Bill Text: MI SB0530 | 2023-2024 | 102nd Legislature | Engrossed
Bill Title: Insurance: no-fault; treatment and services for injuries; revise limitations on charges. Amends sec. 3157 of 1956 PA 218 (MCL 500.3157). TIE BAR WITH: SB 0531'23
Spectrum: Moderate Partisan Bill (Democrat 16-3)
Status: (Engrossed) 2023-10-24 - Referred To Committee On Insurance And Financial Services [SB0530 Detail]
Download: Michigan-2023-SB0530-Engrossed.html
Substitute For
SENATE BILL NO. 530
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
by amending section 3157 (MCL 500.3157), as amended by 2019 PA 21.
the people of the state of michigan enact:
Sec. 3157. (1) Subject to subsections (2) to (14), (15), a physician, hospital, clinic, or other person that lawfully renders treatment to an injured person for an accidental bodily injury covered by personal protection insurance, or a person that provides rehabilitative occupational training following the injury, may charge a reasonable amount for the treatment or training. The charge must not exceed the amount the person customarily charges for like treatment or training in cases that do not involve insurance.
(2) Subject to subsections (3) to (14), (15), a physician, hospital, clinic, or other person that renders treatment or rehabilitative occupational training to an injured person for an accidental bodily injury covered by personal protection insurance is not eligible for payment or reimbursement under this chapter for more than must be reimbursed in an amount equal to the following:
(a) For treatment or training rendered after July 1, 2021 and before July 2, 2022, 200% of the amount payable to the person for the treatment or training under Medicare.
(b) For treatment or training rendered after July 1, 2022 and before July 2, 2023, 195% of the amount payable to the person for the treatment or training under Medicare.
(c) For treatment or training rendered after July 1, 2023 and before July 2, 2024, 190% of the amount payable to the person for the treatment or training under Medicare.
(3) Subject to subsections (5) to (14), (15), a physician, hospital, clinic, or other person identified in subsection (4) that renders treatment or rehabilitative occupational training to an injured person for an accidental bodily injury covered by personal protection insurance is eligible for payment or reimbursement under this chapter of not more than must be reimbursed in an amount that is equal to the following:
(a) For treatment or training rendered after July 1, 2021 and before July 2, 2022, 230% of the amount payable to the person for the treatment or training under Medicare.
(b) For treatment or training rendered after July 1, 2022 and before July 2, 2023, 225% of the amount payable to the person for the treatment or training under Medicare.
(c) For treatment or training rendered after July 1, 2023 and before July 2, 2024, 220% of the amount payable to the person for the treatment or training under Medicare.
(d) For treatment or training rendered after July 1, 2024, 230% of the amount payable to the person for the treatment or training under Medicare.
(4) Subject to subsection (5), subsection (3) only applies to a physician, hospital, clinic, or other person if either of the following applies to the person rendering the treatment or training:
(a) On July 1 of the 2024 and of every third year after 2024 in which the person renders the treatment or training, the person has 20% or more, but less than 30%, indigent volume determined pursuant to a 3-year average of the methodology used by the department of health and human services in determining inpatient medical/surgical factors used in measuring eligibility for Medicaid disproportionate share payments.
(b) The person is a freestanding rehabilitation facility. Each year the director shall designate not more than 2 freestanding rehabilitation facilities to qualify for payments under subsection (3) for that year. As used in this subdivision, "freestanding rehabilitation facility" means an acute care hospital to which all of the following apply:
(i) The hospital has staff with specialized and demonstrated rehabilitation medicine expertise.
(ii) The hospital possesses sophisticated technology and specialized facilities.
(iii) The hospital participates in rehabilitation research and clinical education.
(iv) The hospital assists patients to achieve excellent rehabilitation outcomes.
(v) The hospital coordinates necessary post-discharge services.
(vi) The hospital is accredited by 1 or more third-party, independent organizations focused on quality.
(vii) The hospital serves the rehabilitation needs of catastrophically injured patients in this state.
