Bill Text: MI SB0689 | 2013-2014 | 97th Legislature | Introduced
Bill Title: Insurance; health; health plans for low-income individuals; create, and include direct primary care services and health savings accounts. Creates new act. TIE BAR WITH: SB 0688'13
Spectrum: Partisan Bill (Republican 3-0)
Status: (Introduced - Dead) 2013-11-14 - Referred To Committee On Appropriations [SB0689 Detail]
Download: Michigan-2013-SB0689-Introduced.html
SENATE BILL No. 689
November 14, 2013, Introduced by Senators CASWELL, PAPPAGEORGE and COLBECK and referred to the Committee on Appropriations.
A bill to create health coverage options for certain residents
of this state; to promote the availability and affordability of
health coverage in this state; to create a mechanism for residents
of this state to secure essential health care benefits; to create
funds; to provide for the powers and duties of certain state and
local governmental officers and entities; to allow for the
promulgation of rules; and to repeal acts and parts of acts.
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
"patient-centered care act".
(2) As used in this act, the words and phrases defined in
sections 103 to 111 have the meanings ascribed to them in those
sections.
Sec. 103. (1) "Contracted health plan" means that term as
defined in section 106 of the social welfare act, 1939 PA 280, MCL
400.106.
(2) "Covered primary care benefits" means the health care
treatment and services that are covered under the group 1 health
plan as established by the director under section 203.
(3) "Department" means the department of community health.
(4) "Director" means the director of the department.
Sec. 105. (1) "Exchange" means an entity certified under part
4 to provide a marketplace for residents to secure essential health
benefits through a health plan or government assistance program.
Exchange does not include an American health benefit exchange
operating in this state that is operated by the federal government
or pursuant to a federal-state partnership.
(2) "Federal act" means the patient protection and affordable
care act, Public Law 111-148, as amended by the health care and
education reconciliation act of 2010, Public Law 111-152.
(3) "Federal poverty line" means the poverty line published
periodically in the federal register by the United States
department of health and human services under its authority to
revise the poverty line under 42 USC 9902.
(4) "Government assistance" means financial assistance
received from a government assistance program.
(5) "Government assistance program" means a program of health
care assistance offered by a federal, state, or local governmental
entity, including, but not limited to, medicaid, medicare, the
MIChild program, the veterans health administration, and any other
program of health care assistance identified by the department.
Sec. 107. (1) "Group 1 eligible individual" means an
individual who meets all of the following:
(a) Is a resident.
(b) Is not eligible to enroll in any other government
assistance program.
(c) Has household income that does not exceed 100% of the
federal poverty line, for the size of the family involved.
(d) Is not eligible for minimum essential coverage, as defined
in section 5000A(f) of the internal revenue code of 1986, 26 USC
5000A, or is eligible for an employer-sponsored plan that is not
affordable coverage as determined under section 5000A(e)(2) of the
internal revenue code of 1986, 26 USC 5000A.
(2) "Group 1 health plan" means the Michigan group 1 health
plan created in section 203.
(3) "Group 1 health plan fund" means the Michigan group 1
health plan trust fund created in section 201.
(4) "Group 1 member" means a group 1 eligible individual who
is enrolled in the group 1 health plan and who fulfills all
conditions of participation in the group 1 health plan as provided
in part 2 or established by the department under part 2.
Sec. 109. (1) "Group 2 eligible individual" means an
individual who meets all of the following:
(a) Is a resident.
(b) Is not eligible to enroll in the group 1 health plan or
any other government assistance program.
(c) Has household income that does not exceed 133% of the
federal poverty line for the size of the family involved.
(d) Is not eligible for minimum essential coverage, as defined
in section 5000A(f) of the internal revenue code of 1986, 26 USC
5000A, or is eligible for an employer-sponsored plan that is not
affordable coverage as determined under section 5000A(e)(2) of the
internal revenue code of 1986, 26 USC 5000A.
(2) "Group 2 health plan" means a certified group 2 health
plan under part 3.
(3) "Group 2 health plan fund" means the Michigan group 2
health plan trust fund created in section 301.
