March 15, 2005, Introduced by Rep. Green and referred to the Committee on Tax Policy.
A bill to create the fund for uninsured patients with grave
illnesses; to provide for the investment and expenditure of money
in the fund; to require the promulgation of rules; to provide for
disbursement from the fund; to provide for appropriations; and to
prescribe the powers and duties of certain state and local
governmental officers and agencies.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 1. This act shall be known and may be cited as the "fund
for uninsured patients with grave illnesses act".
Sec. 2. As used in this act:
(a) "Applicant" means the individual who applies for
assistance under this act or, if the application is filed by
another, the individual on whose behalf the application is filed.
(b) "Department" means the department of community health.
(c) "Fund" means the fund for uninsured patients with grave
illnesses created in section 3.
(d) "Fund contract" means a contract between a local health
department and 1 or more health care providers that complies with
section 11 and implements and finances an approved treatment plan.
(e) "Grave illness" means a medical condition that meets both
of the following criteria:
(i) The condition requires specialized medical treatment,
hospitalization, or both.
(ii) The condition will more likely than not result directly in
death within 12 months if not treated.
(f) "Health care provider" means a person licensed, certified,
or registered under parts 161 to 182 of the public health code,
1978 PA 368, MCL 333.16101 to 333.18237.
(g) "Local health department" means that term as defined in
section 1105 of the public health code, 1978 PA 368, MCL 333.1105.
(h) "Physician" means that term as defined in section 17001 or
17501 of the public health code, 1978 PA 368, MCL 333.17001 and
333.17501.
(i) "Prescription drug" means that term as defined in section
17708 of the public health code, 1978 PA 368, MCL 333.17708.
(j) "Private money" means money or other assets available to
finance a treatment plan that do not legally belong to the
applicant and that are not from private insurance or a federal,
state, or local government medical assistance program.
(k) "Treatment plan" means a written plan of services
developed by a health care provider and certified by a physician
under section 8.
Sec. 3. (1) The fund for uninsured patients with grave
illnesses is created within the state treasury.
(2) The state treasurer may receive contributions under
section 441 of the income tax act of 1967, 1967 PA 281, MCL
206.441, and money from any other source for deposit into the fund.
The state treasurer shall direct the investment of the fund. The
state treasurer shall credit to the fund interest and earnings from
fund investments.
(3) Money in the fund at the close of the fiscal year shall
remain in the fund and shall not lapse to the general fund.
Sec. 4. The department shall expend money from the fund, upon
appropriation, only for 1 or both of the following purposes:
(a) To supply money for fund contracts for the treatment of
patients with uninsured grave illnesses.
(b) To pay the costs of a local health department for services
provided under this act if sufficient appropriations are not made
by the legislature to cover those costs and if money from the fund
is available. A local health department is not required to provide
services under this act if the legislature does not appropriate
funds to the local health department to pay those costs.
Sec. 5. The department shall promulgate rules pursuant to the
administrative procedures act of 1969, 1969 PA 306, MCL 24.201 to
24.328, that do all of the following:
(a) Subject to section 7, establish approved medical services
for the treatment of specific grave illnesses based on existing
medicaid reimbursement rules, regulations, manuals, and policies.
(b) Establish criteria for the selection of patients to
receive the following organ and tissue transplant procedures:
(i) Kidney.
(ii) Liver.
(iii) Heart.
(iv) Lung.
(v) Bone marrow.
(c) Establish a schedule of fees for approved medical services
based on existing medicaid reimbursement rates.
(d) Establish methods and procedures to supervise and oversee
the implementation and administration of this act by local health
departments.
(e) Other procedures and policies the department considers
necessary to implement, administer, and enforce this act.
Sec. 6. (1) An individual is eligible to receive money from
the fund if all of the following apply:
(a) The individual is a citizen of the United States or a
legally resident alien.
(b) The individual is a resident of this state.
(c) The individual's household income is less than 300% of the
federal poverty guidelines. Private money shall not be considered
in determining eligibility. As used in this subdivision, "federal
poverty guidelines" means the poverty guidelines published annually
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.
(d) The individual has a grave illness.
(e) The individual has no insurance coverage for the medical
services necessary to treat a grave illness on the date of
application and is not eligible for reimbursement or payment for
the medical services necessary to treat the grave illness through
private insurance or federal, state, or local government medical
assistance programs.
(2) An individual eligible for benefits under subsection (1)
becomes ineligible when 1 or more of the circumstances that made
him or her eligible no longer applies.
