HRS §393-1 Short title
393-1. Short title
This chapter shall be known as the "Hawaii Prepaid Health Care Act".
L 1974, c
210, pt of §1
Short Title; Purpose; Definitions
HRS div. 1, tit. 21, ch. 393, pt. I
in effectHRS §393-2 Findings and purpose
393-2. Findings and purpose
The cost of medical care in case of sudden need may consume all or an excessive part of a person's resources. Prepaid health care plans offer a certain measure of protection against such emergencies. It is the purpose of this chapter in view of the spiraling cost of comprehensive medical care to provide this type of protection for the employees in this State. Although a large segment of the labor force in the State already enjoys coverage of this type either by virtue of collective bargaining agreements, employer-sponsored plans, or individual initiative, there is a need to extend that protection to workers who at present do not possess any or possess only inadequate prepayment coverage.
This chapter shall not be construed to diminish
any protection already provided pursuant to collective bargaining agreements or
employer-sponsored plans that is more favorable to the employees benefited
thereby than the protection provided by this chapter or at least equivalent
thereto, provided that presently existing collective bargaining agreements
shall not be affected by the provisions of this section.
[L 1974, c 210, pt of
§1; am L 1978, c 199, §1]
HRS §393-3 Definitions generally
393-3. Definitions generally
As used in this chapter, unless the context clearly requires otherwise:
"Department" means the department of
labor and industrial relations.
"Director" means the director of
labor and industrial relations.
"Employer" means any individual or
type of organization, including any partnership, association, trust, estate,
joint stock company, insurance company, or corporation, whether domestic or
foreign, a debtor in possession or receiver or trustee in bankruptcy, or the
legal representative of a deceased person, who has one or more regular
employees in the employer's employment. "Employer" does not include:
(1) The State, any of its political subdivisions, or
any instrumentality of the State or its political subdivisions;
(2) The United States government or any
instrumentality of the United States;
(3) Any other state or political subdivision thereof
or instrumentality of such state or political subdivision;
(4) Any foreign government or instrumentality wholly
owned by a foreign government, if[:]
(A) The service performed in its employ is of
a character similar to that performed in foreign countries by employees of the
United States government or of an instrumentality thereof; and
(B) The United States Secretary of State has
certified or certifies to the United States Secretary of the Treasury that the
foreign government, with respect to whose instrumentality exemption is claimed,
grants an equivalent exemption with respect to similar service performed in the
foreign country by employees of the United States government and of
instrumentalities thereof.
"Employment" means service, including
service in interstate commerce, performed for wages under any contract of hire,
written or oral, expressed or implied, with an employer, except as otherwise
provided in sections 393-4 and 393-5.
"Premium" means the amount payable to
a prepaid health care plan contractor as consideration for the contractor's
obligations under a prepaid health care plan.
"Prepaid health care plan" means any
agreement by which any prepaid health care plan contractor undertakes in
consideration of a stipulated premium:
(1) Either to furnish health care, including
hospitalization, surgery, medical or nursing care, drugs or other restorative
appliances, subject to, if at all, only a nominal per service charge; or
(2) To defray or reimburse, in whole or in part, the
expenses of health care.
"Prepaid health care plan contractor"
means:
(1) Any medical group or organization which
undertakes under a prepaid health care plan to provide health care;
(2) Any nonprofit organization which undertakes under
a prepaid health care plan to defray or reimburse in whole or in part the
expenses of health care; or
(3) Any insurer who undertakes under a prepaid health
care plan to defray or reimburse in whole or in part the expenses of health
care.
"Recipient of social service
payments" includes:
(1) A person who is an eligible recipient of social
services such as attendant care and day care services; and
(2) A corporation or private agency that contracts
directly with the department of human services to provide attendant care and
day care authorized under the Social Security Act, as amended.
"Regular employee" means a person
employed in the employment of any one employer for at least twenty hours per
week but does not include a person employed in seasonal employment.
"Seasonal employment" for the purposes of this paragraph means
employment in a seasonal pursuit as defined in section 387-1 by a seasonal
employer during a seasonal period or seasonal periods for the employer in the
seasonal pursuit or employment by an employer engaged in the cultivating,
harvesting, processing, canning, and warehousing of pineapple during its
seasonal periods. The director by rule and regulation may determine the kind
of employment that constitutes seasonal employment.
"Wages" means all remuneration for
services from whatever source, including commissions, bonuses, and tips and
gratuities paid directly to any individual by a customer of the individual's
employer, and the cash value of all remuneration in any medium other than cash.
The director may issue regulations for the
reasonable determination of the cash value of remuneration in any medium other
than cash.
If the employee does not account to the
employee's employer for the tips and gratuities received and is engaged in an
occupation in which the employee customarily and regularly receives more than
$20 a month in tips, the combined amount received by the employee from the
employee's employer and from tips shall be deemed to be at least equal to the
wage required by chapter 387 or a greater sum as determined by regulation of
the director.