(4) "Group 2 member" means a group 2 eligible individual who
is enrolled in a group 2 health plan under part 3 and who fulfills
all conditions of participation in the group 2 health plan as
provided in part 3 or established by the department under part 3.
Sec. 111. (1) "Medicaid" or "medical assistance program" means
the program of medical assistance established under title XIX of
the social security act, 42 USC 1396 to 1396w-5, and administered
by the department under the social welfare act, 1939 PA 280, MCL
400.1 to 400.119b.
(2) "Medicare" means the federal medicare program established
under title XVIII of the social security act, 42 USC 1395 to
1395kkk-1.
(3) "Resident" means an individual who is a citizen of the
United States or is legally present in the United States, who
voluntarily lives in this state with the intention of making his or
her home in this state and not for a temporary purpose, who has
lived in this state for 6 months or more, and who is not receiving
public or government assistance from another state.
Sec. 121. For the purpose of determining household income in
this act, the director shall use the modified adjusted gross
income-equivalent standards for this state that are approved under
section 1902(e)(14)(E) of the social security act, 42 USC 1396a.
Sec. 123. The department may promulgate rules under the
administrative procedures act of 1969, 1969 PA 306, MCL 24.201 to
24.328, that it considers necessary or appropriate to implement and
administer this act.
Sec. 125. The department shall request a determination from
the appropriate federal agency as to whether an employer that has
50 or more employees and that is subject to a penalty under the
federal act may, in lieu of paying the penalty, purchase a
catastrophic-only health benefit plan for an employee who attempts
to purchase a health benefit plan offered through an exchange or
through an American health benefit exchange operating in this state
pursuant to the federal law. If the federal agency approves the
proposal described in this section, the department shall implement
and administer a program to facilitate the purchase of a
catastrophic-only health benefit plan by an employer described in
this section.
Sec. 127. (1) Beginning April 1, 2015, the department shall
submit an annual report of its activities under this act to the
senate majority leader, the speaker of the house of
representatives, the chair of the house and senate appropriations
committees, the chair of the house and senate appropriations
subcommittees on community health, and the chair of the house and
senate appropriations subcommittees on human services. The chair of
the house or senate appropriations committee may request that
specific information regarding the department's activities under
this act be included in an annual report required under this
subsection. The department shall include information requested by a
committee chair in its next annual report required under this
subsection.
(2) In addition to information provided in an annual report
under subsection (1), the chair of the house or senate
appropriations committee may request information regarding the
department's activities under this act from the department at any
time. The department shall respond in a timely manner to a request
for information under this subsection.
PART 2. GROUP 1 HEALTH PLAN
Sec. 201. (1) The Michigan group 1 health plan trust fund is
created within the state treasury.
(2) The state treasurer may receive money or other assets from
any source for deposit into the group 1 health plan fund. The state
treasurer shall direct the investment of the group 1 health plan
fund. The state treasurer shall credit to the group 1 health plan
fund interest and earnings from group 1 health plan fund
investments.
(3) Money in the group 1 health plan fund at the close of the
fiscal year shall remain in the group 1 health plan fund and shall
not lapse to the general fund.
(4) The department is the administrator of the group 1 health
plan fund for auditing purposes.
(5) The director shall expend money from the group 1 health
plan fund to administer this part and, if money is available, to
provide additional benefits for group 1 members, including, but not
limited to, increasing the limit on inpatient hospitalization
coverage under section 203(3)(e)(ii).
Sec. 203. (1) The Michigan group 1 health plan is created in
the department. The director shall implement and administer the
group 1 health plan so that it is in compliance with this part and
is operational by January 1, 2014.
(2) The director shall do all of the following under this
part:
(a) Implement the group 1 health plan so that group 1 eligible
individuals enroll in the group 1 health plan through an exchange.
(b) Implement the group 1 health plan so that group 1 eligible
individuals are enrolled in the group 1 health plan with a
contracted health plan. The director shall ensure that health care
professionals who participate with a contracted health plan will
accept as a patient a group 1 eligible individual who enrolls in
that contracted health plan under this section.
