Bill Text: MI SB0004 | 2013-2014 | 97th Legislature | Introduced

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Bill Title: Insurance; prudent purchaser agreements; authority to refuse reimbursement for certain chiropractic services; eliminate. Amends sec. 3 of 1984 PA 233 (MCL 550.53).

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2013-01-16 - Referred To Committee On Insurance [SB0004 Detail]

Download: Michigan-2013-SB0004-Introduced.html

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SENATE BILL No. 4

 

 

January 16, 2013, Introduced by Senator JANSEN and referred to the Committee on Insurance.

 

 

 

     A bill to amend 1984 PA 233, entitled

 

"Prudent purchaser act,"

 

by amending section 3 (MCL 550.53), as amended by 2009 PA 224.

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

     Sec. 3. (1) An organization may enter into a prudent purchaser

 

agreement with 1 or more health care providers of a specific

 

service to control health care costs, assure appropriate

 

utilization of health care services, and maintain quality of health

 

care. The organization may limit the number of prudent purchaser

 

agreements entered into pursuant to under this section if the

 

number of agreements is sufficient to assure reasonable levels of

 

access to health care services for recipients of those services.

 

The number of prudent purchaser agreements authorized by this

 

section that are necessary to assure reasonable levels of access to

 

health care services for recipients shall be determined by the

 

organization. However, the organization shall offer a prudent

 

purchaser agreement, comparable to those agreements with other

 

members of the provider panel, to at least 1 health care provider

 

that provides the applicable health care services and is located

 

within a reasonable distance from the recipients of those health

 

care services, if a health care provider that provides the

 

applicable health care services is located within that reasonable

 

distance.

 

     (2) An organization shall give all health care providers that

 

provide the applicable health care services and are located in the

 

geographic area served by the organization an opportunity to apply

 

to the organization for membership on the provider panel.

 

     (3) A prudent purchaser agreement shall be based upon the

 

following written standards, which shall be filed by the

 

organization with the commissioner on a form and in a manner that

 

is uniformly developed and applied by the commissioner before the

 

initial provider panel is formed:

 

     (a) Standards for maintaining quality health care.

 

     (b) Standards for controlling health care costs.

 

     (c) Standards for assuring appropriate utilization of health

 

care services.

 

     (d) Standards for assuring reasonable levels of access to

 

health care services.

 

     (e) Other standards considered appropriate by the

 

organization.

 

     (4) An organization shall develop and institute procedures

 

that are designed to notify health care providers located in the

 

geographic area served by the organization of the acceptance of

 

applications for a provider panel. The procedures shall include the

 

giving of notice to providers of the service upon request and shall

 

include publication in a newspaper with general circulation in the

 

geographic area served by the organization at least 30 days before

 

the initial provider application period. An organization shall

 

provide for an initial 60-day provider application period during

 

which providers of the service may apply to the organization for

 

membership on the provider panel. An organization that has entered

 

into a prudent purchaser agreement concerning a particular health

 

care service shall provide, at least once every 4 years, for a 60-

 

day provider application period during which providers of that

 

service may apply to the organization for membership on the

 

provider panel. Notice of this provider application period shall be

 

given to providers of the service upon request and shall be

 

published in a newspaper with general circulation in the geographic

 

area served by the organization at least 30 days before the

 

commencement of the provider application period. The initial 60-day

 

provider application period and procedures and the 4-year 60-day

 

provider application periods and procedures required under this

 

subsection do not apply to organizations whose provider panels are

 

open to application for membership at any time. Upon receipt of a

 

request by a health care provider, the organization shall provide

 

the written standards described in subsection (3) to the health

 

care provider. Within 90 days after the close of a provider

 

application period, or within 30 days following the completion of

 

the applicable physician credentialing process, whichever is later,

 

an organization shall notify an applicant in writing as to whether

 

the applicant has been accepted or rejected for membership on the

 

provider panel. If an applicant has been rejected, the organization

 

shall state in writing the reasons for rejection, citing 1 or more

 

of the standards.

 

     (5) A health care provider whose membership on an

 

organization's provider panel is terminated shall be provided upon

 

request with a written explanation by the organization of the

 

reasons for the termination.

 

     (6) An organization that enters into a prudent purchaser

 

agreement shall institute a program for the professional review of

 

the quality of health care, performance of health care personnel,

 

and utilization of services and facilities under the prudent

 

purchaser agreement. At least every 2 years, the organization shall

 

provide for an evaluation of its professional review program by a

 

professionally recognized independent third party.

 

     (7) If 2 or more classes of health care providers may legally

 

provide the same health care service, the organization shall offer

 

each class of health care providers the opportunity to apply to the

 

organization for membership on the provider panel.

 

     (8) Each prudent purchaser agreement shall state that the

 

health care provider may be removed from the provider panel before

 

the expiration of the agreement if the provider does not comply

 

with the requirements of the contract.

 

     (9) This act does not preclude a health care provider or

 

health care facility from being a member of more than 1 provider

 

panel.

 

     (10) A provider panel may include health care providers and

 

facilities outside Michigan this state if necessary to assure

 

reasonable levels of access to health care services under coverage

 

authorized by this act.

 

     (11) When coverage authorized by this act is offered to a

 

person, the organization shall give or cause to be given to the

 

person the following information:

 

     (a) The identity of the organization contracting with the

 

provider panel.

 

     (b) The identity of the party sponsoring the coverage

 

including, but not limited to, the employer.

 

     (c) The identity of the collective bargaining agent if the

 

coverage is offered pursuant to a collective bargaining agreement.

 

     (12) If a person who has coverage authorized by this act is

 

entitled to receive a health care service when rendered by a health

 

care provider who is a member of the provider panel, the person is

 

entitled to receive the health care service from a health care

 

provider who is not a member of the provider panel for an emergency

 

episode of illness or injury that requires immediate treatment

 

before it can be obtained from a health care provider who is on the

 

provider panel.

 

     (13) Subsections (2) to (12) do not limit the authority of

 

organizations to limit the number of prudent purchaser agreements.

 

     (14) If coverage under a prudent purchaser agreement provides

 

for benefits for services that are within the scope of practice of

 

optometry, this act does not require that coverage or reimbursement

 

be provided for a practice of optometric optometry 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.

 

     (15) If coverage under a prudent purchaser agreement provides

 

for benefits for services that are within the scope of practice of

 

chiropractic, this act does not require that coverage or

 

reimbursement be provided 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.