HOUSE BILL No. 4080


     January 28, 1997, Introduced by Reps. Crissman, McBryde and Goschka and referred to the Committee on Insurance.


        A bill to amend 1978 PA 368, entitled

   "Public health code,"

   by amending section 21004 (MCL 333.21004), as amended by 1982 PA

   354, and by adding section 21053c.

               THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 1         Sec. 21004.  (1) "EMERGENCY HEALTH SERVICES" MEANS SERVICES

 2    PROVIDED TO AN ENROLLEE FOR A CONDITION, INCLUDING SEVERE PAIN,

 3    THAT A PRUDENT LAY PERSON POSSESSING AN AVERAGE KNOWLEDGE OF

 4    HEALTH AND MEDICINE COULD REASONABLY EXPECT TO RESULT IN SERIOUS

 5    IMPAIRMENT TO HIS OR HER HEALTH.

 6         (2) "Enrollee" means an individual who is entitled to

 7    receive health maintenance services under a health maintenance

 8    contract.

 9         SEC. 21053C.  (1) A HEALTH MAINTENANCE ORGANIZATION SHALL

10    PROVIDE COVERAGE IN EACH GROUP AND INDIVIDUAL CONTRACT FOR


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 1    MEDICALLY NECESSARY EMERGENCY HEALTH SERVICES UP TO THE POINT OF

 2    STABILIZATION PROVIDED TO AN ENROLLEE BY A NONPARTICIPATING EMER-

 3    GENCY DEPARTMENT IF EITHER OF THE FOLLOWING APPLIES:

 4         (A) DUE TO CIRCUMSTANCES BEYOND THE ENROLLEE'S CONTROL, THE

 5    ENROLLEE WAS UNABLE TO GO TO A PARTICIPATING EMERGENCY DEPARTMENT

 6    IN A TIMELY FASHION WITHOUT SERIOUS IMPAIRMENT TO HIS OR HER

 7    HEALTH.

 8         (B) A PRUDENT LAY PERSON POSSESSING AN AVERAGE KNOWLEDGE OF

 9    HEALTH AND MEDICINE WOULD HAVE REASONABLY BELIEVED THAT HE OR SHE

10    WOULD BE UNABLE TO GO TO A PARTICIPATING EMERGENCY DEPARTMENT IN

11    A TIMELY FASHION WITHOUT SERIOUS IMPAIRMENT TO HIS OR HER

12    HEALTH.

13         (2) A HEALTH MAINTENANCE ORGANIZATION SHALL PROVIDE COVERAGE

14    IN EACH GROUP AND INDIVIDUAL CONTRACT FOR MEDICALLY NECESSARY

15    SERVICES PROVIDED TO AN ENROLLEE BY A NONPARTICIPATING EMERGENCY

16    DEPARTMENT AFTER STABILIZATION OF THE ENROLLEE IF EITHER OF THE

17    FOLLOWING HAS OCCURRED:

18         (A) THE EMERGENCY PHYSICIAN CONTACTS THE HEALTH MAINTENANCE

19    ORGANIZATION IN A TIMELY FASHION TO SEEK PRIOR AUTHORIZATION FOR

20    ANY ADDITIONAL SERVICES BEYOND STABILIZATION THAT MAY BE PROMPTLY

21    REQUIRED OR ARE NEEDED TO EFFECT A SAFE TRANSFER OF THE

22    ENROLLEE.  AS USED IN THIS SUBDIVISION, "TIMELY FASHION" MEANS

23    EITHER OF THE FOLLOWING:

24         (i) THE EMERGENCY PHYSICIAN SUCCESSFULLY CONTACTED THE

25    HEALTH MAINTENANCE ORGANIZATION AND DID NOT RECEIVE A DENIAL FROM

26    THE PLAN WITHIN 30 MINUTES OF CONTACTING THE PLAN, UNLESS THE

27    PLAN CAN DOCUMENT THAT IT HAD MADE A GOOD FAITH EFFORT BUT WAS



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 1    UNABLE TO REACH THE EMERGENCY PHYSICIAN WITHIN 30 MINUTES AFTER

 2    RECEIVING THE REQUEST FOR AUTHORIZATION.

 3         (ii) THAT DESPITE A DOCUMENTED GOOD FAITH EFFORT BY THE

 4    EMERGENCY PHYSICIAN, HE OR SHE WAS UNABLE TO REACH THE ENROLLEE'S

 5    HEALTH MAINTENANCE ORGANIZATION WITHIN 30 MINUTES AFTER THE INI-

 6    TIAL EXAMINATION OF THE ENROLLEE OR, IF THE ENROLLEE NEEDED TO BE

 7    STABILIZED, WITHIN 30 MINUTES AFTER STABILIZATION.

 8         (B) THE HEALTH MAINTENANCE ORGANIZATION DOES NOT IMMEDIATELY

 9    ARRANGE FOR AN ALTERNATE PLAN OF TREATMENT FOR THE ENROLLEE IF

10    THE NONPARTICIPATING EMERGENCY PROVIDER AND THE ORGANIZATION

11    CANNOT COME TO AN AGREEMENT ON WHICH SERVICES ARE NECESSARY

12    BEYOND THOSE IMMEDIATELY NEEDED TO STABILIZE THE ENROLLEE.

13         (3) AS USED IN THIS SECTION, "STABILIZATION" MEANS THE POINT

14    AT WHICH NO MATERIAL DETERIORATION OF A CONDITION IS LIKELY,

15    WITHIN REASONABLE MEDICAL PROBABILITY, TO RESULT FROM OR OCCUR

16    DURING TRANSFER OF THE PATIENT TO ANOTHER FACILITY.

























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