HOUSE BILL No. 5550 December 21, 2001, Introduced by Reps. Vander Veen, Rivet, Bradstreet, Tabor, Vear, Woronchak, Scranton, Stewart, Rocca, Vander Roest, Hardman, Mortimer, O'Neil, Kuipers, Voorhees, Schauer, Kowall, Jansen and Lemmons and referred to the Committee on Health Policy. A bill to amend 1980 PA 350, entitled "The nonprofit health care corporation reform act," by amending sections 502 and 502a (MCL 550.1502 and 550.1502a), as amended by 1998 PA 446. THE PEOPLE OF THE STATE OF MICHIGAN ENACT: 1 Sec. 502. (1) A health care corporation may enter into par- 2 ticipating contracts for reimbursement with professional health 3 care providers practicing legally in this state for health care 4 services that the professional health care providers may legally 5 perform. A participating contract may cover all members or may 6 be a separate and individual contract on a per claim basis, as 7 set forth in the provider class plan, if, in entering into a sep- 8 arate and individual contract on a per claim basis, the 9 participating provider certifies to the health care corporation: 04170'01 ** DKH 2 1 (a) That the provider will accept payment from the 2 corporation as payment in full for services rendered for the 3 specified claim for the member indicated. 4 (b) That the provider will accept payment from the corpora- 5 tion as payment in full for all cases involving the procedure 6 specified, for the duration of the calendar year. As used in 7 this subdivision, provider does not include a person licensed as 8 a dentist under part 166 of the public health code, 1978 PA 368, 9 MCL 333.16601 to 333.16648. 10 (c) That the provider will not determine whether to partici- 11 pate on a claim on the basis of the race, color, creed, marital 12 status, sex, national origin, residence, age, disability, or 13 lawful occupation of the member entitled to health care 14 benefits. 15 (2) A contract entered into pursuant to subsection (1) shall 16 provide that the private provider-patient relationship shall be 17 maintained to the extent provided for by law. A health care cor- 18 poration shall continue to offer a reimbursement arrangement to 19 any class of providers with which it has contracted prior to 20 August 27, 1985 and that continues to meet the standards set by 21 the corporation for that class of providers. 22 (3) A health care corporation shall not restrict the methods 23 of diagnosis or treatment of professional health care providers 24 who treat members. Except as otherwise provided in section 502a, 25 each member of the health care corporation shall at all times 26 have a choice of professional health care providers. This 27 subsection does not apply to limitations in benefits contained in 04170'01 ** 3 1 certificates, to the reimbursement provisions of a provider 2 contract or reimbursement arrangement, or to standards set by the 3 corporation for all contracting providers. A health care corpo- 4 ration may refuse to reimburse a health care provider for health 5 care services that are overutilized, including those services 6 rendered, ordered, or prescribed to an extent that is greater 7 than reasonably necessary. 8 (4) A health care corporation may provide to a member, upon 9 request, a list of providers with whom the corporation contracts, 10 for the purpose of assisting a member in obtaining a type of 11 health care service. However, except as otherwise provided in 12 section 502a, an employee, agent, or officer of the corporation, 13 or an individual on the board of directors of the corporation, 14 shall not make recommendations on behalf of the corporation with 15 respect to the choice of a specific health care provider. Except 16 as otherwise provided in section 502a, an employee, agent, or 17 officer of the corporation, or a person on the board of directors 18 of the corporation who influences or attempts to influence a 19 person in the choice or selection of a specific professional 20 health care provider on behalf of the corporation, is guilty of a 21 misdemeanor. 22 (5) A health care corporation shall provide a symbol of par- 23 ticipation, which can be publicly displayed, to providers who 24 participate on all claims for covered health care services 25 rendered to subscribers. 04170'01 ** 4 1 (6) This section does not impede the lawful operation of, or 2 lawful promotion of, a health maintenance organization owned by a 3 health care corporation. 4 (7) Contracts entered into under this section are subject to 5 the provisions of sections 504 to 518. 