(c) Establish or provide for the establishment of an
enrollment process that identifies whether an individual who is
attempting to enroll in the group 1 health plan is eligible for
enrollment in a government assistance program and that directs that
individual to enroll in the government assistance program.
(d) Implement a financial participation requirement so that
group 1 members pay a monthly household premium based on household
income for the size of the family involved as follows:
(i) For a household with income that is 25% or less of the
federal poverty line, a monthly household premium of $5.00.
(ii) For a household with income that is more than 25% and 50%
or less of the federal poverty line, a monthly household premium of
$10.00.
(iii) For a household with income that is more than 50% and 79%
or less of the federal poverty line, a monthly household premium of
$15.00.
(iv) For a household with income that is more than 79% and 100%
or less of the federal poverty line, a monthly household premium of
$20.00.
(e) Implement the group 1 health plan so that payments to
federally qualified health centers for a covered primary care
benefit are no more than the medical assistance program paid for
the covered primary care benefit at the levels provided for in the
2011-2012 state fiscal year.
(f) Implement the group 1 health plan in a manner that ensures
that the group 1 health plan is the payor of last resort.
(g) Implement the group 1 health plan so that any cost-sharing
requirements are equal to those required under the medical
assistance program. For the purposes of this subdivision, cost-
sharing requirement includes a copayment, coinsurance, or
deductible.
(3) The director shall establish or modify the health care
treatment and services that will be covered primary care benefits,
subject to all of the following:
(a) Except as otherwise specifically provided in this part,
include at a minimum essential health benefits as described in 42
USC 18022(b).
(b) Provide for the coverage of primary care and preventive
services in the same manner as provided for under medicaid
diagnosis related group codes and at the levels provided for in the
2011-2012 state fiscal year.
(c) Except as otherwise provided in this subdivision, provide
for the coverage of prescription drugs and require the use of
generic prescription drugs if a generic alternative exists for a
brand-name product, as recommended by the group 1 member's
prescribing provider and as is consistent with section 109h of the
social welfare act, 1939 PA 280, MCL 400.109h, and part 97 of the
public health code, 1978 PA 368, MCL 333.9701 to 333.9709.
(d) Provide for the coverage of certain specified outpatient
hospital procedures.
(e) Provide for the coverage of inpatient hospitalization with
coverage limited as follows:
(i) Except as otherwise provided in subparagraph (ii), to an
amount not to exceed the amount that would have been payable for
that coverage under the medical assistance program at the levels
provided for in the 2011-2012 state fiscal year.
(ii) To an amount not to exceed $35,000.00 a year, or a higher
limit if increased under section 201(5), for each covered
individual.
(f) Provide coverage for substance use disorder treatment
services, which services must be bid out based on performance
objectives established by the department.
(g) Provide coverage for mental health services that are
obtained through a specialty prepaid health plan under the medical
assistance program or that are bid out based on performance
objectives established by the department.
Sec. 205. The department shall transmit all money received
under this part, including all financial participation payments
from group 1 members required under section 203, to the state
treasurer for deposit into the group 1 health plan fund.
Sec. 207. A contracted health plan shall comply with this part
to enroll group 1 eligible individuals as members of the group 1
health plan. A contracted health plan shall comply with performance
objectives established by the department under this part. The
department shall establish clear performance objectives in order to
ensure success of the group 1 health plan in this state.
Sec. 209. Upon enrollment, a group 1 member shall comply with
all conditions of participation in the group 1 health plan,
including any financial participation requirements established
under this part. A group 1 member who violates this section may be
removed from enrollment in the group 1 health plan. An individual
who is removed from enrollment in the group 1 health plan is not
eligible for covered primary care benefits under the group 1 health
plan for a period of at least 3 months. An individual who has been
removed from enrollment in the group 1 health plan under this
section may reapply for enrollment in the group 1 health plan after
the 3-month penalty period has expired if the individual has paid
any previously unsatisfied financial participation requirements.
Sec. 211. This part is repealed effective January 1, 2017.