(viii) The hospital was in existence on May 1, 2019.
(5) To qualify for a payment under subsection (4)(a), a physician, hospital, clinic, or other person shall provide the director with all documents and information requested by the director that the director determines are necessary to allow the director to determine whether the person qualifies. The Every third year, the director shall annually review documents and information provided under this subsection and, if the person qualifies under subsection (4)(a), shall certify the person as qualifying and provide a list of qualifying persons to insurers and other persons that provide the security required under section 3101(1). 3101. A physician, hospital, clinic, or other person that provides 30% or more of its total treatment or training as described under subsection (4)(a) is entitled to receive, instead of an applicable percentage under subsection (3), 250% of the amount payable to the person for the treatment or training under Medicare.
(6) Subject to subsections (7) to (14), (15), a hospital that is a level I or level II trauma center that renders treatment to an injured person for an accidental bodily injury covered by personal protection insurance, if the treatment is for an emergency medical condition and rendered before the patient is stabilized and transferred, is not eligible for payment or reimbursement under this chapter of more than the following:
(a) For treatment rendered after July 1, 2021 and before July 2, 2022, 240% of the amount payable to the hospital for the treatment under Medicare.
(b) For treatment rendered after July 1, 2022 and before July 2, 2023, 235% of the amount payable to the hospital for the treatment under Medicare.
(c) For treatment rendered after July 1, 2023 and before July 2, 2024, 230% of the amount payable to the hospital for the treatment under Medicare.
(d) For treatment or training rendered after July 1, 2024, 240% of the amount payable to the person for the treatment or training under Medicare.
(7) If Subject to subsections (8) to (15), if Medicare does not provide an amount payable for a treatment or rehabilitative occupational training under subsection (2), (3), (5), or (6), the physician, hospital, clinic, or other person that renders the treatment or training is not eligible for payment or reimbursement under this chapter of more than the following, as applicable:
(a) For a person to which subsection (2) applies, the applicable following percentage of the amount payable for the treatment or training under the person's charge description master in effect on January 1, 2019 or, if the person did not have a charge description master on that date, the applicable following percentage of the average amount the person charged for the treatment on January 1, 2019:
(i) For treatment or training rendered after July 1, 2021 and before July 2, 2022, 55%.
(ii) For treatment or training rendered after July 1, 2022 and before July 2, 2023, 54%.
(iii) For treatment or training rendered after July 1, 2023, 52.5%.
(b) For a person to which subsection (3) applies, the applicable following percentage of the amount payable for the treatment or training under the person's charge description master in effect on January 1, 2019 or, if the person did not have a charge description master on that date, the applicable following percentage of the average amount the person charged for the treatment or training on January 1, 2019:
(i) For treatment or training rendered after July 1, 2021 and before July 2, 2022, 70%.
(ii) For treatment or training rendered after July 1, 2022 and before July 2, 2023, 68%.
(iii) For treatment or training rendered after July 1, 2023, 66.5%.
(c) For a person to which subsection (5) applies, 78% of the amount payable for the treatment or training under the person's charge description master in effect on January 1, 2019 or, if the person did not have a charge description master on that date, 78% of the average amount the person charged for the treatment on January 1, 2019.
(d) For a person to which subsection (6) applies, the applicable following percentage of the amount payable for the treatment under the person's charge description master in effect on January 1, 2019 or, if the person did not have a charge description master on that date, the applicable following percentage of the average amount the person charged for the treatment on January 1, 2019:
(i) For treatment or training rendered after July 1, 2021 and before July 2, 2022, 75%.
(ii) For treatment or training rendered after July 1, 2022 and before July 2, 2023, 73%.
(iii) For treatment or training rendered after July 1, 2023, 71%.to the injured person for an accidental bodily injury that occurred after June 10, 2019 and that is covered by personal protection insurance must be reimbursed as follows:
(a) For HHA/CNA Supervision Level Services, using code S9122 with modifier 01, or a substantially similar code and modifier, $32.78 per hour for Metro Detroit, $32.29 per hour for Rest of State.
