Bill Text: MI HB5409 | 2011-2012 | 96th Legislature | Introduced
Bill Title: Insurance; health; MIHealth marketplace as health exchange; establish. Creates new act.
Spectrum: Partisan Bill (Democrat 17-0)
Status: (Introduced - Dead) 2012-02-21 - Printed Bill Filed 02/17/2012 [HB5409 Detail]
Download: Michigan-2011-HB5409-Introduced.html
HOUSE BILL No. 5409
February 16, 2012, Introduced by Reps. Talabi, Cavanagh, Rutledge, Irwin, Ananich, Howze, Womack, Tlaib, Durhal, Stapleton, Townsend, Santana, Hovey-Wright, Bauer, Jackson and Oakes and referred to the Committee on Health Policy.
A bill to provide for the establishment of the MiHealth
marketplace as a nonprofit corporation; to create the board of the
MiHealth marketplace and prescribe its powers and duties; to
provide for assessments and user fees; and to provide for the
powers and duties of certain state and local governmental officers
and agencies.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
PART 1
GENERAL PROVISIONS
Sec. 101. (1) This act shall be known and may be cited as the
"MiHealth marketplace act". The marketplace under this act is a
nonexclusive health insurance clearinghouse. The marketplace shall
foster a competitive market for health insurance in this state.
(2) For purposes of this act, the words and phrases defined in
sections 103 to 109 have the meanings ascribed to them in those
sections.
(3) A reference in this act to the federal act includes other
provisions of the laws of the United States relating to health care
coverage for all Americans.
Sec. 103. (1) "Board" means the MiHealth marketplace board
created under section 201.
(2) "Commissioner" means the commissioner of the office of
financial and insurance regulation.
(3) "Educated health care consumer" means an individual who is
knowledgeable about the health care system and has background or
experience in making informed decisions regarding health, medical,
and scientific matters.
(4) "Executive director" means the executive director
appointed by the board under section 207.
(5) "Federal act" means the federal patient protection and
affordable care act, Public Law 111-148, as amended by the federal
health care and education reconciliation act of 2010, Public Law
111-152, and other federal acts, and any regulations promulgated
under those acts.
Sec. 105. (1) "Health benefit plan" means a policy, contract,
certificate, or agreement offered or issued by a health carrier to
provide, deliver, arrange for, pay for, or reimburse any of the
costs of health care services. Health benefit plan does not include
any of the following:
(a) Coverage only for accident or disability income insurance,
or any combination of those coverages.
(b) Coverage issued as a supplement to liability insurance.
(c) Liability insurance, including general liability insurance
and automobile liability insurance.
(d) Worker's compensation or similar insurance.
(e) Automobile medical payment insurance.
(f) Credit-only insurance.
(g) Coverage for on-site medical clinics.
(h) Other similar insurance coverage, specified in federal
regulations issued pursuant to the health insurance portability and
accountability act of 1996, Public Law 104-191, under which
benefits for health care services are secondary or incidental to
other insurance benefits.
(i) A plan that provides the following benefits if those
benefits are provided under a separate policy, certificate, or
contract of insurance or are otherwise not an integral part of the
plan:
(i) Limited scope dental or vision benefits.
(ii) Benefits for long-term care, nursing home care, home
health care, community-based care, or any combination of those
benefits.
(iii) Other similar, limited benefits specified in federal
regulations issued pursuant to the health insurance portability and
accountability act of 1996, Public Law 104-191.
(j) A plan that provides the following benefits if the
benefits are provided under a separate policy, certificate, or
contract of insurance, there is no coordination between the
provision of the benefits and any exclusion of benefits under any
group health benefit plan maintained by the same plan sponsor, and
the benefits are paid with respect to an event without regard to
whether benefits are provided with respect to such an event under
any group health benefit plan maintained by the same plan sponsor:
(i) Coverage only for a specified disease or illness.
(ii) Hospital indemnity or other fixed indemnity insurance.
(k) Any of the following if offered as a separate policy,
certificate, or contract of insurance:
(i) A medicare supplemental policy as defined in section
1882(g)(1) of the social security act, 42 USC 1395ss.
(ii) Coverage supplemental to the coverage provided by the
TRICARE program under 10 USC 1071 to 1110b.
(iii) Similar coverage supplemental to coverage provided under a
group health plan.