6 (8) A health care corporation shall not deny participation 7 to a freestanding surgical outpatient facility on the basis of 8 ownership if the facility meets the reasonable standards set by 9 the health care corporation for similar facilities, is licensed 10 under part 208 of the public health code, 1978 PA 368, 11 MCL 333.20801 to 333.20821, and complies with part 222 of the 12 public health code, 1978 PA 368, MCL 333.22201 to 333.22260. 13(9) Notwithstanding any other provision of this act, if a14certificate provides for benefits for services that are within15the scope of practice of optometry, a health care corporation is16not required to provide benefits or reimburse for a practice of17optometric service unless that service was included in the defi-18nition of practice of optometry under section 17401 of the public19health code, 1978 PA 368, MCL 333.17401, as of May 20, 1992.20 (9)(10)Notwithstanding any other provision of this act, 21 a health care corporation is not required to reimburse for serv- 22 ices otherwise covered under a certificate if the services were 23 performed by a member of a health care profession, which health 24 care profession was not licensed or registered by this state on 25 or before January 1, 1998 but that becomes a health care profes- 26 sion licensed or registered by this state after January 1, 1998. 27 This subsection does not change the status of a health care 04170'01 ** 5 1 profession that was licensed or registered by this state on or 2 before January 1, 1998. 3 Sec. 502a. (1) For the purpose of doing business as an 4 organization under the prudent purchaser act, 1984 PA 233, MCL 5 550.51 to 550.63, a health care corporation may enter into pru- 6 dent purchaser agreements with health care providers pursuant to 7 this section and the prudent purchaser act, 1984 PA 233, MCL 8 550.51 to 550.63. 9 (2) A health care corporation may offer group contracts 10 under which subscribers shall be required, as a condition of cov- 11 erage, to obtain services exclusively from health care providers 12 who have entered into prudent purchaser agreements. 13 (3) An individual who is a member of a group who is offered 14 the option of being a subscriber under a contract pursuant to 15 subsection (2) shall also be offered the option of being a sub- 16 scriber under a contract pursuant to subsection (4). This sub- 17 section applies only if the group in which the individual is a 18 member has 25 or more members or if the provider panel that is 19 providing the services under the contract is limited by the 20 organization to a specific number pursuant to section 3(1) of the 21 prudent purchaser act, 1984 PA 233, MCL 550.53. 22 (4) A health care corporation may offer group contracts 23 under which subscribers who elect to obtain services from health 24 care providers who have entered into prudent purchaser agreements 25 shall realize a financial advantage or other advantage by select- 26 ingsuchTHOSE providers. Contracts offered pursuant to this 27 subsection shall not, as a condition of coverage, require 04170'01 ** 6 1 subscribers to obtain services exclusively from health care 2 providers who have entered into prudent purchaser agreements. 3 (5) An individual who is a member of a group who is offered 4 the option of being a subscriber under a contract pursuant to 5 subsection (2) or (4) shall also be offered the option of being a 6 subscriber under a contract that: 7 (a) Does not, as a condition of coverage, require subscrib- 8 ers to obtain services exclusively from health care providers who 9 have entered into prudent purchaser agreements. 10 (b) Does not give a financial advantage or other advantage 11 to a subscriber who elects to obtain services from health care 12 providers who have entered into prudent purchaser agreements. 13 (6) Subsection (5) applies only if the group in which the 14 individual is a member has 25 or more members and if the group on 15 December 20, 1984 had health care coverage through the group 16 sponsor. 17 (7) A health care corporation may offer individual contracts 18 under which subscribers shall be required, as a condition of cov- 19 erage, to obtain services exclusively from health care providers 20 who have entered into prudent purchaser agreements. A person to 21 whom such a contract is offered shall also be offered a contract 22 that: 23 (a) Does not, as a condition of coverage, require subscrib- 24 ers to obtain services exclusively from health care providers who 25 have entered into prudent purchaser agreements. 