(b) For HHA/CNA Basic Care Level Services, using code S9122 with modifier 02, or a substantially similar code and modifier, $36.57 per hour for Metro Detroit, $34.97 per hour for Rest of State.
(c) For HHA/CNA High-Tech Care Level Services, using code S9122 with modifier 03, or a substantially similar code and modifier, $40.37 per hour for Metro Detroit, $38.60 per hour for Rest of State.
(d) For Licensed Practical Nurse Home Health Care Level Services, using code S9124, or a substantially similar code, $77.50 per hour for Metro Detroit, $74.50 per hour for Rest of State.
(e) For Licensed Practical Nurse Home Health Care Level Services, using code T1031, or a substantially similar code, $181.15 per visit for Metro Detroit, $178.95 per visit for Rest of State.
(f) For Registered Nurse Home Health Care Level Services, using code S9123, or a substantially similar code, $86.56 per hour for Metro Detroit, $82.76 per hour for Rest of State.
(g) For Registered Nurse Home Health Care Level Services, using code T1030, or a substantially similar code, $220.88 per visit for Metro Detroit, $211.19 per visit for Rest of State.
(h) For Residential Services Level 1, using code T2048 with modifier 01, or a substantially similar code and modifier, $454.65 per day for Metro Detroit, $434.71 per day for Rest of State.
(i) For Residential Services Level 2, using code T2048 with modifier 02, or a substantially similar code and modifier, $599.62 per day for Metro Detroit, $573.32 per day for Rest of State.
(j) For Residential Services Level 3, using code T2048 with modifier 03, or a substantially similar code and modifier, $754.46 per day for Metro Detroit, $721.37 per day for Rest of State.
(k) For Residential Services Bed Hold, using code T2048 with modifier 04, or a substantially similar code and modifier, 55% of the daily rate for the applicable care level.
(l) For One-on-One Staffing – Aide Services, using code S5125, or a substantially similar code, $9.66 per 15 minutes for Metro Detroit, $9.24 per 15 minutes for Rest of State.
(m) For Day Treatment – Half Day, using code H2001 with modifier 01, or a substantially similar code and modifier, $216.77 per day for Metro Detroit, $207.26 per day for Rest of State.
(n) For Day Treatment – Full Day, using code H2001 with modifier 02, or a substantially similar code and modifier, $433.96 per day for Metro Detroit, $414.93 per day for Rest of State.
(o) For Day Treatment – 15 minutes, using code H2032, or a substantially similar code, $18.36 per 15 minutes for Metro Detroit, $17.81 for Rest of State.
(p) For Home- and Community-Based Therapies, using codes 97535, 97110, 97530, 97537, 92507, 97129, or 97130, with Place of Service codes 12 or 99, or a substantially similar code, $82.23 per 15 minutes for Metro Detroit, $78.63 per 15 minutes for Rest of State.
(q) For In-Home Occupational Therapy, using code S9129, or a substantially similar code, $269.55 per visit for Metro Detroit, $256.07 per visit for Rest of State.
(r) For In-Home Physical Therapy, using code S9131, or a substantially similar code, $267.71 per visit for Metro Detroit, $254.32 per visit for Rest of State.
(s) For In-Home Speech Language Pathology, using code S9128, or a substantially similar code, $291.00 per visit for Metro Detroit, $274.45 per visit for Rest of State.
(t) For Job Development/Job Placement, using code H2015, or a substantially similar code, $45.03 per 15 minutes for Metro Detroit, $43.06 per 15 minutes for Rest of State.
(u) For Job Coaching, using code H2025, or a substantially similar code, $21.44 per 15 minutes for Metro Detroit, $20.50 per 15 minutes for Rest of State.
(v) For Enclave Work Site – Group, using code H2023, or a substantially similar code, $17.25 per 15 minutes for Metro Detroit, $16.49 per 15 minutes for Rest of State.
