Bill Text: MI SB0872 | 2009-2010 | 95th Legislature | Introduced
Bill Title: Mental health; other; local grievance process and request for external review; modify. Amends 1974 PA 258 (MCL 330.1001 - 330.2106) by adding sec. 709.
Spectrum: Partisan Bill (Democrat 10-0)
Status: (Introduced - Dead) 2009-09-24 - Referred To Committee On Health Policy [SB0872 Detail]
Download: Michigan-2009-SB0872-Introduced.html
SENATE BILL No. 872
September 24, 2009, Introduced by Senators THOMAS, BRATER, JACOBS, CLARK-COLEMAN, SCOTT, CHERRY, OLSHOVE, ANDERSON, BASHAM and SWITALSKI and referred to the Committee on Health Policy.
A bill to amend 1974 PA 258, entitled
"Mental health code,"
(MCL 330.1001 to 330.2106) by adding section 709.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 709. (1) The department shall establish a policy
directive on local grievance procedures that all community mental
health services programs shall be required to follow.
(2) The department's policy directive shall require a
community mental health services program to reach a decision on a
local grievance within 35 calendar days from the date a grievance
is filed by an applicant, a recipient, a guardian of an applicant
or recipient, or an authorized representative of the applicant,
recipient, or guardian.
(3) If a mental health professional communicates orally or in
writing to a community mental health services program that the
applicant or recipient is experiencing an emergency situation, the
community mental health services program is required to reach a
decision within 72 hours of receiving that communication.
(4) If the filing applicant, recipient, guardian, or
authorized representative is dissatisfied with the decision of the
community mental health services program under the local grievance
process, he or she may request within 60 calendar days of that
decision, or within 10 calendar days if the grievance represented
an emergency situation, that the department arrange for an external
review of the grievance if both of the following apply:
(a) The grievance involves a community mental health services
program determination that an admission, availability of care,
continued stay, or other specialty mental health service or support
is denied, reduced, suspended, or terminated due to lack of medical
necessity.
(b) The applicant or recipient does not have legal recourse to
participate in the medicaid fair hearing process regarding the
determination of the community mental health services program.
(5) Upon receipt of a request for an external review, the
department shall provide written notification of receipt to the
involved community mental health services program.
(6) Not later than 5 business days after receiving a request
for an external review, or not later than 24 hours if the grievance
represented an emergency situation, the department shall determine
whether external review is warranted. The person filing the
grievance and the involved community mental health services program
shall receive written notification of the determination according
to 1 of the following:
(a) If external review is not warranted, the department shall
attempt to mediate the disagreement between the person filing the
grievance and the involved community mental health services
program.
(b) If external review is warranted and the service in
question is solely or primarily of a treatment nature, the
department shall arrange for the review to be conducted by a
psychiatrist who has no employment, contractual, or other
relationship with the department or any community mental health
services program.
(c) If external review is warranted and the service in
question is solely or primarily of a support nature, the department
shall arrange for the external review to be conducted by a mental
health professional who has experience with the service in
question, and who has no employment, contractual, or other
relationship with the department or any community mental health
services program.
(7) In arranging for an external review, the department shall
forward immediately to the external reviewer written material
submitted to the department by the person filing the grievance. The
external reviewer may request that the person filing the grievance
provide additional information within 7 business days or within 1
business day if the grievance represented an emergency situation.
(8) Upon receiving notification that an external review is to
be conducted, the involved community mental health services program
has 7 business days to provide the external reviewer with all
documents and information utilized by the community mental health
services program in making its local grievance decision. If the
grievance represented an emergency situation, the material shall be
provided within 1 business day. Initial notification of the 1-day
requirement may be verbal. Failure of a community mental health
services program to provide the required material within the
prescribed time frame shall result in the department ordering an
immediate reversal of the local grievance decision.
(9) An external reviewer shall make a recommendation to the
department within 10 business days after receipt of information
under subsections (7) and (8) or within 48 hours from the receipt
of that information if the grievance represented an emergency
situation.