PART 3. GROUP 2 HEALTH PLANS
Sec. 301. (1) The Michigan group 2 health plan trust fund is
created within the state treasury.
(2) The state treasurer may receive money or other assets from
any source for deposit into the group 2 health plan fund. The state
treasurer shall direct the investment of the group 2 health plan
fund. The state treasurer shall credit to the group 2 health plan
fund interest and earnings from group 2 health plan fund
investments.
(3) Money in the group 2 health plan fund at the close of the
fiscal year shall remain in the group 2 health plan fund and shall
not lapse to the general fund.
(4) The department is the administrator of the group 2 health
plan fund for auditing purposes.
(5) Except as otherwise provided in subsection (6), the
director shall expend money from the group 2 health plan fund only
for the purposes of implementing and administering this part and
for any other purpose enumerated in this part.
(6) Except as otherwise provided in this subsection, the
director shall expend money from the group 2 health plan fund that
is attributable to deposits pursuant to section 105g of the social
welfare act, 1939 PA 280, MCL 400.105g, only as a deposit into a
health savings account for use by the group 2 member to which that
deposit is directed or to pay for the package of benefits selected
by a group 2 member to which that deposit is directed, or both. The
department shall expend money from the group 2 health plan that is
in excess of the amount necessary for the purposes described in
this subsection for use by group 2 members to cover any expenses
related to obtaining quality health care that are not covered under
the package of benefits selected by the group 2 member under this
part.
Sec. 303. (1) For the purpose of health plan choices for
residents, the department shall certify as a group 2 health plan a
benefit plan that complies with 42 USC 18021 or 42 USC 18022 and
that meets the requirements of this section. If the federal act is
repealed or the department determines that it is no longer
effective in this state, a benefit plan does not need to comply
with 42 USC 18021 or 42 USC 18022 to be certified as a group 2
health plan under this section.
(2) In certifying a benefit plan as a group 2 health plan
under this section, the director shall ensure that the benefit plan
meets all of the following requirements:
(a) Is offered by a health insurer issuer as described in 42
USC 18021(a)(1)(C).
(b) Offers access to quality health care by providing coverage
under a package of benefits that is equal to or greater than that
required as an essential health benefits package as defined in 42
USC 18022. The department shall consider all of the following when
making its determination under this subdivision:
(i) The availability in the package of benefits under a
traditional insurance option.
(ii) The availability in the package of direct primary care
services.
(iii) The availability in the package of fee-for-service
options, but only if there is a sufficient balance in the group 2
member's health savings account to cover minimum essential benefits
in combination with other coverage.
(iv) The availability in the package of the benefits available
under Medicaid.
(v) The availability in the package of any combination of the
options described in subparagraphs (i) to (iv).
(c) Enrolls group 2 eligible individuals in a group 2 health
plan through an exchange.
(d) For a group 2 member who receives money from the group 2
health plan fund that is attributable to a deposit pursuant to
section 105g of the social welfare act, 1939 PA 280, MCL 400.105g,
provides coverage for elective abortions only by an optional rider.
To be eligible to purchase a rider described in this subdivision, a
group 2 member shall deposit money from his or her personal money
into a health savings account sufficient to cover the cost of the
rider.
Sec. 305. The department shall transmit all money received
under this part to the state treasurer for deposit into the group 2
health plan fund. The department shall transmit all money received
under section 105g of the social welfare act, 1939 PA 280, MCL
400.105g, designated for use under this part to the state treasurer
for deposit into the group 2 health plan fund but only for the use
described in section 301(6).
PART 4. MARKETPLACE
Sec. 401. (1) If money is received under section 105g of the
social welfare act, 1939 PA 280, MCL 400.105g, and deposited into
the group 2 health fund, the director shall, subject to this
section and section 301, expend the money to defray the cost to
this state to pay for the package of benefits selected by a group 2
member, for deposit into group 2 member's health savings accounts,
and to cover other expenses related to obtaining quality health
care that are not covered under the package of benefits selected by
group 2 members.
(2) The director shall not pay deductibles or make payments to
cover other expenses as described in subsection (1) for services
related to an elective abortion.