Sec. 7. (1) The department shall include in rules promulgated
under section 5(a) only medical services it determines to be
effective in treating or ameliorating a grave illness and
reflective of the standard of practice for treating that grave
illness.
(2) The department may include the following types of medical
services in rules promulgated under section 5(a):
(a) Inpatient hospital services.
(b) Outpatient hospital services and ambulatory surgical
center services.
(c) Ambulatory care.
(d) Laboratory and x-ray services.
(e) Physician's services.
(f) Services provided by a health care provider within the
scope of his or her practice.
(g) Prescription drugs.
(h) Rehabilitative services to the extent necessary to recover
from medical treatment or the grave illness.
(i) If the patient meets selection criteria contained in rules
promulgated under section 5, the following organ and tissue
transplant procedures, including the procurement of necessary
organs and tissues:
(i) Kidney.
(ii) Liver.
(iii) Heart.
(iv) Lung.
(v) Bone marrow.
(3) The department shall not include the following types of
medical services in rules promulgated under section 5(a):
(a) Experimental or investigational medical services.
(b) Treatment for an illness that is expected to be terminal
even with the treatment.
(c) Transportation services.
(d) Mental health services.
(e) Nursing facility services.
(f) Case management.
(g) Hospice care.
(h) Private duty nursing services.
(i) Prosthetic devices.
(j) Eyeglasses, dentures, hearing aids, and other similar
devices.
(k) Alternative medicine therapies, including, but not limited
to, homeopathic remedies, hypnosis, or herbal remedies.
(l) Emergency medical services.
Sec. 8. (1) An application for assistance from the fund shall
be on a form prescribed by the department. An application may be
filed for or on behalf of an applicant who is a minor or
incapacitated individual by a parent, guardian, conservator, agent
or attorney in fact operating under a power of attorney, or patient
advocate designated to exercise powers concerning the individual's
care, custody, and medical treatment as provided in section 5506 of
the estates and protected individuals code, 1998 PA 386, MCL
700.5506. The application shall be signed by the applicant or
person filing the application for the applicant, and filed with a
local health department that has jurisdiction over the area where
the applicant resides. An applicant or person filing the
application for the applicant shall fully disclose in the
application all private money available to pay for a treatment
plan.
(2) An applicant or person filing the application for the
applicant shall submit both of the following with an application
under subsection (1):
(a) A statement signed by a physician who has examined the
applicant certifying that the applicant has a grave illness and
identifying the illness.
(b) A plan containing a course of medical services developed
by a potential contracting health care provider and certified by a
physician as appropriate for the applicant's grave illness.
(3) It is the responsibility of an applicant or the person
filing the application for the applicant to provide all information
necessary for a local health department to determine eligibility
and decide whether to approve the treatment plan. Failure to
complete the application, submit the items enumerated in subsection
(2), or provide information requested by the local health
department within 45 days after the date the original application
is filed is grounds to deny an application.
Sec. 9. (1) A local health department shall determine
eligibility for assistance from the fund and approve, modify, or
deny the treatment plan within 60 days after the date it received
the original signed application. The local health department is not
required to evaluate an application fully if it has determined that
there is at least 1 cause for denial. A local health department
shall advise an applicant or the person filing the application for
the applicant of its determination in writing within 60 days after
the date it received the original signed application.
(2) A local health department may approve a treatment plan as
submitted, modify and approve the submitted treatment plan, or deny
the submitted treatment plan. An approved treatment plan shall only
contain medical services contained in rules promulgated under
section 5(a).
(3) A local health department shall calculate an aggregate fee
for all of the medical services in an approved treatment plan
according to the schedule of fees established by the department in
rules promulgated under section 5.
(4) A local health department shall notify the department of
the local health department's approval of a treatment plan, the
aggregate fee determined for the treatment plan under subsection
(3), and the date of receipt of the original signed application.
(5) When advised by the department that money is available
from the fund for an approved treatment plan, a local health
department shall enter into a fund contract.
(6) An application may be denied if a health care provider
necessary to the approved treatment plan does not enter into a fund
contract within 30 days after the date that the local health
department is advised of the availability of money under subsection
(5). It is the responsibility of the applicant or the person who
filed the application for the applicant to find all necessary
health care providers willing to enter into a fund contract.