04170'01 ** 7 1 (b) Does not give a financial advantage or other advantage 2 to a subscriber who elects to obtain services from health care 3 providers who have entered into prudent purchaser agreements. 4 (8) A health care corporation may offer individual contracts 5 under which subscribers who elect to obtain services from health 6 care providers who have entered into prudent purchaser agreements 7 shall realize a financial advantage or other advantage by select- 8 ingsuchTHOSE providers. Contracts offered pursuant to this 9 subsection shall not, as a condition of coverage, require sub- 10 scribers to obtain services exclusively from health care provid- 11 ers who have entered into prudent purchaser agreements. A person 12 to whom such a contract is offered shall also be offered a con- 13 tract that: 14 (a) Does not, as a condition of coverage, require subscrib- 15 ers to obtain services exclusively from health care providers who 16 have entered into prudent purchaser agreements. 17 (b) Does not give a financial advantage or other advantage 18 to a subscriber who elects to obtain services from health care 19 providers who have entered into prudent purchaser agreements. 20 (9) The rates charged by a corporation for coverage under 21 contracts issued under this section shall not be unreasonably 22 lower than what is necessary to meet the expenses of the corpora- 23 tion for providing this coverage and shall not have an anticom- 24 petitive effect or result in predatory pricing in relation to 25 prudent purchaser agreement coverages offered by other 26 organizations. 04170'01 ** 8 1 (10) Contracts entered into under this section are not 2 subject to the provisions of sections 504 to 518. 3 (11) A corporation shall not discriminate against a class of 4 health care providers when entering into prudent purchaser agree- 5 ments with health care providers for its provider panel. This 6 subsection does not: 7 (a) Prohibit the formation of a provider panel consisting of 8 a single class of providers when a service provided for in the 9 specifications of a purchaser may be legally provided only by a 10 single class of providers. 11 (b) Prohibit the formation of a provider panel that conforms 12 to the specifications of a purchaser of the coverage authorized 13 by this section so long as the specifications do not exclude any 14 class of health care providers who may legally perform the serv- 15 ices included in the coverage. 16 (c) Require an organization that has uniformly applied the 17 standards filed pursuant to section 3(3) of the prudent purchaser 18 act, 1984 PA 233, MCL 550.53, to contract with any individual 19 provider. 20 (12) Nothing in the 1984 amendatory act that added this sec- 21 tion applies to any contract that was in existence before 22 December 20, 1984, or the renewal ofsuchTHAT contract. 23(13) Notwithstanding any other provision of this act, if24coverage under a prudent purchaser agreement provides for bene-25fits for services that are within the scope of practice of optom-26etry, a health care corporation is not required to provide27benefits or reimburse for a practice of optometric service unless04170'01 ** 9 1that service was included in the definition of practice of2optometry under section 17401 of the public health code, 1978 PA3368, MCL 333.17401, as of May 20, 1992.4 (13)(14)Notwithstanding any other provision of this act, 5 a health care corporation offering coverage under a prudent pur- 6 chaser agreement is not required to reimburse for services other- 7 wise covered if the services were performed by a member of a 8 health care profession, which health care profession was not 9 licensed or registered by this state on or before January 1, 1998 10 but that becomes a health care profession licensed or registered 11 by this state after January 1, 1998. This subsection does not 12 change the status of a health care profession that was licensed 13 or registered by this state on or before January 1, 1998. 14 Enacting section 1. This amendatory act does not take 15 effect unless all of the following bills of the 91st Legislature 16 are enacted into law: 17 (a) Senate Bill No. _____ or House Bill No. 5548 (request 18 no. 04169'01 **). 19 (b) Senate Bill No. _____ or House Bill No. 5551 (request 20 no. 04171'01 **). 21 (c) Senate Bill No. _____ or House Bill No. 5549 (request 22 no. 04172'01 **). 04170'01 ** Final page. DKH