Bill Text: MI HB6537 | 2017-2018 | 99th Legislature | Introduced

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Bill Title: Labor; public service employment; claims utilization and cost information compilation; modify. Amends secs. 3 & 15 of 2007 PA 106 (MCL 124.73 & 124.85).

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2018-12-06 - Referred To Second Reading [HB6537 Detail]

Download: Michigan-2017-HB6537-Introduced.html

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HOUSE BILL No. 6537

 

 

November 27, 2018, Introduced by Rep. Kelly and referred to the Committee on Education Reform.

 

     A bill to amend 2007 PA 106, entitled

 

"Public employees health benefit act,"

 

by amending sections 3 and 15 (MCL 124.73 and 124.85), section 15

 

as amended by 2011 PA 93.

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

     Sec. 3. As used in this act:

 

     (a) "Carrier" means a health, dental, or vision insurance

 

company authorized to do business in this state under, and a health

 

maintenance organization or multiple employer welfare arrangement

 

operating under, the insurance code of 1956, 1956 PA 218, MCL

 

500.100 to 500.8302; a system of health care delivery and financing

 

operating under section 3573 of the insurance code of 1956, 1956 PA

 

218, MCL 500.3573; a nonprofit dental care corporation operating

under 1963 PA 125, MCL 550.351 to 550.373; a nonprofit health care

 

corporation operating under the nonprofit health care corporation

 

reform act, 1980 PA 350, MCL 550.1101 to 550.1704; a voluntary

 

employees' beneficiary association described in section 501(c)(9)

 

of the internal revenue code, 26 USC 501(c)(9); a pharmacy benefits

 

manager; and any other person providing a plan of health benefits,

 

coverage, or insurance in this state.

 

     (b) "Commissioner" means the commissioner director of the

 

office department of financial and insurance and financial

 

services.

 

     (c) "Covered individual" means an individual covered by a

 

contract under section 15(3)(a)(iv).

 

     (d) (c) "Medical benefit plan" means a plan, established and

 

maintained by a carrier or 1 or more public employers, that

 

provides for the payment of medical, optical, or dental benefits,

 

including, but not limited to, hospital and physician services,

 

prescription drugs, and related benefits, to public employees.

 

     (e) (d) "Public employee" means an employee of a public

 

employer.

 

     (f) (e) "Public employer" means a city, village, township,

 

county, or other political subdivision of this state; any

 

intergovernmental, metropolitan, or local department, agency, or

 

authority, or other local political subdivision; a school district,

 

a public school academy, or an intermediate school district, as

 

those terms are defined in the revised school code, 1976 PA 451,

 

MCL 380.1 to 380.1852; or a community college or junior college

 

described in section 7 of article VIII of the state constitution of

1963. Public employer includes a public university that elects to

 

come under the provisions of this act.

 

     (g) (f) "Public employer pooled plan" or "pooled plan" means a

 

public employer pooled plan established pursuant to section

 

5(1)(b).

 

     (h) (g) "Public university" means a public university

 

described in section 4, 5, or 6 of article VIII of the state

 

constitution of 1963.

 

     (i) "Specialty prescription drug" means a prescription drug

 

used to treat a rare, complex, or chronic medical condition that

 

meets any of the following requirements:

 

     (i) Requires special administration including, but not limited

 

to, inhalation or infusion.

 

     (ii) Requires special delivery or special storage.

 

     (iii) Requires special oversight, intensive monitoring, or

 

care coordination with a person licensed under article 15 of the

 

public health code, 1978 PA 368, MCL 333.16101 to 333.18838.

 

     Sec. 15. (1) Notwithstanding subsection (2), a public employer

 

that has 100 50 or more employees in a medical benefit plan plans

 

shall be provided with claims utilization and cost information as

 

provided in subsection (3).

 

     (2) A public employer that is Two or more public employers

 

that are in an arrangement with 1 or more other public employers,

 

and together have 100 50 or more employees in a medical benefit

 

plan plans or have signed a letter of intent to enter together 100

 

50 or more public employees into a medical benefit plan, plans,

 

shall each be provided with claims utilization and cost information

as provided in subsection (3) that is aggregated for all the public

 

employees together of those public employers, and, except as

 

otherwise permitted under subsection (1), shall not be separated

 

out for any of those public employers.

