September 10, 2015, Introduced by Senator SCHMIDT 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 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.