(w) For Case Management, using code T1016, or a substantially similar code, $42.90 per 15 minutes for Metro Detroit, $41.01 per 15 minutes for Rest of State.
(x) For Pharmacy – Generic Drugs, Dispensing Fee, using an unidentified code, $6.36 per prescription for Metro Detroit, $6.53 per prescription for Rest of State.
(y) For Pharmacy – Generic Drugs, Drug Payment, using an unidentified code, 12% discount to average wholesale price for Metro Detroit, 12% discount to average wholesale price for Rest of State.
(z) For Pharmacy – Name Brand Drugs, Dispensing Fee, using an unidentified code, $4.05 per prescription for Metro Detroit, $4.05 per prescription for Rest of State.
(aa) For Pharmacy – Name Brand Drugs, Drug Payment, using an unidentified code, 12% discount to average wholesale price for Metro Detroit, 12% discount to average wholesale price for Rest of State.
(bb) For Pharmacy – Custom Compounds, Dispensing Fee, using an unidentified code, $14.45 per prescription for Metro Detroit, $14.45 per prescription for Rest of State.
(cc) For Pharmacy – Custom Compounds, Drug Payment, using an unidentified code, 12% discount to average wholesale price for Metro Detroit, 12% discount to average wholesale price for Rest of State.
(dd) For Pharmacy – Commercially Manufactured Topicals, Dispensing Fee, using an unidentified code, $9.83 per prescription for Metro Detroit, $9.83 per prescription for Rest of State.
(ee) For Nonemergency Medical Transport – Charge per Mile while Rider Is in the Vehicle, using code S0215, or a substantially similar code, $3.47 per mile for Metro Detroit, $3.47 per mile for Rest of State.
(ff) For Nonemergency Medical Transport – Wheelchair Van Pickup Fee – Weekday, using code A0130 with modifier 01, or a substantially similar code and modifier, $39.30 per pickup for Metro Detroit, $39.30 per pickup for Rest of State.
(gg) For Nonemergency Medical Transport – Nonwheelchair Van Pickup Fee – Weekday, using code A0100 with modifier 01, or a substantially similar code and modifier, $36.61 per pickup for Metro Detroit, $36.61 per pickup for Rest of State.
(hh) For Nonemergency Medical Transport – Wheelchair Van Pickup Fee – Weekend, using code A0130 with modifier 02, or a substantially similar code and modifier, $45.37 per pickup for Metro Detroit, $45.37 per pickup for Rest of State.
(ii) For Nonemergency Medical Transport – Nonwheelchair Van Pickup Fee – Weekend, using code A0100 with modifier 02, or a substantially similar code and modifier, $40.46 per pickup for Metro Detroit, $40.46 per pickup for Rest of State.
(jj) For Nonemergency Medical Transport – Wait Time, using code T2007, or a substantially similar code, $8.45 per 15 minutes for Metro Detroit, $8.45 per 15 minutes for Rest of State.
(8) For any change to increase in an amount payable under Medicare as provided in subsection (2), (3), (5), or (6) that occurs after the effective date of the amendatory act that added this subsection, June 11, 2019, the change must be applied to the amount allowed for payment or reimbursement under that subsection. However, an amount allowed for payment or reimbursement under subsection (2), (3), (5), or (6) must not exceed the average amount charged by the physician, hospital, clinic, or other person for the treatment or training on January 1, 2019.
(9) A personal caregiver who renders home care services to an injured person for an accidental bodily injury that occurred after June 10, 2019, and that is covered by personal protection insurance, must be reimbursed as follows:
(a) For HHA/CNA Supervision Level Services, $19.67 per hour for Metro Detroit, $19.37 per hour for Rest of State.
(b) For HHA/CNA Basic Care Level Services, $21.94 per hour for Metro Detroit, $20.98 per hour for Rest of State.
(c) For HHA/CNA High-Tech Care Level Services, $24.22 per hour for Metro Detroit, $23.16 per hour for Rest of State.
(d) For Licensed Practical Nurse Home Health Care Level Services, $46.50 per hour for Metro Detroit, $44.70 per hour for Rest of State.
