HOUSE BILL No. 4978


     June 19, 2001, Introduced by Reps. Reeves, Bovin, Schauer, Adamini, Rivet, Bernero, Hardman, Phillips and Lemmons and referred to the
Committee on Insurance and Financial Services.


        A bill to amend 1956 PA 218, entitled

   "The insurance code of 1956,"

   (MCL 500.100 to 500.8302) by adding section 3518.

               THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

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           SEC. 3518.  (1) IF REQUESTED BY AN ENROLLEE, A HEALTH MAIN-

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      TENANCE ORGANIZATION SHALL PROVIDE OR AUTHORIZE A SECOND OPINION

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      BY AN APPROPRIATELY QUALIFIED HEALTH PROFESSIONAL FOR ANY OF THE

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      FOLLOWING REASONS:

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           (A) IF THE ENROLLEE QUESTIONS THE REASONABLENESS OR NECES-

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      SITY OF A RECOMMENDED SURGICAL PROCEDURE.

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           (B) IF THE ENROLLEE QUESTIONS A DIAGNOSIS OR PLAN OF CARE

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      FOR A CONDITION THAT THREATENS LOSS OF LIFE, LOSS OF LIMB, LOSS

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      OF BODILY FUNCTION, OR SUBSTANTIAL IMPAIRMENT, INCLUDING, BUT NOT

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      LIMITED TO, A SERIOUS CHRONIC CONDITION.




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           (C) IF THE CLINICAL INDICATIONS ARE NOT CLEAR OR ARE COMPLEX

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      AND CONFUSING, A DIAGNOSIS IS IN DOUBT DUE TO CONFLICTING TEST

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      RESULTS, OR THE TREATING HEALTH PROFESSIONAL IS UNABLE TO DIAG-

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      NOSE THE CONDITION.

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           (D) IF THE TREATMENT PLAN IN PROGRESS IS NOT IMPROVING THE

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      ENROLLEE'S MEDICAL CONDITION WITHIN AN APPROPRIATE PERIOD OF TIME

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      GIVEN THE DIAGNOSIS AND PLAN OF CARE.

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           (2) IF THE HEALTH MAINTENANCE ORGANIZATION APPROVES A

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      REQUEST FOR A SECOND OPINION TO BE GIVEN BY A NONAFFILIATED QUAL-

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      IFIED HEALTH PROFESSIONAL, THE HEALTH MAINTENANCE ORGANIZATION IS

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      RESPONSIBLE TO PAY FOR THE SECOND OPINION ONLY WHAT THE HEALTH

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      MAINTENANCE ORGANIZATION WOULD PAY FOR A SECOND OPINION BY AN

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      AFFILIATED QUALIFIED HEALTH PROFESSIONAL.

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           (3) AS USED IN THIS SECTION, "APPROPRIATELY QUALIFIED HEALTH

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      PROFESSIONAL" MEANS A PRIMARY CARE PHYSICIAN OR A SPECIALIST WHO

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      IS ACTING WITHIN HIS OR HER SCOPE OF PRACTICE AND WHO POSSESSES A

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      CLINICAL BACKGROUND, INCLUDING TRAINING AND EXPERTISE, RELATED TO

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      THE PARTICULAR ILLNESS, DISEASE, OR CONDITION ASSOCIATED WITH THE

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      REQUEST FOR A SECOND OPINION.



















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