Bill Text: MI HB5236 | 2011-2012 | 96th Legislature | Introduced

---

Bill Title: Insurance; health care corporations; reimbursement for physical therapy services; allow health care corporation to withhold unless patient has a prescription from a licensed health professional. Amends secs. 502 & 502a of 1980 PA 350 (MCL 550.1502 & 550.1502a).

Spectrum: Slight Partisan Bill (Democrat 2-1)

Status: (Introduced - Dead) 2012-02-02 - Recommendation Concurred In [HB5236 Detail]

Download: Michigan-2011-HB5236-Introduced.html

---

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOUSE BILL No. 5236

 

December 15, 2011, Introduced by Reps. Rutledge, Liss and O'Brien and referred to the Committee on Insurance.

 

     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 2009 PA 225.

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

     Sec. 502. (1) A health care corporation may enter into

 

participating contracts for reimbursement with professional health

 

care providers practicing legally in this state for health care

 

services or with health practitioners practicing legally in any

 

other jurisdiction for health care services that the professional

 

health care providers or practitioners may legally perform. A

 

participating contract may cover all members or may be a separate

 

and individual contract on a per claim basis, as set forth in the

 

provider class plan, if, in entering into a separate and individual

 

contract on a per claim basis, the participating provider certifies

 

all of the following to the health care corporation:

 

     (a) That the provider will accept payment from the corporation

 

as payment in full for services rendered for the specified claim

 

for the member indicated.

 

     (b) That the provider will accept payment from the corporation

 

as payment in full for all cases involving the procedure specified,

 

for the duration of the calendar year. As used in this subdivision,

 

provider does not include a person licensed as a dentist under part

 

166 of the public health code, 1978 PA 368, MCL 333.16601 to

 

333.16648.

 

     (c) That the provider will not determine whether to

 

participate on a claim on the basis of the race, color, creed,

 

marital status, sex, national origin, residence, age, disability,

 

or lawful occupation of the member entitled to health care

 

benefits.

 

     (2) A contract entered into pursuant to under subsection (1)

 

shall provide that the private provider-patient relationship shall

 

be maintained to the extent provided for by law. A health care

 

corporation shall continue to offer a reimbursement arrangement to

 

any class of providers with which it has contracted prior to before

 

August 27, 1985 and that continues to meet the standards set by the

 

corporation for that class of providers.

 

     (3) A health care corporation shall not restrict the methods

 

of diagnosis or treatment of professional health care providers who

 

treat members. Except as otherwise provided in section 502a, each

 

member of the health care corporation shall at all times have a

 

choice of professional health care providers. This subsection does

 

not apply to limitations in benefits contained in certificates, to

 

the reimbursement provisions of a provider contract or

 

reimbursement arrangement, or to standards set by the corporation

 

for all contracting providers. A health care corporation may refuse

 

to reimburse a health care provider for health care services that

 

are overutilized, including those services rendered, ordered, or

 

prescribed to an extent that is greater than reasonably necessary.

 

     (4) A health care corporation may provide to a member, upon

 

request, a list of providers with whom the corporation contracts,

 

for the purpose of assisting a member in obtaining a type of health

 

care service. However, except as otherwise provided in section

 

502a, an employee, agent, or officer of the corporation, or an

 

individual on the board of directors of the corporation, shall not

 

make recommendations on behalf of the corporation with respect to

 

the choice of a specific health care provider. Except as otherwise

 

provided in section 502a, an employee, agent, or officer of the

 

corporation, or a person on the board of directors of the

 

corporation who influences or attempts to influence a person in the

 

choice or selection of a specific professional health care provider

 

on behalf of the corporation, is guilty of a misdemeanor.

 

     (5) A health care corporation shall provide a symbol of

 

participation, which can be publicly displayed, to providers who

 

participate on all claims for covered health care services rendered

 

to subscribers.

 

     (6) This section does not impede the lawful operation of, or

 

lawful promotion of, a health maintenance organization owned by a

 

health care corporation.

 

     (7) Contracts entered into under this section with

 

professional health care providers licensed in this state are

 

subject to the provisions of sections 504 to 518.

 

     (8) A health care corporation shall not deny participation to

 

a freestanding surgical outpatient facility on the basis of

 

ownership if the facility meets the reasonable standards set by the

 

health care corporation for similar facilities, is licensed under

 

part 208 of the public health code, 1978 PA 368, MCL 333.20801 to

 

333.20821, and complies with part 222 of the public health code,

 

1978 PA 368, MCL 333.22201 to 333.22260.

 

     (9) Notwithstanding any other provision of this act, if a

 

certificate provides for benefits for services that are within the

 

scope of practice of optometry, a health care corporation is not

 

required to provide benefits or reimburse for a practice of

 

optometric optometry service unless that service was included in

 

the definition of practice of optometry under section 17401 of the

 

public health code, 1978 PA 368, MCL 333.17401, as of May 20, 1992.

