June 16, 2009, Introduced by Rep. Angerer and referred to the Committee on Insurance.
A bill to amend 1980 PA 350, entitled
"The nonprofit health care corporation reform act,"
by amending sections 502 and 502a (MCL 550.1502 and 550.1502a),
section 502 as amended by 2003 PA 59 and section 502a as amended by
1998 PA 446.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 502. (1) A health care corporation may enter into
participating contracts for reimbursement with professional health
care providers practicing legally in this state for health care
services or with health practitioners practicing legally in any
other jurisdiction for health care services that the professional
health care providers or practitioners may legally perform. A
participating contract may cover all members or may be a separate
and individual contract on a per claim basis, as set forth in the
provider class plan, if, in entering into a separate and individual
contract on a per claim basis, the participating provider certifies
to the health care corporation:
(a) That the provider will accept payment from the corporation
as payment in full for services rendered for the specified claim
for the member indicated.
(b) That the provider will accept payment from the corporation
as payment in full for all cases involving the procedure specified,
for the duration of the calendar year. As used in this subdivision,
provider does not include a person licensed as a dentist under part
166 of the public health code, 1978 PA 368, MCL 333.16601 to
333.16648.
(c) That the provider will not determine whether to
participate on a claim on the basis of the race, color, creed,
marital status, sex, national origin, residence, age, disability,
or lawful occupation of the member entitled to health care
benefits.
(2) A contract entered into pursuant to subsection (1) shall
provide that the private provider-patient relationship shall be
maintained to the extent provided for by law. A health care
corporation shall continue to offer a reimbursement arrangement to
any class of providers with which it has contracted prior to August
27, 1985 and that continues to meet the standards set by the
corporation for that class of providers.
(3) A health care corporation shall not restrict the methods
of diagnosis or treatment of professional health care providers who
treat members. Except as otherwise provided in section 502a, each
member of the health care corporation shall at all times have a
choice of professional health care providers. This subsection does
not apply to limitations in benefits contained in certificates, to
the reimbursement provisions of a provider contract or
reimbursement arrangement, or to standards set by the corporation
for all contracting providers. A health care corporation may refuse
to reimburse a health care provider for health care services that
are overutilized, including those services rendered, ordered, or
prescribed to an extent that is greater than reasonably necessary.
(4) A health care corporation may provide to a member, upon
request, a list of providers with whom the corporation contracts,
for the purpose of assisting a member in obtaining a type of health
care service. However, except as otherwise provided in section
502a, an employee, agent, or officer of the corporation, or an
individual on the board of directors of the corporation, shall not
make recommendations on behalf of the corporation with respect to
the choice of a specific health care provider. Except as otherwise
provided in section 502a, an employee, agent, or officer of the
corporation, or a person on the board of directors of the
corporation who influences or attempts to influence a person in the
choice or selection of a specific professional health care provider
on behalf of the corporation, is guilty of a misdemeanor.
(5) A health care corporation shall provide a symbol of
participation, which can be publicly displayed, to providers who
participate on all claims for covered health care services rendered
to subscribers.
(6) This section does not impede the lawful operation of, or
lawful promotion of, a health maintenance organization owned by a
health care corporation.
(7) Contracts entered into under this section with
professional health care providers licensed in this state are
subject to the provisions of sections 504 to 518.
(8) A health care corporation shall not deny participation to
a freestanding surgical outpatient facility on the basis of
ownership if the facility meets the reasonable standards set by the
health care corporation for similar facilities, is licensed under
part 208 of the public health code, 1978 PA 368, MCL 333.20801 to
333.20821, and complies with part 222 of the public health code,
1978 PA 368, MCL 333.22201 to 333.22260.
(9) Notwithstanding any other provision of this act, if a
certificate provides for benefits for services that are within the
scope of practice of optometry, a health care corporation is not
required to provide benefits or reimburse for a practice of
optometric service unless that service was included in the
definition of practice of optometry under section 17401 of the
public health code, 1978 PA 368, MCL 333.17401, as of May 20, 1992.
(10) Notwithstanding any other provision of this act, a health
care corporation is not required to reimburse for services
otherwise covered under a certificate if the services were
performed by a member of a health care profession, which health
care profession was not licensed or registered by this state on or
before January 1, 1998 but that becomes a health care profession
licensed or registered by this state after January 1, 1998. This
subsection does not change the status of a health care profession
that was licensed or registered by this state on or before January
1, 1998.
(11) Notwithstanding any other provision of this act, if a
certificate provides for benefits for services that are within the
scope of practice of chiropractic, a health care corporation is not
required to provide benefits or reimburse for a practice of
chiropractic service unless that service was included in the
definition of practice of chiropractic under section 16401 of the
public health code, 1978 PA 368, MCL 333.16401, as of January 1,
2009.
Sec. 502a. (1) For the purpose of doing business as an
organization under the prudent purchaser act, 1984 PA 233, MCL
550.51 to 550.63, a health care corporation may enter into prudent
purchaser agreements with health care providers pursuant to this
section and the prudent purchaser act, 1984 PA 233, MCL 550.51 to
550.63.
