Bill Text: MI SB0096 | 2017-2018 | 99th Legislature | Introduced

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Bill Title: Insurance; health insurers; health insurance claims assessment act; exempt Michigan's federally recognized Indian tribes. Amends sec. 2 of 2011 PA 142 (MCL 550.1732) & adds sec. 2a.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2017-02-02 - Referred To Committee On Insurance [SB0096 Detail]

Download: Michigan-2017-SB0096-Introduced.html

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SENATE BILL No. 96

 

 

February 2, 2017, Introduced by Senators SCHMIDT, NOFS and JONES and referred to the Committee on Insurance.

 

 

 

     A bill to amend 2011 PA 142, entitled

 

"Health insurance claims assessment act,"

 

by amending section 2 (MCL 550.1732) and by adding section 2a.

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

     Sec. 2. As used in this act:

 

     (a) "Carrier" means any of the following:

 

     (i) An insurer or health maintenance organization regulated

 

under the insurance code of 1956, 1956 PA 218, MCL 500.100 to

 

500.8302.

 

     (ii) A health care corporation regulated under the nonprofit

 

health care corporation reform act, 1980 PA 350, MCL 550.1101 to

 

550.1704.

 

     (iii) A nonprofit dental care corporation subject to 1963 PA

 

125, MCL 550.351 to 550.373.

 

     (iv) A specialty prepaid health plan.

     (v) A group health plan sponsor including, but not limited to,

 

1 or more of the following:

 

     (A) An employer if a group health plan is established or

 

maintained by a single employer.

 

     (B) An employee organization if a plan is established or

 

maintained by an employee organization.

 

     (C) If a plan is established or maintained by 2 or more

 

employers or jointly by 1 or more employers and 1 or more employee

 

organizations, the association, committee, joint board of trustees,

 

or other similar group of representatives of the parties that

 

establish or maintain the plan.

 

     (b) "Claims-related expenses" means all of the following:

 

     (i) Cost containment expenses including, but not limited to,

 

payments for utilization review, care or case management, disease

 

management, medication review management, risk assessment, and

 

similar administrative services intended to reduce the claims paid

 

for health and medical services rendered to covered individuals by

 

attempting to ensure that needed services are delivered in the most

 

efficacious manner possible or by helping those covered individuals

 

maintain or improve their health.

 

     (ii) Payments that are made to or by an organized group of

 

health and medical service providers in accordance with managed

 

care risk arrangements or network access agreements, which payments

 

are unrelated to the provision of services to specific covered

 

individuals.

 

     (iii) General administrative expenses.

 

     (c) "Commissioner" means the commissioner of the office of

financial and insurance regulation or his or her designee.director.

 

     (d) "Department" means the department of treasury.

 

     (e) "Director" means the director of the department of

 

insurance and financial services or his or her designee.

 

     (f) (e) "Excess loss" or "stop loss" means coverage that

 

provides insurance protection against the accumulation of total

 

claims exceeding a stated level for a group as a whole or

 

protection against a high-dollar claim on any 1 individual.

 

     (g) (f) "Federal employee health benefit program" means the

 

program of health benefits plans, as defined in 5 USC 8901,

 

available to federal employees under 5 USC 8901 to 8914.

 

     (h) (g) "Fund" means the health insurance claims assessment

 

fund created in section 7.

 

     (i) (h) "Group health plan" means an employee welfare benefit

 

plan as defined in section 3(1) of subtitle A of title I of the

 

employee retirement income security act of 1974, Public Law 93-406,

 

29 USC 1002, to the extent that the plan provides medical care,

 

including items and services paid for as medical care to employees

 

or their dependents as defined under the terms of the plan directly

 

or through insurance, reimbursement, or otherwise.

 

     (j) (i) "Group insurance coverage" means a form of voluntary

 

health and medical services insurance that covers members, with or

 

without their eligible dependents, and that is written under a

 

master policy.

 

     (k) (j) "Health and medical services" means 1 or more of the

 

following:

 

     (i) Services included in furnishing medical care, dental care,

pharmaceutical benefits, or hospitalization, including, but not

 

limited to, services provided in a hospital or other medical

 

facility.

 

     (ii) Ancillary services, including, but not limited to,

 

ambulatory services and emergency and nonemergency transportation.

 

     (iii) Services provided by a physician or other practitioner,

 

including, but not limited to, health professionals, other than

 

veterinarians, marriage and family therapists, athletic trainers,

 

massage therapists, licensed professional counselors, and

 

sanitarians, as defined by article 15 of the public health code,

 

1978 PA 368, MCL 333.16101 to 333.18838.

 

     (iv) Behavioral health services, including, but not limited

 

to, mental health and substance abuse services.

 

     (l) (k) "Managed care risk arrangement" means an arrangement

 

where by which participating hospitals and physicians agree to a

 

managed care risk incentive which that shares favorable and

 

unfavorable claims experience. Under a managed care risk

 

arrangement, payment to a participating physician is generally

 

subject to a retention requirement and the distribution of that

 

retained payment is contingent on the result of the risk incentive

 

arrangement.

 

     (m) (l) "Medicaid contracted health plan" means a contracted

 

health plan as that term as is defined in section 106 of the social

 

welfare act, 1939 PA 280, MCL 400.106.

 

     (n) (m) "Medicaid managed care organization" means a medicaid

 

Medicaid contracted health plan or a specialty prepaid health plan.