 

     (10) Notwithstanding any other provision of this act, a health

 

care corporation is not required to reimburse for services

 

otherwise covered under a certificate if the services were

 

performed by a member of a health care profession, which health

 

care profession was not licensed or registered by this state on or

 

before January 1, 1998 but that becomes a health care profession

 

licensed or registered by this state after January 1, 1998. This

 

subsection does not change the status of a health care profession

 

that was licensed or registered by this state on or before January

 

1, 1998.

 

     (11) Notwithstanding any other provision of this act,

 

including subsections (1) to (10), if a certificate provides for

 

benefits for services that are within the scope of practice of

 

chiropractic, a health care corporation is not required to provide

 

benefits or reimburse for a practice of chiropractic service unless

 

that service was included in the definition of practice of

 

chiropractic under section 16401 of the public health code, 1978 PA

 

368, MCL 333.16401, as of January 1, 2009.

 

     (12) Notwithstanding any other provision of this act, if a

 

certificate provides for benefits for services provided by a

 

licensed physical therapist or physical therapist assistant under

 

the supervision of a licensed physical therapist, a health care

 

corporation is not required to provide benefits or reimburse for a

 

practice of physical therapy service or practice as a physical

 

therapist assistant service unless that service was provided by a

 

licensed physical therapist or physical therapist assistant under

 

the supervision of a licensed physical therapist pursuant to a

 

prescription issued by an individual holding a license issued under

 

part 166, 170, 175, or 180 of the public health code, 1978 PA 368,

 

MCL 333.16601 to 333.16648, 333.17001 to 333.17084, 333.17501 to

 

333.17556, or 333.18001 to 333.18058, or the equivalent license

 

issued by another state.

 

     Sec. 502a. (1) For the purpose of doing business as an

 

organization under the prudent purchaser act, 1984 PA 233, MCL

 

550.51 to 550.63, a health care corporation may enter into prudent

 

purchaser agreements with health care providers pursuant to this

 

section and the prudent purchaser act, 1984 PA 233, MCL 550.51 to

 

550.63.

 

     (2) A health care corporation may offer group contracts under

 

which subscribers shall be required, as a condition of coverage, to

 

obtain services exclusively from health care providers who have

 

entered into prudent purchaser agreements.

 

     (3) An individual who is a member of a group who is offered

 

the option of being a subscriber under a contract pursuant to under

 

subsection (2) shall also be offered the option of being a

 

subscriber under a contract pursuant to under subsection (4). This

 

subsection applies only if the group in which the individual is a

 

member has 25 or more members or if the provider panel that is

 

providing the services under the contract is limited by the

 

organization to a specific number pursuant to under section 3(1) of

 

the prudent purchaser act, 1984 PA 233, MCL 550.53.

 

     (4) A health care corporation may offer group contracts under

 

which subscribers who elect to obtain services from health care

 

providers who have entered into prudent purchaser agreements shall

 

realize a financial advantage or other advantage by selecting such

 

providers who have entered into prudent purchaser agreements.

 

Contracts offered pursuant to under this subsection shall not, as a

 

condition of coverage, require subscribers to obtain services

 

exclusively from health care providers who have entered into

 

prudent purchaser agreements.

 

     (5) An Subject to subsection (6), an individual who is a

 

member of a group who is offered the option of being a subscriber

 

under a contract pursuant to under subsection (2) or (4) shall also

 

be offered the option of being a subscriber under a contract that

 

does not do any of the following:

 

     (a) Does not, as As a condition of coverage, require

 

subscribers to obtain services exclusively from health care

 

providers who have entered into prudent purchaser agreements.

 

     (b) Does not give Give a financial advantage or other

 

advantage to a subscriber who elects to obtain services from health

 

care providers who have entered into prudent purchaser agreements.

 

     (6) Subsection (5) applies only if the group in which the

 

individual is a member has 25 or more members and if the group on

 

December 20, 1984 had health care coverage through the group

 

sponsor.

 

     (7) A health care corporation may offer individual contracts

 

under which subscribers shall be required, as a condition of

 

coverage, to obtain services exclusively from health care providers

 

who have entered into prudent purchaser agreements. A person to

 

whom such a contract described in this subsection is offered shall

 

also be offered a contract that does not do any of the following:

 

     (a) Does not, as As a condition of coverage, require

 

subscribers to obtain services exclusively from health care

 

providers who have entered into prudent purchaser agreements.

 

     (b) Does not give Give a financial advantage or other

 

advantage to a subscriber who elects to obtain services from health

 

care providers who have entered into prudent purchaser agreements.