(10) Upon receipt of a recommendation from an external
reviewer, the department shall make a binding administrative
decision about the case within 7 business days or within 24 hours
if the grievance represented an emergency situation. Initial notice
of the decision may be provided orally to the person filing the
grievance and the involved community mental health services
program. In all cases, both parties shall be provided written
notification that shall minimally include both of the following:
(a) The recommendation made by the external reviewer and the
rationale for that recommendation.
(b) If applicable, the rationale for why the department did
not follow the external reviewer's recommendation.
(11) At any time before the binding administrative decision
from the department, the external review process is abrogated if
the person filing the grievance makes a written request for
withdrawal or if the involved community mental health services
program provides written notification that it has elected to
authorize the action sought by the person filing the grievance.
(12) In making a determination under subsection (6) or (10),
the department may consider all information it considers relevant,
including, but not limited to, all of the following:
(a) The applicant's or recipient's diagnosis, prognosis, and
case history.
(b) The severity of the applicant's or recipient's condition
and the degree to which the applicant's or recipient's
circumstances meet the criteria described in section 208 for
priority services.
(c) The financial resources available to the involved
community mental health services program.
(d) The degree to which the community mental health services
program utilized appropriate person-centered planning procedures.
(e) The quality of the written individualized plan of service
and the degree of consumer participation in developing it.
(f) The availability of the service desired by the person
filing the grievance.
(g) The existence of co-occurring medical conditions.
(h) The degree of involvement required from any provider who
is not a mental health human service provider in addressing the
situation.
(13) The department shall provide the legislature annually
with a report for each community mental health services program and
the state in aggregate that includes the following details:
(a) The number of local grievances filed, categorized
according to emergent or nonemergent status and whether or not the
person filing the grievance had legal recourse to the medicaid fair
hearing process.
(b) The number of filed local grievances, categorized
according to subdivision (a), in which agreement between the
parties negated a need for a local grievance decision by the
community mental health services program.
(c) The number of local grievance decisions, categorized
according to subdivision (a), upholding the initial determination
of the community mental health services program.
(d) The number of local grievance decisions, categorized
according to emergent or nonemergent status, resulting in requests
for external review.
(e) The number of requests for external review, categorized
according to subdivision (d), that were not honored by the
department, and the outcomes of the department's mediation efforts
for those cases.
(f) The number of requests for external review, categorized
according to subdivision (d), honored by the department.
(g) The number of external review cases, categorized according
to subdivision (d), in which the community mental health services
program's failure to provide required material within prescribed
time frames resulted in default judgment for the person filing the
grievance.
(h) The number of external review cases, categorized according
to subdivision (d), withdrawn before final administrative decision
at the request of community mental health services programs.
(i) The number of external review cases, categorized according
to subdivision (d), withdrawn before final administrative decision
at the request of a person filing a grievance.
(j) The number of external review cases, categorized according
to subdivision (d), in which the external review recommendation
respectively favored community mental health services programs and
parties filing grievances.
(k) The number of external review cases, categorized according
to subdivision (d), in which the department overturned the external
reviewer recommendation, and the numbers of those overturned
external reviewer recommendations that respectively favored
community mental health services programs and parties filing
grievances.
(14) As used in this section:
(a) "Grievance" means a written communication from or on
behalf of the applicant or recipient, reflecting disagreement with
a community mental health services program or its provider network
over 1 or more of the following:
(i) The denial, reduction, suspension, or termination of
services.
(ii) The timeliness of responses to requests for services.
(iii) The clinical, cultural, or linguistic appropriateness of
services offered or rendered.
(iv) The availability of services offered or rendered.
(v) The performance and behavior of individual service
providers and employees.
(b) "Medical necessity" means screening, assessment, treatment
or support that is consistent with generally accepted mental health
and health care practices, addresses symptoms or the existence of
serious mental illness, serious emotional disturbance,
developmental disability, or substance use disorder, as well as
impairments in daily functioning related to these disorders, and is
for the purpose of preventing either the need for more intensive
levels of treatment or relapses and deterioration of an
individual's mental, emotional, developmental, or behavioral
condition.