(2) "Health carrier" or "carrier" means an entity subject to
the insurance laws and regulations of this state, or subject to the
jurisdiction of the commissioner, that contracts or offers to
contract to provide, deliver, arrange for, pay for, or reimburse
any of the costs of health care services, including, but not
limited to, any of the following:
(a) A health insurer operating pursuant to the insurance code
of 1956, 1956 PA 218, MCL 500.100 to 500.8302.
(b) A health maintenance organization operating pursuant to
the insurance code of 1956, 1956 PA 218, MCL 500.100 to 500.8302.
(c) A health care corporation operating pursuant to the
nonprofit health care corporation reform act of 1980, 1980 PA 350,
MCL 550.1101 to 550.1704.
(d) Any other entity providing a plan of health insurance,
health benefits, or health services.
(3) "Marketplace" or "MiHealth marketplace" means the
nonprofit corporation organized under section 203.
(4) "Medicaid" means a program for medical assistance
established under title XIX of the social security act, 42 USC 1396
to 1396w-5.
(5) "MIChild" means the children's health insurance program
established under title XXI of the social security act, 42 USC
1397aa to 1397mm.
Sec. 107. (1) "Producer" means insurance producer as defined
in section 1201 of the insurance code of 1956, 1956 PA 218, MCL
500.1201.
(2) "Qualified dental plan" means a limited scope dental plan
that has been certified under section 215.
(3) "Qualified employer" means a small employer that elects to
make its full-time employees eligible for 1 or more qualified
health plans offered through the SHOP and, at the option of the
employer, some or all of its part-time employees, provided that the
employer meets any of the following:
(a) Has its principal place of business in this state and
elects to provide coverage through the SHOP to all of its eligible
employees, wherever employed.
(b) Elects to provide coverage through the SHOP to all of its
eligible employees who are principally employed in this state.
(4) "Qualified health plan" means a health benefit plan that
has been certified under section 215.
(5) "Qualified individual" means an individual, including a
minor, who meets all of the following requirements:
(a) Is seeking to enroll in a qualified health plan offered to
individuals through the marketplace.
(b) Resides in this state.
(c) At the time of enrollment, is not incarcerated, other than
incarceration pending the disposition of charges.
(d) Is, and is reasonably expected to be, for the entire
period for which enrollment is sought, a citizen or national of the
United States or an alien lawfully present in the United States.
(e) Is eligible to participate in the MiHealth marketplace
based upon the policies and procedures of the marketplace.
Sec. 109. (1) "Secretary" means the secretary of the United
States department of health and human services.
(2) "SHOP" means the small business health options
program established by the marketplace under section 211.
(3) "Small employer", until January 1, 2016, means both a sole
proprietor and small employer as those terms are defined in section
3701 of the insurance code of 1956, 1956 PA 218, MCL 500.3701.
Effective January 1, 2016, "small employer" means an employer that
employed an average of not more than 100 employees during the
preceding calendar year. Effective January 1, 2016, all of the
following apply to an employer to determine if it is a small
employer under this act:
(a) All persons treated as a single employer under section
414(b), (c), (m), or (o) of the internal revenue code of 1986, 26
USC 414, shall be treated as a single employer.
(b) An employer and any predecessor employer shall be treated
as a single employer.
(c) All employees shall be counted, including part-time
employees and employees who are not eligible for coverage through
the employer.
(d) If an employer was not in existence for the entire
preceding calendar year, the determination of whether that employer
is a small employer shall be based on the average number of
employees that it is reasonably expected the employer will employ
on business days in the current calendar year.
(e) An employer that makes enrollment in qualified health
plans available to its employees through the SHOP, and would cease
to be a small employer because of an increase in the number of its
employees, shall continue to be treated as a small employer for
purposes of this act as long as it continuously makes enrollment
through the SHOP available to its employees.
PART 2
MIHEALTH MARKETPLACE
Sec. 201. (1) The MiHealth marketplace board consisting of 7
voting members is created to organize and govern the MiHealth
marketplace. The board is the incorporator of the marketplace for
the purposes of the nonprofit corporation act, 1982 PA 162, MCL
450.2101 to 450.3192. The commissioner shall serve as a nonvoting
ex officio member of the board.
(2) The governor shall appoint 5 of the initial voting members
of the board with the advice and consent of the senate, including
at least 1 who is a member of the general public and who is
medicaid-eligible. The senate majority leader and the speaker of
the house of representatives shall each appoint 1 of the initial
voting members of the board. Except as otherwise provided in this
subsection, a vacancy in the board after the initial appointment
under this subsection shall be filled in the manner specified in
the marketplace's articles of incorporation or bylaws. A board
member shall not serve more than 2 consecutive terms of office.