 

     (o) (n) "Medical inflation rate" means that rate determined by

the annual national health expenditures accounts report issued by

 

the federal centers Centers for medicare Medicare and medicaid

 

services, office Medicaid Services, Office of the actuary. Actuary.

 

     (p) (o) "Medicare" means the federal medicare Medicare program

 

established under title XVIII of the social security act, 42 USC

 

1395 to 1395kkk-1.1395lll.

 

     (q) (p) "Medicare advantage plan" means a plan of coverage for

 

health benefits under part C of title XVIII of the social security

 

act, 42 USC 1395w-21 to 1395w-29.1395w-28.

 

     (r) (q) "Medicare part D" means a plan of coverage for

 

prescription drug benefits under part D of title XVIII of the

 

social security act, 42 USC 1395w-101 to 1395w-152.1395w-154.

 

     (s) "Michigan Indian tribe" means a federally recognized

 

Indian tribe that has trust lands located within this state.

 

     (t) (r) "Network access agreement" means an agreement that

 

allows a network access to another provider network for certain

 

services that are not readily available in the accessing network.

 

     (u) (s) "Paid claims" means actual payments, net of

 

recoveries, made to a health and medical services provider or

 

reimbursed to an individual by a carrier, third party

 

administrator, or excess loss or stop loss carrier. Paid claims

 

include payments, net of recoveries, made under a service contract

 

for administrative services only, cost-plus or noninsured benefit

 

plan arrangements under section 211 of the nonprofit health care

 

corporation reform act, 1980 PA 350, MCL 550.1211, or section 5208

 

of the insurance code of 1956, 1956 PA 218, MCL 500.5208, for

 

health and medical services provided under group health plans, any

claims for service in this state by a pharmacy benefits manager,

 

and individual, nongroup, and group insurance coverage to residents

 

of this state in this state that affect the rights of an insured in

 

this state and bear a reasonable relation to this state, regardless

 

of whether the coverage is delivered, renewed, or issued for

 

delivery in this state. If a carrier or a third party administrator

 

is contractually entitled to withhold a certain amount from

 

payments due to providers of health and medical services in order

 

to help ensure that the providers can fulfill any financial

 

obligations they may have under a managed care risk arrangement,

 

the full amounts due the providers before that amount is withheld

 

shall must be included in paid claims. Paid claims include claims

 

or payments made under any federally approved waiver or initiative

 

to integrate medicare Medicare and medicaid Medicaid funding for

 

dual eligibles under the patient protection and affordable care

 

act, Public Law 111-148, and the health care and education

 

reconciliation act of 2010, Public Law 111-152. Paid claims do not

 

include any of the following:

 

     (i) Claims-related expenses.

 

     (ii) Payments made to a qualifying provider under an incentive

 

compensation arrangement if the payments are not reflected in the

 

processing of claims submitted for services rendered to specific

 

covered individuals.

 

     (iii) Claims paid by carriers or third party administrators

 

for specified accident, accident-only coverage, credit, disability

 

income, long-term care, health-related claims under automobile

 

insurance, homeowners insurance, farm owners, commercial multi-

peril, and worker's compensation, or coverage issued as a

 

supplement to liability insurance.

 

     (iv) Claims paid for services rendered to a nonresident of

 

this state.

 

     (v) The proportionate share of claims paid for services

 

rendered to a person covered under a health benefit plan for

 

federal employees.

 

     (vi) Claims paid for services rendered outside of this state

 

to a person who is a resident of this state.

 

     (vii) Claims paid under a federal employee health benefit

 

program, medicare, medicare advantage, medicare Medicare, Medicare

 

Advantage, Medicare part D, tricare, Tricare, by the United States

 

veterans administration, Veterans Administration, and for high-risk

 

pools established pursuant to the patient protection and affordable

 

care act, Public Law 111-148, and the health care and education

 

reconciliation act of 2010, Public Law 111-152.

 

     (viii) Reimbursements to individuals under a flexible spending

 

arrangement as that term is defined in section 106(c)(2) of the

 

internal revenue code of 1986, 26 USC 106, a health savings account

 

as that term is defined in section 223 of the internal revenue code

 

of 1986, 26 USC 223, an Archer medical savings account MSA as that

 

term is defined in section 220 of the internal revenue code of

 

1986, 26 USC 220, a medicare Medicare advantage medical savings

 

account MSA as that term is defined in section 138 of the internal

 

revenue code of 1986, 26 USC 138, or other health reimbursement

 

arrangement authorized under federal law.

 

     (ix) Health and medical services costs paid by an individual

for cost-sharing requirements, including deductibles, coinsurance,

 

or copays.

 

     (v) (t) "Qualifying provider" means a provider that is paid

 

based on an incentive compensation arrangement.

 

     (w) (u) "Specialty prepaid health plan" means that term as

 

described in section 109f of the social welfare act, 1939 PA 280,

 

MCL 400.109f.

 

     (x) (v) "Third party administrator" means an entity that

 

processes claims under a service contract and that may also provide

 

1 or more other administrative services under a service contract.

 

     Sec. 2a. This act does not apply to claims paid under an

 

employee health benefit program that is maintained by a Michigan

 

Indian tribe.

 

     Enacting section 1. This amendatory act takes effect 90 days

 

after the date it is enacted into law.