H.B. 4080 (H-3): COMMITTEE SUMMARY - HMO EMERGENCY SERVICES

House Bill 4080 (Substitute H-3 as passed by the House)

Sponsor: Representative Penny Crissman

House Committee: Insurance

Senate Committee: Health Policy and Senior Citizens

Date Completed: 9-23-97

CONTENT

The bill would amend Part 210 of the Public Health Code, which governs health maintenance organizations (HMOs), to define "emergency health services", and to forbid an HMO from denying payment for emergency health services under circumstances specified in the bill.

Currently, Part 210 requires a contract between an HMO and a subscriber or group of subscribers to provide, at a minimum, primary health maintenance services. Primary health maintenance services, as specified in Part 210, include several types of health services including emergency health services; however, emergency health services are not defined.

The bill provides that "emergency health services" would mean medically necessary services provided to an enrollee for the sudden onset of a medical condition that manifested itself by signs and symptoms of sufficient severity (including severe pain), such that in the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health (or to a pregnancy in the case of a pregnant women); serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

An HMO could not deny payment for emergency health services up to the point of "stabilization" provided to an enrollee because of the final diagnosis or because the HMO had not given prior authorization before emergency health services were provided. "Stabilization" would mean the point at which no material deterioration of a condition was likely, within reasonable medical probability, to result from or occur during transfer of the patient.

MCL 333.21004 - Legislative Analyst: G. Towne

FISCAL IMPACT

This language appears to be substantively similar to that included in Section 4704 (Increased Beneficiary Protections) of the Federal Balanced Budget Act of 1997. Section 4704 is applicable to managed care organizations serving Medicaid recipients and is not expected to have any fiscal impact.

Likewise, House Bill 4080 (H-3) would apply to all other enrollees of health maintenance organizations (HMOs), including Medicaid enrollees, and appears to be cost neutral.

Note: As used in the case, "cost neutral" refers to the total health care system's cost. To the extent that such payment practices exist, the impact of this bill would be to shift costs from the enrollee to the HMO.

- Fiscal Analyst: J. Walker

S9798\S4080SA

This analysis was prepared by nonpartisan Senate staff for use by the Senate in its deliberations and does not constitute an official statement of legislative intent.