its partners, officers, and employees. The commissioner may, in the exercise of the commissioner's sole discretion, refuse to issue such a license in the name of any person if not satisfied that any officer, employee, identified stockholder, or partner thereof who may materially influence the applicant's conduct meets the standards under subsection (j).

(i) A provider license issued to a partnership, corporation, or other entity authorizes all members, officers, and designated employees to act as a licensee under the license, if those persons are named in the application and any supplements to the application. A business entity licensed pursuant to this subsection shall designate an individual who is responsible for the actions of the entity and its agents. The designated individual shall be licensed pursuant to this chapter.

(j) Upon the filing of an application and the payment of the license fee, the commissioner shall make an investigation of each applicant and may issue a provider or a broker license if the commissioner finds that the applicant:

(1) If a provider, has provided a detailed plan of operation;

(2) Is competent and trustworthy and intends to transact its business in good faith;

(3) Has a good business reputation and has had experience, training, or education so as to be qualified in the business for which the license is applied;

(4) If a legal entity, is formed or organized pursuant to the laws of this State or is a foreign legal entity authorized to transact business in this State, or provides a certificate of good standing from the state of its domicile; and

(5) Has provided to the commissioner an anti-fraud plan that meets the requirements of section 431C-48.

(k) Each licensed nonresident broker or provider shall appoint the commissioner as its agent to receive service of legal process issued against the broker or provider in this State upon causes of action arising within this State. Service upon the commissioner as agent shall constitute effective legal service upon the broker or provider. The appointment shall be irrevocable for as long as there could be any cause of action against the broker or provider arising out of the broker's or provider's insurance transactions in this State. Service of process on the commissioner shall be made in accordance with section 431:2-206.

(l) Each licensee shall file with the commissioner on or before the first day of March of each year an annual statement containing the information as the commissioner by rule may prescribe.

(m) A provider may not use any person to perform the functions of a broker unless the person holds a current, valid license as a broker.

(n) A broker may not use any person to perform the functions of a provider as defined in this chapter unless such person holds a current, valid license as a provider, and as provided in this section.

(o) A provider or broker shall provide to the commissioner new or revised information about officers, ten per cent or more stockholders, partners, directors, members, or designated employees within thirty days of the change. [L 2012, c 256, pt of §1]
Haw. Rev. Stat. § 435E-46 — HI Code / Division 2 / Title 24 / Chapter 435E / Section 435E-46
Attendance and testimony.
Status: in_force

No person is excused from attending or testifying or from producing any document or record before the commissioner, or in obedience to the subpoena of the commissioner or any officer designated by the commissioner, or in any proceeding instituted by the commissioner, on the ground that the testimony or evidence (documentary or otherwise) required of the person may tend to incriminate the person or subject the person to a penalty or forfeiture; but no individual may be prosecuted or subjected to any penalty or forfeiture for or on account of any transaction, matter, or thing concerning which the individual is compelled, after validly claiming the individual's privilege against self-incrimination, to testify or produce evidence (documentary or otherwise), except that the individual testifying is not exempt from prosecution and punishment for perjury or contempt committed in testifying.
Haw. Rev. Stat. § 435E-3 — HI Code / Division 2 / Title 24 / Chapter 435E / Section 435E-3
Rules.
Status: in_force

The commissioner may adopt, amend, and repeal rules necessary to implement this chapter, subject to chapter 91.
Haw. Rev. Stat. § 431P-14 — HI Code / Division 2 / Title 24 / Chapter 431P / Section 431P-14
Immunity and limitation on liability.
Status: in_force