(2) A health care corporation may offer group contracts under
which subscribers shall be required, as a condition of coverage, to
obtain services exclusively from health care providers who have
entered into prudent purchaser agreements.
(3) An individual who is a member of a group who is offered
the option of being a subscriber under a contract pursuant to
subsection (2) shall also be offered the option of being a
subscriber under a contract pursuant to subsection (4). This
subsection applies only if the group in which the individual is a
member has 25 or more members or if the provider panel that is
providing the services under the contract is limited by the
organization to a specific number pursuant to section 3(1) of the
prudent purchaser act, 1984 PA 233, MCL 550.53.
(4) A health care corporation may offer group contracts under
which subscribers who elect to obtain services from health care
providers who have entered into prudent purchaser agreements shall
realize a financial advantage or other advantage by selecting such
providers. Contracts offered pursuant to this subsection shall not,
as a condition of coverage, require subscribers to obtain services
exclusively from health care providers who have entered into
prudent purchaser agreements.
(5) An individual who is a member of a group who is offered
the option of being a subscriber under a contract pursuant to
subsection (2) or (4) shall also be offered the option of being a
subscriber under a contract that:
(a) Does not, as a condition of coverage, require subscribers
to obtain services exclusively from health care providers who have
entered into prudent purchaser agreements.
(b) Does not give a financial advantage or other advantage to
a subscriber who elects to obtain services from health care
providers who have entered into prudent purchaser agreements.
(6) Subsection (5) applies only if the group in which the
individual is a member has 25 or more members and if the group on
December 20, 1984 had health care coverage through the group
sponsor.
(7) A health care corporation may offer individual contracts
under which subscribers shall be required, as a condition of
coverage, to obtain services exclusively from health care providers
who have entered into prudent purchaser agreements. A person to
whom such a contract is offered shall also be offered a contract
that:
(a) Does not, as a condition of coverage, require subscribers
to obtain services exclusively from health care providers who have
entered into prudent purchaser agreements.
(b) Does not give a financial advantage or other advantage to
a subscriber who elects to obtain services from health care
providers who have entered into prudent purchaser agreements.
(8) A health care corporation may offer individual contracts
under which subscribers who elect to obtain services from health
care providers who have entered into prudent purchaser agreements
shall realize a financial advantage or other advantage by selecting
such providers. Contracts offered pursuant to this subsection shall
not, as a condition of coverage, require subscribers to obtain
services exclusively from health care providers who have entered
into prudent purchaser agreements. A person to whom such a contract
is offered shall also be offered a contract that:
(a) Does not, as a condition of coverage, require subscribers
to obtain services exclusively from health care providers who have
entered into prudent purchaser agreements.
(b) Does not give a financial advantage or other advantage to
a subscriber who elects to obtain services from health care
providers who have entered into prudent purchaser agreements.
(9) The rates charged by a corporation for coverage under
contracts issued under this section shall not be unreasonably lower
than what is necessary to meet the expenses of the corporation for
providing this coverage and shall not have an anticompetitive
effect or result in predatory pricing in relation to prudent
purchaser agreement coverages offered by other organizations.
(10) Contracts entered into under this section are not subject
to the provisions of sections 504 to 518.
(11) A corporation shall not discriminate against a class of
health care providers when entering into prudent purchaser
agreements with health care providers for its provider panel. This
subsection does not:
(a) Prohibit the formation of a provider panel consisting of a
single class of providers when a service provided for in the
specifications of a purchaser may be legally provided only by a
single class of providers.
(b) Prohibit the formation of a provider panel that conforms
to the specifications of a purchaser of the coverage authorized by
this section so long as the specifications do not exclude any class
of health care providers who may legally perform the services
included in the coverage.
(c) Require an organization that has uniformly applied the
standards filed pursuant to section 3(3) of the prudent purchaser
act, 1984 PA 233, MCL 550.53, to contract with any individual
provider.
(12) Nothing in the 1984 amendatory act that added this
section applies to any contract that was in existence before
December 20, 1984, or the renewal of such contract.
(13) Notwithstanding any other provision of this act, if
coverage under a prudent purchaser agreement provides for benefits
for services that are within the scope of practice of optometry, a
health care corporation is not required to provide benefits or
reimburse for a practice of optometric service unless that service
was included in the definition of practice of optometry under
section 17401 of the public health code, 1978 PA 368, MCL
333.17401, as of May 20, 1992.
(14) Notwithstanding any other provision of this act, a health
care corporation offering coverage under a prudent purchaser
agreement is not required to reimburse for services otherwise
covered if the services were performed by a member of a health care
profession, which health care profession was not licensed or
registered by this state on or before January 1, 1998 but that
becomes a health care profession licensed or registered by this
state after January 1, 1998. This subsection does not change the
status of a health care profession that was licensed or registered
by this state on or before January 1, 1998.
(15) Notwithstanding any other provision of this act, if a
certificate provides for benefits for services that are within the
scope of practice of chiropractic, a health care corporation is not
required to provide benefits or reimburse for a practice of
chiropractic service unless that service was included in the
definition of practice of chiropractic under section 16401 of the
public health code, 1978 PA 368, MCL 333.16401, as of January 1,
2009.