(3) A board member shall not be employed, directly or
indirectly, by a carrier, a producer, a health care provider, or
any other entity, affiliate, or subsidiary of a health benefit
plan.
(4) The members first appointed to the board shall be
appointed within 30 days after the effective date of this act.
Except as otherwise provided in this subsection, an appointed board
member shall serve for a term of 4 years or until a successor is
appointed, whichever is later. The following apply to the members
first appointed under subsection (2):
(a) For the members appointed by the governor, 1 member shall
serve for 1 year, 1 member shall serve for 2 years, 2 members shall
serve for 3 years, and 1 member shall serve for 4 years.
(b) For the member appointed by the senate majority leader,
the member shall serve for 4 years.
(c) For the member appointed by the speaker of the house of
representatives, the member shall serve for 2 years.
(5) The first meeting of the board shall be called by the
commissioner. A chairperson shall be elected at the first meeting
of the board. After the first meeting, the board shall meet at
least quarterly, or more frequently at the call of the chairperson
or if requested by 4 or more members.
(6) Four members of the board constitute a quorum for the
transaction of business at a meeting of the board. An affirmative
vote of 4 board members is necessary for official action of the
board.
(7) The business that the board may perform shall be conducted
at a meeting of the board that is held in this state, is open to
the public, and is held in a place that is available to the general
public. However, the board may establish reasonable rules and
regulations to minimize disruption of a meeting of the board. At
least 10 days or more before but not more than 60 days before a
meeting, the board shall provide public notice of its meeting at
its principal office and on its internet website. The board shall
include in the public notice of its meeting the address where board
minutes required under subsection (8) may be inspected by the
public. The board may meet in a closed session for any of the
following purposes:
(a) To consider the hiring, dismissal, suspension, or
disciplining of board members or its employees or agents.
(b) To consult with its attorney.
(c) To comply with state or federal law, rules, or regulations
regarding privacy or confidentiality.
(8) The board shall keep minutes of each meeting. Board
minutes shall be open to public inspection, and the board shall
make the minutes available at the address designated on the public
notice of its meeting under subsection (7). The board shall make
copies of the minutes available to the public at the reasonable
estimated cost for printing and copying. The board shall include
all of the following in its board minutes:
(a) The date, time, and place of the meeting.
(b) Board members who are present and absent.
(c) Board decisions made at a meeting open to the public.
(d) All roll call votes taken at the meeting.
(9) Board members shall serve without compensation. However,
board members may be reimbursed for their actual and necessary
expenses incurred in the performance of their official duties as
board members.
(10) The board shall adopt a code of ethics for its members,
employees, and agents and for the directors, officers, and
employees of the marketplace pursuant to federal law, state law,
and the standard of practice applicable to nonprofit corporations.
The board shall include in the code of ethics policies and
procedures requiring the disclosure of relationships that may give
rise to a conflict of interest.
(11) In addition to complying with the code of ethics under
subsection (10), a board member shall declare any conflicts of
interest. The board shall require that any board member with a
direct or indirect interest in any matter before the marketplace
disclose the member's interest to the board before the board takes
any action on the matter. If a board member or a member of his or
her immediate family, organizationally or individually, would
derive direct and specific benefit from a decision of the board,
that member shall recuse himself or herself from the discussion and
vote on the issue.
(12) The board may establish committees as the board considers
appropriate to obtain recommendations concerning the operation and
implementation of the marketplace in this state. Committees
established by the board under this subsection shall be given a
specific charge and may include individuals who are not board
members, including, but not limited to, representatives of consumer
groups, carriers, health care providers, and other health industry
representatives.
(13) There is no liability on the part of, and no cause of
action shall arise against, any member of the board for any lawful
action taken by him or her in the performance of his or her powers
and duties under this act.
Sec. 203. (1) The initial board appointed under section 201
shall organize a nonprofit corporation, on a nonstock, directorship
basis, under the nonprofit corporation act, 1982 PA 162, MCL
450.2101 to 450.3192. The nonprofit corporation shall be known as
the MiHealth marketplace and is organized to provide both an
individual and SHOP marketplace for qualified health plans in this
state.
(2) The marketplace has the following powers and duties as a
nonprofit corporation:
(a) To contract with others, public or private, for the
provision of all or a portion of services necessary for the
management and operation of the marketplace.