There shall be no liability on the part of, and no cause of action of any nature shall arise against, any servicing facility or its authorized insurance producers; the fund or its agents, employees, or board; the State; the commissioner; or the commissioner's representatives for any action taken by them in the performance of their powers and duties under this chapter; provided that this section shall not be construed to prohibit any exercise of the commissioner's power pursuant to this chapter or any other law or rule adopted pursuant to law or chapters 661 and 662, any other law to the contrary notwithstanding. Nothing in this chapter shall create an obligation, debt, claim, cause of action, claim for relief, charge, or any other liability of any kind whatsoever in favor of any person or entity without regard to whether that person or entity received any benefits under this chapter, against the State, or its officers and employees. The State and its officers and employees shall not be liable for the results of any application, denial of application, claim, loss, or other benefits provided by the fund pursuant to this chapter. Nothing in this chapter shall be construed as authorizing any claim against the State whatsoever, nor shall this chapter be construed as authorizing any claim against the fund in excess of any note, loan, liability, or other obligation incurred by the fund. Nothing in this section shall be construed to alter any obligation to pay assessments or charges authorized to be imposed or levied by the board pursuant to this chapter. The fund shall be subject to chapter 431 only as provided for in this chapter.
Haw. Rev. Stat. § 435E-15 — HI Code / Division 2 / Title 24 / Chapter 435E / Section 435E-15
Funds, investment.
Status: in_force

All funds held in trust which are in excess of current financial needs shall be invested and reinvested from time to time, under the direction of the board of trustees, in a manner consistent with the requirements of article 8 of chapter 412, or in certificates of deposits or time deposits issued by banks, savings banks, savings and loan associations and depository financial services loan companies in Hawaii duly insured by instrumentalities of the United States government.
Haw. Rev. Stat. § 431L-1 — HI Code / Division 2 / Title 24 / Chapter 431L / Section 431L-1
Insurers prohibited from taking medicaid status into account.
Status: in_force

Any health insurer (including a self-insured plan, a group health plan as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, a health service benefit plan, a mutual benefit society, a fraternal benefit society, a health maintenance organization, a managed care organization, a pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service) is prohibited, in enrolling an individual or in making any payments for benefits to the individual or on the individual's behalf, from taking into account that the individual is eligible for or is provided medical assistance under title 42 United States Code section 1396a (section 1902 of the Social Security Act) herein referred to as medicaid, for this State, or any other state.
Haw. Rev. Stat. § 435E-44 — HI Code / Division 2 / Title 24 / Chapter 435E / Section 435E-44
Hearing, subpoena.
Status: in_force

For the purpose of any investigation or proceeding, the commissioner or any person designated by the commissioner may hold hearings subject to chapter 91.
Haw. Rev. Stat. § 431K-4 — HI Code / Division 2 / Title 24 / Chapter 431K / Section 431K-4
Compulsory associations.
Status: in_force

(a) No risk retention group shall be permitted to join or contribute financially to any insurance insolvency guaranty fund, or similar mechanism, in this State, nor shall any risk retention group or its insureds receive any benefit from any such fund for claims arising out of the operations of such risk retention group.

(b) When a purchasing group obtains insurance covering its members' risks from an insurer not authorized in this State or a risk retention group, no such risks wherever resident or located shall be covered by any insurance insolvency guaranty fund or similar mechanism in this State.

(c) When a purchasing group obtains insurance covering its members' risks from an insurer authorized in Hawaii, claims shall be covered by the property and liability insurance guaranty association, subject to the provisions of chapter 431, article 16.

(d) A risk retention group shall participate in this State's joint underwriting associations and mandatory liability pools as provided by any law of this State. [L 1987, c 180, pt of §1; am L 1989, c 272, §5]
Haw. Rev. Stat. § 431P-2 — HI Code / Division 2 / Title 24 / Chapter 431P / Section 431P-2
Establishment of Hawaii hurricane relief fund.
Status: in_force

There shall be a Hawaii hurricane relief fund to be placed within the department of commerce and consumer affairs for administrative purposes. The fund shall be a public body and a body corporate and politic. Any applicant for insurance from the fund shall provide proof, to the satisfaction of the board, of the inability to obtain hurricane property insurance from insurers licensed to transact business in the State.