"Wages" does not include the amount
of any payment specified in section 383-11 or 392-22 or chapter 386.
[L 1974, c
210, pt of §1; am L 1976, c 78, §1; gen ch 1985; am L 2007, c 259, §5]
HRS §393-4 Place of performance
393-4. Place of performance
"Employment" includes an individual's entire service, performed within or both within and without this State if:
(1) The service is localized in this State; or
(2) The service is not localized in any state but
some of the service is performed in this State and[:]
(A) The individual's base of operation, or,
if there is no base of operation, the place from which such service is directed
or controlled, is in the State; or
(B) The individual's base of operation or
place from which the service is directed or controlled is not in any state in
which some part of the service is performed but the individual's residence is
in this State.
[L 1974, c 210, pt of §1]
HRS §393-5 Excluded services
393-5. Excluded services
"Employment" as defined in section 393-3 does not include:
(1) Service performed by an individual in the employ
of an employer who, by the laws of the United States, is responsible for care
and cost in connection with such service;
(2) Service performed by an individual in the employ
of [the] individual's spouse, son, or daughter, and service performed by an
individual under the age of twenty-one in the employ of the individual's father
or mother;
(3) Service performed in the employ of a voluntary
employee's beneficiary association providing for the payment of life, sick,
accident, or other benefits to the members of the association or their
dependents or their designated beneficiaries, if:
(A) Admission to membership in the
association is limited to individuals who are officers or employees of the
United States government; and
(B) No part of the net earnings of the
association inures (other than through such payments) to the benefits of any
private shareholder or individual;
(4) Service performed by an individual for an
employer as an insurance agent or as an insurance solicitor if all service
performed by the individual for the employer is performed for remuneration by
way of commission;
(5) Service performed by an individual for an
employer as a real estate salesperson or as a real estate broker if all service
performed by the individual for the employer is performed for remuneration by
way of commission;
(6) Service performed by an individual who, pursuant
to the federal Economic Opportunity Act of 1964, is not subject to the
provisions of law relating to federal employment, including unemployment
compensation;
(7) Domestic in-home and community-based services for
persons with developmental and intellectual disabilities under the medicaid
home and community-based services program pursuant to title 42 Code of Federal
Regulations sections 440.180 and 441.300, and title 42 Code of Federal
Regulations, part 434, subpart A, as amended, or when provided through state
funded medical assistance to individuals ineligible for medicaid, and
identified as chore, personal assistance and habilitation, residential
habilitation, supported employment, respite, and skilled nursing services, as
the terms are defined and amended from time to time by the department of human
services, performed by an individual whose services are contracted by a
recipient of social service payments and who voluntarily agrees in writing to
be an independent contractor of the recipient of social service payments; and
(8) Domestic services, which include attendant care,
and day care services authorized by the department of human services under the
Social Security Act, as amended, or when provided through state-funded medical
assistance to individuals ineligible for medicaid, when performed by an
individual in the employ of a recipient of social service payments. For the
purposes of this paragraph only, a "recipient of social service
payments" is a person who is an eligible recipient of social services such
as attendant care or day care services.
[L 1974, c 210, pt of §1; am L 1978, c
110, §6; gen ch 1985; am L 1987, c 339, §4; am L 1989, c 217, §2; gen ch 1993;
am L 2007, c 259, §9; am L 2011, c 220, §15; am L 2012, c 157, §3 and c 158, §4]
HRS §393-6 Principal and secondary employer defined; coercion, interference, etc. prohibited
393-6. Principal and secondary employer defined; coercion, interference, etc. prohibited
If an individual is concurrently a regular employee of two or more employers as defined in this chapter, the principal employer shall be the employer who pays the individual the most wages; provided that if one of the employers, who does not pay the most wages, employs the regular employee for at least thirty-five hours per week, the employee shall determine which of the employers shall be the employee's principal employer. The employee's other employers are secondary employers. An employer so designated as the principal employer shall remain as such principal employer for one year or until change of employment, whichever is earlier.
If an individual is concurrently a regular
employee of a public entity which is not an employer as defined in section
393-3 and of an employer as defined in section 393-3 the latter shall be deemed
to be a secondary employer.
An employer who, directly or indirectly,
interferes with or coerces or attempts to coerce an employee in making a
determination under this section shall be subject to the penalty provided under
subsection 393-33(b).
[L 1974, c 210, pt of §1; am L 1975, c 51, §1; gen ch
1985]
HRS §393-7 Required health care benefits
393-7. Required health care benefits
(a) A prepaid health care plan shall qualify as a plan providing the mandatory health care benefits required under this chapter if it provides for health care benefits equal to, or medically reasonably substitutable for, the benefits provided by prepaid health plans of the same type, as specified in section 393-12(a)(1) or (2), which have the largest numbers of subscribers in the State. This applies to the types and quantity of benefits as well as to limitations on reimbursability, including deductibles, and to required amounts of co-insurance.