(b) To make contracts, give guarantees, incur liabilities,
borrow money at such rates of interest as the marketplace may
determine, issue its notes, bonds, and other obligations, and
secure any of its obligations by mortgage or pledge of any of its
property or an interest in the property, wherever situated.
(c) To sue and be sued in all courts and to participate in
actions and proceedings judicial, administrative, arbitrative, or
otherwise, in the same manner as a natural person.
(d) To have a corporate seal, and to alter the seal, and to
use it by causing it or a facsimile to be affixed, impressed, or
reproduced in any other manner.
(e) To adopt, amend, or repeal bylaws, including emergency
bylaws, relating to the purposes of the marketplace, the conduct of
its affairs, its rights and powers, and the rights and powers of
its board members, directors, or officers.
(f) To elect or appoint officers, employees, and other agents
of the marketplace, to prescribe their duties, to fix their
compensation and the compensation of directors, and to indemnify
corporate directors, officers, employees, and agents.
(g) To purchase, receive, take by grant, gift, devise,
bequest, or otherwise, lease, or otherwise acquire, own, hold,
improve, employ, use, and otherwise deal in and with, real or
personal property, or an interest in real or personal property,
wherever situated, either absolutely or in trust and without
limitation as to amount or value.
(h) To sell, convey, lease, exchange, transfer, or otherwise
dispose of, or mortgage or pledge, or create a security interest
in, any of its property, or an interest in the property, wherever
situated.
(i) To purchase, take, receive, subscribe for, or otherwise
acquire, own, hold, vote, employ, sell, lend, lease, exchange,
transfer, or otherwise dispose of, mortgage, pledge, use, and
otherwise deal in and with, bonds and other obligations, shares or
other securities or interests or memberships issued by others,
whether engaged in similar or different business, governmental, or
other activities, including banking corporations or trust
companies. The marketplace shall not guarantee or become surety
upon a bond or other undertaking securing the deposit of public
money.
(j) To make contracts, give guarantees, and incur liabilities,
borrow money at rates of interest as the marketplace may determine,
issue its notes, bonds, and other obligations, and secure any of
its obligations by mortgage or pledge of any of its property or an
interest in the property, wherever situated.
(k) To invest and reinvest its funds, and take and hold real
and personal property as security for the payment of funds loaned
or invested.
(l) To establish and carry out savings, thrift, and other
incentive, and benefit plans, trusts, and provisions for any of its
directors, officers, and employees. The marketplace shall not
establish and carry out pension or retirement benefit plans.
(m) To purchase, receive, take, otherwise acquire, own, hold,
sell, lend, exchange, transfer, otherwise dispose of, pledge, use,
and otherwise deal in and with its own shares, bonds, and other
securities.
(n) To cease its corporate activities and dissolve pursuant to
the nonprofit corporation act, 1982 PA 162, MCL 450.2101 to
450.3192, and the affordable care act, except that upon dissolution
the assets of the marketplace shall be distributed as follows:
(i) All liabilities shall be paid and discharged.
(ii) Assets remaining after subparagraph (i) is fulfilled shall
be distributed as provided in a plan of action developed and
adopted by the board and approved by the commissioner.
(o) To conduct its affairs, carry on its operations, and have
offices and exercise the powers granted by this act in any
jurisdiction within this state, and, for the transaction of
business, the receipt and payment of money, the care and custody of
property, and other incidental business matters, to transact
business, receive, collect, and disburse money, and to engage in
other incidental business matters as are naturally or properly
within the scope of its articles.
(3) Other than a power or duty under section 261 of the
nonprofit corporation act, 1982 PA 162, MCL 450.2261, the
marketplace has the powers and duties of a nonprofit corporation
under the nonprofit corporation act, 1982 PA 162, MCL 450.2101 to
450.3192. Subsection (2) controls regarding the powers and duties
of the marketplace in lieu of section 261 of the nonprofit
corporation act, 1982 PA 162, MCL 450.2261. If a conflict between a
power or duty of the marketplace under this act conflicts with a
power or duty under other state law, this act controls.
Sec. 204. Beginning on the effective date of this act, an
entity shall not incorporate, file, register, or otherwise form in
this state using a name that is the same as or deceptively or
confusingly similar to the name "MiHealth marketplace".