(7) If more than 60 days have elapsed between the date that a
local health department initially determines that an applicant is
eligible and approves the treatment plan and the date that the
local health department is advised of the availability of money to
fund a treatment plan under subsection (5), the local health
department may review and revise the eligibility and treatment plan
decisions and may require an applicant to update the information
provided in or with the original application.
Sec. 10. (1) The department shall review the information
received under section 9 from a local health department and
determine whether money is available in the fund for each approved
treatment plan.
(2) The department shall promptly advise a local health
department of its determination under this section.
Sec. 11. (1) A fund contract shall contain and is subject to
all of the provisions of this section.
(2) Reimbursement for services under a fund contract shall be
the aggregate fee calculated under section 9(3).
(3) A contracting health care provider may agree to less than
the full aggregate fee calculated under section 9(3) if the
contracting health care provider agrees to complete the approved
treatment plan with no additional payment by the applicant or,
except as provided in subsection (4), on behalf of the applicant.
(4) A contracting health care provider may accept private
money as payment for services. The total of private money and money
committed by the fund may not exceed the aggregate fee under
subsection (2). A fund contract shall not be contingent on private
money to be raised in the future.
(5) A fund contract shall commit money from the fund to a
treatment plan for up to 1 year from the date the contract is
entered into. The fund contract shall not commit money or pay for
services provided before the date the contract is entered into.
(6) A local health department may establish a schedule of
payments in the fund contract consistent with phases of the
approved treatment plan. A contracting health care provider shall
be paid on completion of the approved treatment plan or phases of
the approved treatment plan as specified in the contract. Payment
under a fund contract shall only be made directly to a contracting
health care provider.
(7) Payment as agreed to in the fund contract is payment in
full. The fund, the department, and a local health department are
not responsible for maintenance medication or any additional
treatment or services not contained in the approved treatment plan.
(8) An approved treatment plan may be modified after a fund
contract is entered into by all necessary health care providers
only if the medical condition of the applicant substantially
changes and all contracting health care providers determine that
the original course of treatment is no longer appropriate. A
modification under this subsection shall comply with section 9(2)
and shall not exceed either the aggregate fee calculated under
section 9(3) or the time period of the initial fund contract.
(9) Money committed to be paid under a fund contract that is
not paid within 1 year from the date the contract is entered into
shall be made available for other applicants. If the applicant
becomes ineligible or dies during the period of the fund contract,
the fund is responsible to pay for only the completed portion of
the approved treatment plan. The remainder of the committed money
shall be made available for other applicants.
Sec. 12. (1) The department shall establish a waiting list if
money in the fund is insufficient to make commitments for all
approved treatment plans. An applicant shall be placed on the
waiting list in the order of the date the applicant's original
signed application was received by a local health department.
(2) An applicant shall be taken off the waiting list if 1 or
more of the following occur:
(a) The applicant is determined not to be eligible and does
not request an expedited appeal in a timely manner.
(b) The applicant's treatment plan is denied.
(c) The applicant requests to be taken off the waiting list.
(d) The applicant dies.
(3) An applicant who prevails on appeal will be restored to
the waiting list based on the date of receipt of the original
signed application, but the restoration does not affect any fund
contracts entered into in the interim.
Sec. 13. (1) Except as otherwise provided in this section, an
applicant may appeal an adverse determination regarding eligibility
or approval, modification, or denial of the treatment plan. The
appeal shall be conducted as a contested case under the
administrative procedures act of 1969, 1969 PA 306, MCL 24.201 to
24.328. An applicant has no right to appeal a determination that
money for the applicant's treatment plan is not available in the
fund.
(2) An applicant shall remain on the waiting list established
under section 12 during an appeal if the applicant follows an
expedited appeal process. Taking an expedited appeal does not
affect the right to appeal under subsection (1). All of the
following apply to an expedited appeal:
(a) An expedited appeal shall be filed with the department
within 15 days of receiving an adverse determination.
(b) An expedited appeal shall be filed in writing by
facsimile, e-mail, or regular mail or in person.
(c) A department hearing officer shall make the decision on an
expedited appeal.
(d) A decision on an expedited appeal shall be made within 15
days of receiving the appeal.
(e) The department shall advise the appellant of its decision
within 1 day.
(f) The contested case provisions of the administrative
procedures act of 1969, 1969 PA 306, MCL 24.201 to 24.328, do not
apply to expedited appeals under this subsection.
Enacting section 1. This act does not take effect unless
Senate Bill No.____ or House Bill No. 4497(request no. 00284'05) of
the 93rd Legislature is enacted into law.