 

     (8) A health care corporation may offer individual contracts

 

under which subscribers who elect to obtain services from health

 

care providers who have entered into prudent purchaser agreements

 

shall realize a financial advantage or other advantage by selecting

 

such providers who have entered into prudent purchaser agreements.

 

Contracts offered pursuant to under this subsection shall not, as a

 

condition of coverage, require subscribers to obtain services

 

exclusively from health care providers who have entered into

 

prudent purchaser agreements. A person to whom such a contract

 

described in this subsection is offered shall also be offered a

 

contract that does not do any of the following:

 

     (a) Does not, as As a condition of coverage, require

 

subscribers to obtain services exclusively from health care

 

providers who have entered into prudent purchaser agreements.

 

     (b) Does not give Give a financial advantage or other

 

advantage to a subscriber who elects to obtain services from health

 

care providers who have entered into prudent purchaser agreements.

 

     (9) The rates charged by a corporation for coverage under

 

contracts issued under this section shall not be unreasonably lower

 

than what is necessary to meet the expenses of the corporation for

 

providing this coverage and shall not have an anticompetitive

 

effect or result in predatory pricing in relation to prudent

 

purchaser agreement coverages offered by other organizations.

 

     (10) Contracts entered into under this section are not subject

 

to the provisions of sections 504 to 518.

 

     (11) A health care corporation shall not discriminate against

 

a class of health care providers when entering into prudent

 

purchaser agreements with health care providers for its provider

 

panel. This subsection does not do any of the following:

 

     (a) Prohibit the formation of a provider panel consisting of a

 

single class of providers when if a service provided for in the

 

specifications of a purchaser may be legally provided only by a

 

single class of providers.

 

     (b) Prohibit the formation of a provider panel that conforms

 

to the specifications of a purchaser of the coverage authorized by

 

this section so long as if the specifications do not exclude any

 

class of health care providers who may legally perform the services

 

included in the coverage.

 

     (c) Require an organization that has uniformly applied the

 

standards filed pursuant to under section 3(3) of the prudent

 

purchaser act, 1984 PA 233, MCL 550.53, to contract with any

 

individual provider.

 

     (12) Nothing in the 1984 amendatory act that added this

 

section PA 230 applies to any contract that was in existence before

 

December 20, 1984, or the renewal of such that contract.

 

     (13) Notwithstanding any other provision of this act, if

 

coverage under a prudent purchaser agreement provides for benefits

 

for services that are within the scope of practice of optometry, a

 

health care corporation is not required to provide benefits or

 

reimburse for a practice of optometric optometry service unless

 

that service was included in the definition of practice of

 

optometry under section 17401 of the public health code, 1978 PA

 

368, MCL 333.17401, as of May 20, 1992.

 

     (14) Notwithstanding any other provision of this act, a health

 

care corporation offering coverage under a prudent purchaser

 

agreement is not required to reimburse for services otherwise

 

covered if the services were performed by a member of a health care

 

profession, which health care profession was not licensed or

 

registered by this state on or before January 1, 1998 but that

 

becomes a health care profession licensed or registered by this

 

state after January 1, 1998. This subsection does not change the

 

status of a health care profession that was licensed or registered

 

by this state on or before January 1, 1998.

 

     (15) Notwithstanding any other provision of this act,

 

including subsections (1) to (14), if a certificate if coverage

 

under a prudent purchaser agreement provides for benefits for

 

services that are within the scope of practice of chiropractic, a

 

health care corporation is not required to provide benefits or

 

reimburse for a practice of chiropractic service unless that

 

service was included in the definition of practice of chiropractic

 

under section 16401 of the public health code, 1978 PA 368, MCL

 

333.16401, as of January 1, 2009.

 

     (16) Notwithstanding any other provision of this act, if

 

coverage under a prudent purchaser agreement provides for benefits

 

for services provided by a licensed physical therapist or physical

 

therapist assistant under the supervision of a licensed physical

 

therapist, a health care corporation is not required to provide

 

benefits or reimburse for a practice of physical therapy service or

 

practice as a physical therapist assistant service unless that

 

service was provided by a licensed physical therapist or physical

 

therapist assistant under the supervision of a licensed physical

 

therapist pursuant to a prescription issued by an individual

 

holding a license issued under part 166, 170, 175, or 180 of the

 

public health code, 1978 PA 368, MCL 333.16601 to 333.16648,

 

333.17001 to 333.17084, 333.17501 to 333.17556, or 333.18001 to

 

333.18058, or the equivalent license issued by another state.

 

     Enacting section 1. This amendatory act does not take effect

 

unless House Bill No. 4603 of the 96th Legislature is enacted into

 

law.