Sec. 205. The board shall develop criteria for rating each
qualified health plan offered through the marketplace based on
relative value and quality. The criteria developed by the board
shall be in compliance with federal law, state law, and the
purposes of this act. The board shall consult with the commissioner
and the medical services administration for the department of
community health on the development of the rating criteria.
Sec. 207. (1) The board shall appoint an executive director to
manage the marketplace. The executive director shall be independent
and have no material relationship with the marketplace. The
executive director may appoint staff as necessary.
(2) The executive director may contract with others, public or
private, to provide all or a portion of the services necessary to
manage and operate the marketplace.
(3) To ensure efficient operation of the marketplace, the
executive director may seek assistance and support as may be
required in the performance of his or her duties from appropriate
state departments, agencies, and offices. Upon request of the
executive director, the state department, agency, or office may
provide assistance and support to the executive director.
(4) The executive director shall display on the marketplace
internet website information relevant to the public, as defined by
the board, concerning the marketplace's operations and
efficiencies, as well as the board's assessments of those
activities.
Sec. 209. (1) The marketplace shall make qualified health
plans available through its internet website for review, purchase,
and enrollment by qualified individuals and qualified employers
beginning on or before January 1, 2014 or as otherwise provided for
by federal law, rule, or regulation.
(2) The marketplace shall not make available any health
benefit plan that is not a qualified health plan. However, the
marketplace shall allow a health carrier to offer a plan that
provides limited scope dental benefits meeting the requirements of
section 9832(c)(2)(A) of the internal revenue code of 1986, 26 USC
9832, through the marketplace, either separately or in conjunction
with a qualified health plan, if the plan provides pediatric dental
benefits meeting the requirements of section 1302(b)(1)(J) of the
federal act.
(3) The marketplace or a carrier offering health benefit plans
through the marketplace shall not charge an individual a fee or
penalty for termination of coverage if the individual enrolls in
another type of minimum essential coverage because the individual
has become newly eligible for that coverage or because the
individual's employer-sponsored coverage has become affordable
under the standards of section 36B(c)(2)(C) of the internal revenue
code of 1986, 26 USC 36B.
Sec. 211. The marketplace shall do all of the following:
(a) Perform all duties and obligations of an exchange required
by federal law, state law, and the purposes of this act.
(b) Implement procedures consistent with section 215 for the
certification, recertification, and decertification of health
benefit plans as qualified health plans.
(c) Make available in the marketplace all qualified health
plans consistent with section 215.
(d) Provide for the operation of a toll-free telephone hotline
to respond to requests for assistance.
(e) Provide for enrollment periods, as provided under section
1311(c)(6) of the federal act.
(f) Maintain an internet website through which enrollees and
prospective enrollees of qualified health plans may obtain
standardized comparative information on the plans. At the direction
of the board, the marketplace shall also include on the internet
website information relative to individual health and wellness.
(g) Assign a rating to each qualified health plan offered
through the marketplace pursuant to the rating criteria developed
by the board under section 205.
(h) Use a standardized format for presenting health benefit
options in the marketplace, including the use of the uniform
outline of coverage established under section 2715 of the public
health service act, 42 USC 300gg-15.
(i) Inform individuals of eligibility requirements for
medicaid, MIChild, or any applicable health subsidy program
pursuant to the federal act. If through screening an application
the marketplace determines that an individual is eligible for
medicaid, the marketplace shall enroll the individual in the
medicaid program. If through screening an application the
marketplace determines that an individual is potentially eligible
for any other health subsidy program described in this subdivision,
the marketplace shall provide the individual with information about
the program. If requested by the individual, the marketplace shall
enroll the individual in the program, if applicable, or direct that
individual to the appropriate authority for final eligibility
determination and enrollment.
(j) Establish and make available by electronic means a
calculator to determine the actual cost of coverage after
application of any premium tax credit under section 36B of the
internal revenue code of 1986, 26 USC 36B, and any cost-sharing
reduction under section 1402 of the federal act.
(k) Establish a small business health options program through
which qualified employers may access coverage for their employees.
The SHOP shall enable any qualified employer to specify a level of
coverage so that any of its employees may enroll in any qualified
health plan offered through the SHOP at the specified level of
coverage.
(l) Notify employees using the SHOP of potential eligibility
for medicaid or MIChild.
(m) Grant a certification attesting that, for purposes of the
individual responsibility penalty under section 5000A of the
internal revenue code of 1986, 26 USC 5000A, an individual is
exempt from the individual responsibility requirement or from the
penalty imposed by that section because of any of the following:
(i) There is no affordable qualified health plan available
through the marketplace, or the individual's employer, covering the
individual.