 

     (3) All medical benefit plans in this state shall compile, and

 

shall make available electronically as provided in subsections (1)

 

and (2), in an electronic, spreadsheet-compatible format complete

 

and accurate claims utilization and cost information for the

 

medical benefit plan in the aggregate and for each public employer

 

entitled to that information under subsection (1) or (2) and each

 

subgroup of public employees of such a public employer if the

 

subgroup has 50 or more public employees covered by the medical

 

benefit plan, as follows:

 

     (a) A census of all covered employees, including all of the

 

following:

 

     (i) Year of birth.

 

     (ii) Gender.

 

     (iii) Zip code.

 

     (iv) The contract coverage type for the employee, such as

 

single, dependent, 2-person, or family, and number of individuals

 

covered by contract.

 

     (b) Claims Incurred and paid claims data for the employee

 

group covered by the medical benefit plan, including at least all

 

of the following:

 

     (i) For a plan that provides health medical benefits,

 

information concerning enrollment and hospital and medical claims

 

under the plan, presented in a manner that clearly shows all of the

following: for each of the 3 most recent experience years:

 

     (A) For each month, the total number of covered employees and

 

the number of covered employees in each contract coverage type

 

included in the census under subdivision (a)(iv).

 

     (B) For each month, the total number of covered individuals

 

and the number of covered individuals in each contract coverage

 

type included in the census under subdivision (a)(iv).

 

     (C) (A) Number and total expenditures for hospital inpatient

 

claims for each month.

 

     (D) (B) Number and total expenditures for medical outpatient

 

claims for each month.

 

     (C) Number of hospital claims exceeding $50,000.00.

 

     (D) Number of medical claims exceeding $50,000.00.

 

     (E) Total expenditures for claims exceeding $50,000.00.

 

     (E) Number and total expenditures for all other medical claims

 

for equipment, devices, and services, including services rendered

 

in the private office of a physician or other health professional,

 

for each month.

 

     (ii) For a plan that provides prescription drug benefits,

 

information concerning enrollment and prescription drugs claims

 

under the plan, presented in a manner that clearly shows all of the

 

following:

 

     (A) For each month, the total number of covered employees and

 

the number of covered employees in each contract coverage type

 

included in the census under subdivision (a)(iv).

 

     (B) For each month, the total number of covered individuals

 

and the number of covered individuals in each contract coverage

type included in the census under subdivision (a)(iv).

 

     (C) (A) Amount charged and amount paid for prescription drugs

 

claims for each of the 3 most recent experience years.month.

 

     (D) (B) Total amount charged and amount paid for brand

 

prescription drugs claims for each of the 3 most recent experience

 

years.month.

 

     (E) (C) Total amount charged and amount paid for generic

 

prescription drugs claims for each of the 3 most recent experience

 

years.month.

 

     (F) Total amount charged and amount paid for specialty

 

prescription drug claims for each month.

 

     (G) (D) The 50 most frequently prescribed brand prescription

 

drugs for which claims were made for the most recent experience

 

period.frequently paid.

 

     (H) (E) The 50 most frequently prescribed generic prescription

 

drugs for which claims were made for the most recent experience

 

period.for which expenditures were the largest.

 

     (iii) For a plan that provides medical or prescription drug

 

benefits, in addition to the information required under

 

subparagraphs (i) and (ii), as applicable, information concerning

 

covered individuals with total medical or prescription drug claims,

 

or both, exceeding $25,000.00 for any 12-month period for which

 

claims utilization and cost information are provided, presented in

 

a manner that clearly shows all of the following separately for

 

each covered individual:

 

     (A) Total medical expenditures for the individual.

 

     (B) Total prescription drug expenditures for the individual.

     (C) Whether the covered individual is currently covered by the

 

medical benefit plan.

 

     (D) The covered individual's diagnoses.

 

     (iv) (iii) For a plan that provides dental benefits,

 

information concerning dental claims and total expenditures for

 

these claims under the plan, presented in a manner that clearly

 

shows at least all of the following: for each of the 3 most recent

 

experience years:

 

     (A) Number of claims submitted and total charged.

