HOUSE BILL No. 5536


     December 13, 2001, Introduced by Rep. Kolb and referred to the Committee on Health Policy.


        A bill to amend 1956 PA 218, entitled

   "The insurance code of 1956,"

   by amending section 3501 (MCL 500.3501), as added by 2000 PA

   252.

               THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 1
           Sec. 3501.  As used in this chapter:

 2
           (a) "Affiliated provider" means a health professional,

 3
      licensed hospital, licensed pharmacy, or any other institution,

 4
      organization, or person having a contract with a health mainte-

 5
      nance organization to render 1 or more health maintenance serv-

 6
      ices to an enrollee.

 7
           (b) "Basic health services" means:

 8
           (i) Physician services including consultant and referral

 9
      services by a physician, but not including psychiatric services.




   01067'01                                                 DKH                                   2

 1
           (ii) Ambulatory services.

 2
           (iii) Inpatient hospital services, other than those for the

 3
      treatment of mental illness.

 4
           (iv) Emergency health services.

 5
           (v) Outpatient mental health services, not fewer than 20

 6
      visits per year.

 7
           (vi) Intermediate and outpatient care for substance abuse as

 8
      follows:

 9
           (A) For group contracts, if the fees for a group contract

10
      would be increased by 3% or more because of the provision of

11
      services under this subparagraph, the group subscriber may

12
      decline the services.  For individual contracts, if the total

13
      fees for all individual contracts would be increased by 3% or

14
      more because of the provision of the services required under this

15
      subparagraph in all of those contracts, the named subscriber of

16
      each contract may decline the services.

17
           (B) Charges, terms, and conditions for the services required

18
      to be provided under this subparagraph shall not be less favor-

19
      able than the maximum prescribed for any other comparable

20
      service.

21
           (C) The services required to be provided under this subpara-

22
      graph shall not be reduced by terms or conditions that apply to

23
      other services in a group or individual contract.  This

24
      sub-subparagraph shall not be construed to prohibit contracts

25
      that provide for deductibles and copayment provisions for serv-

26
      ices for intermediate and outpatient care for substance abuse.





   01067'01                                   3

 1
           (D) The services required to be provided under this

 2
      subparagraph shall, at a minimum, provide for up to $2,968.00 in

 3
      services for intermediate and outpatient care for substance abuse

 4
      per individual per year.  This minimum shall be adjusted annually

 5
      by March 31 each year in accordance with the annual average per-

 6
      centage increase or decrease in the United States consumer price

 7
      index for the 12-month period ending the preceding December 31.

 8
           (E) As used in this subparagraph, "intermediate care",

 9
      "outpatient care", and "substance abuse" have those meanings

10
       ascribed to them  AS DEFINED in section 3425.

11
           (vii) Diagnostic laboratory and diagnostic and therapeutic

12
      radiological services.

13
           (viii) Home health services.

14
           (ix) Preventive health services.

15
           (X) OTHER HEALTH SERVICES IF CONSIDERED MEDICALLY NECESSARY

16
      BY THE TREATING PHYSICIAN.

17
           (c) "Credentialing verification" means the process of

18
      obtaining and verifying information about a health professional

19
      and evaluating that health professional when that health profes-

20
      sional applies to become a participating provider with a health

21
      maintenance organization.

22
           (d) "Enrollee" means an individual who is entitled to

23
      receive health maintenance services under a health maintenance

24
      contract.

25
           (e) "Health maintenance contract" means a contract between a

26
      health maintenance organization and a subscriber or group of

27
      subscribers, to provide, when medically indicated, designated



   01067'01                                   4

 1
      health maintenance services, as described in and pursuant to the

 2
      terms of the contract, including, at a minimum, basic health

 3
      maintenance services.  Health maintenance contract includes a

 4
      prudent purchaser contract.

 5
           (f) "Health maintenance organization" means an entity that

 6
      does the following:

 7
           (i) Delivers health maintenance services that are medically

 8
      indicated to enrollees under the terms of its health maintenance

 9
      contract, directly or through contracts with affiliated provid-

10
      ers, in exchange for a fixed prepaid sum or per capita prepay-

11
      ment, without regard to the frequency, extent, or kind of health

12
      services.

13
           (ii) Is responsible for the availability, accessibility, and

14
      quality of the health maintenance services provided.

15
           (g) "Health maintenance services" means services provided to

16
      enrollees of a health maintenance organization under their health

17
      maintenance contract.

18
           (h) "Health professional" means an individual licensed, cer-

19
      tified, or authorized in accordance with state law to practice a

20
      health profession in his or her respective state.

21
           (i) "Primary verification" means verification by the health

22
      maintenance organization of a health professional's credentials

23
      based upon evidence obtained from the issuing source of the

24
      credential.

25
           (j) "Prudent purchaser contract" means a contract offered by

26
      a health maintenance organization to groups or to individuals

27
      under which enrollees who select to obtain health care services



   01067'01                                   5

 1
      directly from the organization or through its affiliated

 2
      providers receive a financial advantage or other advantage by

 3
      selecting those providers.

 4
           (k) "Secondary verification" means verification by the

 5
      health maintenance organization of a health professional's cre-

 6
      dentials based upon evidence obtained by means other than direct

 7
      contact with the issuing source of the credential.

 8
           (l) "Service area" means a defined geographical area in

 9
      which health maintenance services are generally available and

10
      readily accessible to enrollees and where health maintenance

11
      organizations may market their contracts.

12
           (m) "Subscriber" means an individual who enters into a

13
      health maintenance contract, or on whose behalf a health mainte-

14
      nance contract is entered into, with a health maintenance organi-

15
      zation that has received a certificate of authority under this

16
      chapter and to whom a health maintenance contract is issued.

























   01067'01          Final page.                            DKH