(ii) The individual meets the requirements for any other
exemption from the individual responsibility requirement or
penalty.
(n) Contract with the office of financial and insurance
regulation to certify health benefit plans as qualified health
plans consistent with section 215.
(o) Transfer to the federal secretary of the treasury all data
and information required to be transferred under regulations
promulgated under the federal act.
(p) Provide to each employer defined in this subdivision the
name of each employee of the employer who ceases coverage under a
qualified health plan during a plan year and the effective date of
the cessation. As used in this subdivision, "employer" includes all
of the following:
(i) An employer that did not provide minimum essential
coverage.
(ii) An employer that provided the minimum essential coverage,
but the coverage was determined under section 36B(c)(2)(C) of the
internal revenue code of 1986, 26 USC 36B, to either be
unaffordable to the employee or not provide the required minimum
actuarial value.
(q) Perform duties required of the marketplace by the
secretary or the federal secretary of the treasury related to
determining eligibility for premium tax credits, reduced cost-
sharing, or individual responsibility requirement exemptions.
(r) Select entities qualified to serve as navigators pursuant
to the federal act, and standards developed by the secretary. The
marketplace shall give consideration to community organizations and
grassroots organizations when making the selections under this
subdivision and shall award grants to enable navigators to do all
of the following:
(i) Conduct public education activities to raise awareness of
the availability of qualified health plans.
(ii) Distribute fair, accurate, and impartial information
concerning qualified health plans and acknowledge other health
plans.
(iii) Facilitate enrollment in qualified health plans and in
medicaid, as applicable. A navigator shall not engage in any
activity that constitutes the sale or negotiation of insurance.
(iv) Provide referrals to any applicable office of health
insurance consumer assistance or health insurance ombudsman program
established under section 2793 of the public health service act, 42
USC 300gg-93, or any other appropriate state agency or agencies,
for any enrollee with a grievance, complaint, or question regarding
his or her health benefit plan or coverage or a determination under
that plan or coverage.
(v) Provide information in a manner that is culturally and
linguistically appropriate to the needs of the population being
served by the marketplace.
(s) Review the rate of premium growth within the marketplace
and outside the marketplace and consider the information in
developing recommendations on whether to continue limiting
qualified employer status to small employers.
(t) Permit producers to do all of the following:
(i) Subject to subdivision (r), serve as navigators.
(ii) Receive grants from the marketplace as described in
subdivision (r).
(iii) Facilitate enrollment and enroll qualified individuals,
qualified employers, and qualified employees in qualified health
plans.
(iv) Assist individuals in applying for advance payments of
premium tax credits under section 36B of the internal revenue code
of 1986, 26 USC 36B, and cost-sharing reductions under section 1402
of the federal act.
(u) Consult with stakeholders relevant to carrying out the
activities required under this act, including, but not limited to,
the following:
(i) Educated health care consumers who are enrollees in
qualified health plans.
(ii) Individuals and entities with experience in facilitating
enrollment in qualified health plans.
(iii) Representatives of small businesses and self-employed
individuals.
(iv) The medical services administration of the department of
community health.
(v) Advocates for enrolling hard-to-reach populations.
(vi) Federally recognized tribes, as defined in the federally
recognized Indian tribe law of 1994, 25 USC 479a.
(v) Widely advertise the availability of qualified health
plans through the marketplace by utilizing all media outlets
available.
Sec. 213. (1) The board shall appoint an audit committee. The
audit committee shall contract with an external auditor for the
preparation of at least 1 audit of the financial statements of the
marketplace in every fiscal year. The audit committee shall be
independent of the marketplace and shall not have contractual
relationships with the marketplace or the external auditor other
than for the marketplace audit.
(2) The executive director shall do all of the following:
(a) Review and certify the reports of the external auditor.
(b) Make the external auditor reports available to the board
and the general public.
(3) The marketplace shall meet all of the following financial
integrity requirements:
(a) Keep an accurate accounting of all activities, receipts,
and expenditures and annually submit to the secretary, the
governor, the commissioner, and the senate and house of
representatives appropriations committees and standing committees
on insurance issues a report concerning those accountings.
(b) Fully cooperate with any investigation conducted by this
state or a federal agency pursuant to authority under federal or
state law, to do any of the following:
(i) Investigate the affairs of the marketplace.