The director, after advice by the prepaid
health care advisory council, shall determine whether benefits provided in a
plan, other than the plan of the respective type having the largest numbers of
subscribers in the State, comply with the standards specified in this
subsection.
(b) A prepaid group health care plan shall
also qualify for the mandatory health care benefits required under this chapter
if it is demonstrated by the health care plan contractor offering such coverage
to the satisfaction of the director after advice by the prepaid health care
advisory council that the plan provides for sound basic hospital, surgical,
medical, and other health care benefits at a premium commensurate with the
benefits included taking proper account of the limitations, co-insurance features,
and deductibles specified in such plan. Coverage under a plan which provides
aggregate benefits that are more limited than those provided by plans
qualifying under subsection (a) shall be in compliance with section 393-11 only
if the employer contributes at least half of the cost of the coverage of
dependents under such plan.
(c) Subject to the provisions of subsections
(a) and (b) without limiting the development of medically more desirable
combinations and the inclusion of new types of benefits, a prepaid health care
plan qualifying under this chapter shall include at least the following benefit
types:
(1) Hospital benefits:
(A) In-patient care for a period of at least
one hundred twenty days of confinement in each calendar year covering:
(i) Room accommodations;
(ii) Regular and special diets;
(iii) General nursing services;
(iv) Use of operating room, surgical supplies,
anesthesia services, and supplies; and
(v) Drugs, dressings, oxygen, antibiotics, and
blood transfusion services; and
(B) Out-patient care:
(i) Covering use of out-patient hospital; and
(ii) Facilities for surgical procedures or
medical care of an emergency and urgent nature;
(2) Surgical benefits:
(A) Surgical services performed by a licensed
physician, as determined by plans meeting the standards of subsections (a) and
(b);
(B) After-care visits for a reasonable
period; and
(C) Anesthesiologist services;
(3) Medical benefits:
(A) Necessary home, office, and hospital
visits by a licensed physician;
(B) Intensive medical care while
hospitalized; and
(C) Medical or surgical consultations while
confined;
(4) Diagnostic laboratory services, x-ray films, and
radio-therapeutic services, necessary for diagnosis or treatment of injuries or
diseases;
(5) Maternity benefits, at least if the employee has
been covered by the prepaid health care plan for nine consecutive months prior
to the delivery; and
(6) Substance abuse benefits:
(A) Alcoholism and drug addiction are
illnesses and shall receive benefits as such. In-patient and out-patient
benefits for the diagnosis and treatment of substance abuse, including but not
limited to alcoholism and drug addiction, shall be specifically stated and
shall not be less than the benefits for any other illness, except as provided
in this subsection. Medical treatment of substance abuse shall not be limited
or reduced by restricting coverage to the mental health or psychiatric benefits
of a plan. However, any psychiatric services received as a result of the
treatment of substance abuse may be limited to the psychiatric benefits of the
plan;
(B) Out-patient benefits provided by a
physician, psychiatrist, or psychologist, without restriction as to place of
service; provided that health plans of the type specified in section 393-12(a)
shall retain for the contractor the option of:
(i) Providing the benefits in its own facility
and utilizing its own staff;
(ii) Contracting for the provision of these
benefits; or
(iii) Authorizing the patient to utilize outside
services and defraying or reimbursing the expenses at a rate not to exceed that
for provision of services utilizing the health contractor's own facilities and
staff;
(C) Detoxification and acute care benefits in
a hospital or any other public or private treatment facility, or portion
thereof, providing services especially for the detoxification of intoxicated
persons or drug addicts, which is appropriately licensed, certified, or
approved by the department of health in accordance with the standards
prescribed by The Joint Commission. In-patient benefits for detoxification and
acute care shall be limited in the case of alcohol abuse to three admissions
per calendar year, not to exceed seven days per admission, and shall be limited
in the case of other substance abuse to three admissions per calendar year, not
to exceed twenty-one days per admission; and
(D) Prepaid health plans shall not be
required to make reimbursements for care furnished by government agencies and
available at no cost to a patient, or for which no charge would have been made
if there were no health plan coverage.
(d) The prepaid health care advisory council
shall be appointed by the director and shall include representatives of the
medical and public health professions, representatives of consumer interests,
and persons experienced in prepaid health care protection; provided that a
person representing a health maintenance organization under chapter 432D, a
mutual benefit society issuing individual and group hospital or medical service
plans under chapter 432, or any other health care organization shall not be a
member. The membership of the council shall not exceed seven individuals.
[L
1974, c 210, pt of §1; am L 1976, c 25, §2; am L 2003, c 206, §2; am L 2020, c
70, §50]
Source: Hawaii State Legislature (capitol.hawaii.gov), via Internet Archive capturesURL: http://www.capitol.hawaii.gov/hrscurrent/Vol07_Ch0346-0398/HRS0393/HRS_0393-.htmFetched: 11/10/2026