 

     (B) Number of and total expenditures for claims paid.

 

     (C) Total expenditures for claims submitted to network

 

providers.

 

     (v) (iv) For a plan that provides optical benefits,

 

information concerning optical claims and total expenditures for

 

these claims under the plan, presented in a manner that clearly

 

shows at least all of the following: for each of the 3 most recent

 

experience years:

 

     (A) Number of claims submitted and total charged.

 

     (B) Number of and total expenditures for claims paid.

 

     (C) Total expenditures for claims submitted to network

 

providers.

 

     (c) Fees and administrative expenses for the most recent

 

experience year, reported separately for health, medical,

 

prescription drug, dental, and optical plans, and presented in a

 

manner that clearly shows at least all of the following:

 

     (i) The dollar amounts paid for specific and aggregate stop-

 

loss insurance.

     (ii) The dollar amount of administrative expenses incurred or

 

paid, reported separately for medical, pharmacy, dental, and

 

vision.

 

     (iii) The total dollar amount of retentions and other

 

expenses.

 

     (iv) The dollar amount for all service fees paid.

 

     (v) The dollar amount of any fees or commissions paid to

 

agents, consultants, third party administrators, or brokers by the

 

medical benefit plan or by any public employer or carrier

 

participating in or providing services to the medical benefit plan,

 

reported separately for medical, pharmacy, prescription drug, stop-

 

loss, dental, and vision.

 

     (vi) Other information as may be required by the commissioner.

 

     (d) For health, medical, prescription drug, dental, and

 

optical plans, a benefit summary for the current year's plan and,

 

if benefits have changed during any of the 3 2 most recent

 

experience years, 12-month periods for which claims utilization and

 

cost information are provided, a brief benefit summary for each of

 

those experience years periods for which the benefits were

 

different.

 

     (4) Except as otherwise provided in subsection (3) and subject

 

to subsection (5), claims utilization and cost information required

 

to be compiled under this section shall must be compiled on an as

 

follows:

 

     (a) On an annual basis.

 

     (b) At the request of a public employer. A public employer may

 

not request claims utilization and cost information more than 4

times per calendar year. Claims utilization and cost information

 

compiled upon the request of a public employer must be compiled

 

within 30 days after the request. and shall

 

     (5) Claims utilization and cost information compiled under

 

this section must cover a relevant period. For purposes of this

 

subsection, the term "relevant period" means the 36-month 24-month

 

period ending no more than 120 60 days prior to before the

 

effective date or renewal date of compilation of the information

 

for the medical benefit plan under consideration. However, if the

 

medical benefit plan has been in effect for a period of less than

 

36 24 months, the relevant period shall be that shorter period.

 

     (6) (5) A public employer or combination of public employers

 

shall disclose the claims utilization and cost information required

 

to be provided under subsections (1) and (2) to any carrier or

 

administrator it solicits to provide benefits or administrative

 

services for its medical benefit plan, and to the employee

 

representative of employees covered under the medical benefit plan,

 

and upon request to any carrier or administrator who requests the

 

opportunity to submit a proposal to provide benefits or

 

administrative services for the medical benefit plan at the time of

 

the request for bids. The public employer shall make the claims

 

utilization and cost information required under this section

 

available at cost and within a reasonable period of time.

 

     (7) (6) The claims utilization and cost information required

 

under this section shall include only de-identified health

 

information as permitted under the health insurance portability and

 

accountability act of 1996, Public Law 104-191, or regulations

promulgated under that act, 45 CFR parts 160 and 164, and shall not

 

include any protected health information as defined in the health

 

insurance portability and accountability act of 1996, Public Law

 

104-191, or regulations promulgated under that act, 45 CFR parts

 

160 and 164.

 

     (7) All claims utilization and cost information described in

 

this section is required to be compiled beginning 60 days after the

 

effective date of this act. However, claims utilization and cost

 

information already being compiled on the effective date of this

 

act is subject to this section on the effective date of this act.

 

     Enacting section 1. This amendatory act takes effect 90 days

 

after the date it is enacted into law.