(3) The director shall pay deductibles and make payments to
cover other expenses as described in subsection (1) for a group 2
member until such time as the group 2 member's individual health
savings account balance is determined by the department to be
actuarially sufficient to cover his or her deductibles and other
expenses.
Sec. 403. (1) The department shall establish and administer a
program to certify a private entity as an exchange eligible to
enroll residents in the group 1 health plan or a group 2 health
plan in this state. The granting of a certificate to a
nongovernmental entity to be an exchange eligible to enroll
residents in the group 1 health plan or a group 2 health plan in
this state is governed solely by this act and is not subject to
federal regulations governing the establishment and operation of an
American health benefit exchange under the federal act. The
department shall develop an application form and require the
submission of documents and information sufficient to determine if
the applicant is eligible for a certificate or renewal of a
certificate as an exchange eligible for a certificate under this
section. The director shall issue a certificate or renewal of a
certificate to a person who applies to be an exchange and who meets
all of the following requirements:
(a) The individuals who are identified as being a part of or
associated with the exchange are of good moral character as defined
in section 1200 of the insurance code of 1956, 1956 PA 218, MCL
500.1200.
(b) The person submits with an application a plan of operation
that details its ability to meet the requirements of this section.
(2) The department shall determine the merits of each
application submitted by a person under this section. The
department may request additional information from an applicant
under this section. An applicant shall comply with requests for
additional information from the department in a timely manner.
(3) In addition to criteria established by the department
under this section, the department shall determine that the
exchange to be operated by the applicant meets all of the following
requirements before issuing a certificate or certificate renewal
under this section:
(a) Is designed to enroll group 1 eligible individuals in the
group 1 health plan under part 2.
(b) Is designed to offer 1 or more group 2 health plans and
enroll a group 2 eligible individual in a group 2 health plan.
(c) Except as otherwise provided in this subdivision, is
designed to offer 1 or more qualified health plans as that term is
defined in the federal act to residents. If the federal act is
repealed or the department determines that it is no longer
effective in this state, an exchange does not need to be designed
to offer 1 or more qualified health plans to residents.
(d) Will comply with all data security requirements
established by the department for an exchange.
(e) Is designed so that the enrollment process provides a
resident with the option to provide information necessary to
determine the resident's eligibility for government assistance
programs.
(f) Will ensure accuracy in all aspects of the operation of
the exchange.
(g) Will operate with fiscal solvency.
(h) Will seamlessly and securely make data transmissions that
are required under this act.
(i) Will convey government assistance program eligibility
information to residents.
(j) Will comply with any other applicable federal or state law
governing the privacy of any personally identifying information or
health or medical information of a resident.
(k) Will ensure that a resident who is eligible for a
government assistance program receives a discount from the base
cost of a benefit package in a manner that will enable the resident
to realize 100% of the value of the government assistance program.
(l) If the department determines that the conveyance of
government assistance through an exchange is not allowed under the
federal act, will be authorized to issue a coupon to a resident who
is eligible for government assistance that may be redeemed by the
resident at the government assistance portal or other appropriate
state or local agency.
(4) In developing security standards and data transmission
requirements applicable to an exchange under this act, the
department shall ensure all of the following:
(a) That no information beyond that information necessary to
determine eligibility for government assistance programs is
transmitted to any person outside of the exchange.
(b) That a standardized data schema is used for exchanges to
collect the information that is necessary to determine eligibility
for government assistance programs and convey information
pertaining to that eligibility.
Sec. 405. (1) The department shall develop and maintain a
government assistance portal for use by exchanges and, if the
department determines appropriate, by government assistance
programs that facilitates the receipt and transmission of data but
only for uses approved by the department under this act.
(2) The department shall reconcile an individual's eligibility
for group 1 membership, for group 2 membership, and for multiple
government assistance programs to ensure that enrollment or benefit
eligibility is determined in the context of cumulative benefits
received as a means of reducing duplication of benefits and fraud.
Enacting section 1. This act does not take effect unless
Senate Bill No.680
of the 97th Legislature is enacted into law.