(ii) Examine the properties and records of the marketplace.
(iii) Require periodic reports in relation to the activities
undertaken by the marketplace.
(c) In carrying out its activities under this act, not use any
money intended for the administrative and operational expenses of
the marketplace for staff retreats, promotional giveaways,
excessive executive compensation, or promotion of federal or state
legislative and regulatory modifications.
Sec. 215. (1) The marketplace shall contract with the office
of financial and insurance regulation to certify health benefit
plans under this section. Subject to subsection (2), the
commissioner shall certify a health benefit plan as a qualified
health plan if either of the following requirements is met:
(a) The health benefit plan meets the requirements of federal
law, state law, and the purposes of this act.
(b) If, as determined by the commissioner, the requirements of
the federal act have changed substantially after the effective date
of this act, and the health benefit plan is offered by a carrier
that is licensed or has a certificate of authority under the laws
of this state and is in good standing to offer the health benefit
plan to all residents of this state.
(2) The commissioner shall not certify a health benefit plan
as a qualified health plan unless the premium rates and contract
language have been approved by the commissioner.
(3) The commissioner shall not exclude a health benefit plan
as a qualified health plan as follows:
(a) On the basis that the plan is a fee-for-service plan.
(b) Through the imposition of premium price controls in the
marketplace.
(c) On the basis that the health benefit plan provides
treatments necessary to prevent patients' deaths in circumstances
the commissioner determines are inappropriate or too costly.
(4) The commissioner shall require each carrier seeking
certification of a health benefit plan as a qualified health plan
to do all of the following:
(a) Submit a justification for any premium increase before
implementation of that increase. The carrier shall prominently post
the information on its internet website. The commissioner shall
take this information into consideration when determining whether
to allow the carrier to make plans available through the
marketplace.
(b) Make available to the public, in plain language, as that
term is defined in section 1311(e)(3)(B) of the federal act, and
submit to the marketplace, the secretary, and the commissioner
accurate and timely disclosure of all of the following:
(i) Claims payment policies and practices.
(ii) Periodic financial disclosures.
(iii) Data on enrollment.
(iv) Data on disenrollment.
(v) Data on the number of claims that are denied.
(vi) Data on rating practices.
(vii) Information on cost-sharing and payments with respect to
any out-of-network coverage.
(viii) Information on enrollee and participant rights under
title I of the federal act.
(ix) Other information as determined appropriate by the
secretary.
(c) Permit individuals to determine, in a timely manner upon
the request of the individual, the amount of cost-sharing,
including deductibles, copayments, and coinsurance, under the
individual's plan or coverage that the individual would be
responsible for paying with respect to the furnishing of a specific
item or service by a participating provider. At a minimum, this
information shall be made available to the individual through an
internet website and through other means for individuals without
access to the internet.
(4) The provisions of this act that are applicable to
qualified health plans apply to the extent relevant to qualified
dental plans except as modified in this subsection or by the board
as permitted by the federal act. A carrier offering a qualified
dental plan shall be licensed to offer dental coverage, but need
not be licensed to offer other health benefits. The qualified
dental plan shall be limited to dental and oral health benefits,
without substantially duplicating the benefits typically offered by
health benefit plans without dental coverage, and shall include, at
a minimum, the essential pediatric dental benefits prescribed by
the secretary under section 1302(b)(1)(J) of the federal act, and
any other dental benefits the board or the secretary specify.
Carriers may jointly offer a comprehensive plan through the
marketplace in which the dental benefits are provided by a carrier
through a qualified dental plan and the other benefits are provided
by a carrier through a qualified health plan, if the plans are
priced separately and are also made available for purchase
separately at the same price.
Sec. 217. (1) This act does not authorize the expending of any
state money by the marketplace.
(2) The marketplace may charge assessments or user fees to
health carriers or otherwise may generate funding necessary to
support its operations under this act.
(3) The marketplace shall publish the average costs of fees
and any other payments required by the marketplace, and the
administrative costs of the marketplace, on its internet website.
The marketplace shall include information on money lost to waste,
fraud, and abuse.
Sec. 219. (1) This act does not preempt or supersede the
authority of the commissioner to regulate the business of insurance
within this state or of the single state agency to administer
medicaid.
(2) Except as expressly provided to the contrary in this act,
all carriers offering qualified health plans in this state shall
comply fully with all applicable health insurance laws of this
state and rules promulgated and orders issued by the commissioner.