(e) For Registered Nurse Home Health Care Level Services, $51.94 per hour for Metro Detroit, $49.66 per hour for Rest of State.
(10) A chiropractic provider that renders treatment or training to an injured person for an accidental bodily injury that occurred after June 10, 2019, and that is covered by personal protection insurance, must be reimbursed as follows:
(a) For low-level laser treatment, using code S8948, $25.24 per 15 minutes for Metro Detroit, $24.61 per 15 minutes for Rest of State.
(b) For vertebral axial decompression, using code S9090, $48.63 per session for Metro Detroit, $47.41 per session for Rest of State.
(11) (9) An amount that is to be applied under subsection (7), or (8), that was in effect on January 1, 2019, including any prior adjustments to the amount made under this subsection, (9), or (10) must be adjusted annually by the percentage change in the medical care component of the Consumer Price Index for the year preceding the adjustment.
(10) For attendant care rendered in the injured person's home, an insurer is only required to pay benefits for attendant care up to the hourly limitation in section 315 of the worker's disability compensation act of 1969, 1969 PA 317, MCL 418.315. This subsection only applies if the attendant care is provided directly, or indirectly through another person, by any of the following:
(a) An individual who is related to the injured person.
(b) An individual who is domiciled in the household of the injured person.
(c) An individual with whom the injured person had a business or social relationship before the injury.
(11) An insurer may contract to pay benefits for attendant care for more than the hourly limitation under subsection (10).
(12) A neurological rehabilitation clinic provider that renders home care or residential services, or both, is not entitled to payment or reimbursement for a treatment , or training , product, service, or accommodation under this section unless the neurological rehabilitation clinic provider is accredited by the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO, the Commission on Accreditation of Rehabilitation Facilities, or CARF, the Community Health Accreditation Partner Program, or CHAP, the Accreditation Commission for Health Care, or ACHC, or a similar organization recognized by the director for purposes of accreditation under this subsection. This subsection does not apply to a neurological rehabilitation clinic provider that is in or begins the process of becoming accredited, as required under this subsection on July 1, 2021, verified by the accrediting body, within 1 year after the effective date of the 2023 amendatory act that amended this subsection, unless 3 years have passed since the beginning of that process effective date of the 2023 amendatory act that amended this subsection and the neurological rehabilitation clinic provider is still not accredited. The accreditation requirement under this subsection does not apply to a personal caregiver. For care rendered by a personal caregiver, the insurer is only required to pay benefits for not more than 16 hours per day per individual but may contract to pay for more than 16 hours per day per individual. A personal caregiver shall not seek payment from an insurer for care rendered to more than 2 injured persons at the same time.
(13) Subsections (2) to (12) do not apply to emergency medical services rendered by an ambulance operation. As used in this subsection:
(a) "Ambulance operation" means that term as defined in section 20902 of the public health code, 1978 PA 368, MCL 333.20902.
(b) "Emergency medical services" means that term as defined in section 20904 of the public health code, 1978 PA 368, MCL 333.20904.
(14) Subsections (2) to (13) apply to treatment or rehabilitative occupational training rendered after July 1, 2021.
(14) For all treatment or training provided to an injured person for an accidental bodily injury that occurred after June 10, 2019, and that is covered by personal protection insurance, to which subsections (2) to (10) do not apply, reimbursement must be issued in accordance with section 3107(1)(a) and subsection (1).
(15) For all treatment or training provided to an injured person for an accidental bodily injury that occurred before June 11, 2019, and that is covered by personal protection insurance, reimbursement must be issued in accordance with section 3107(1)(a) and subsection (1).
(16) (15) As used in this section:
(a) "Charge description master" means a uniform schedule of charges represented by the person as its gross billed charge for a given service or item, regardless of payer type.
(a) "BADLs" means basic activities of daily living and may include bathing, dressing, grooming, toileting, personal hygiene, feeding, and other basic self‐care activities.
(b) "Case Management" means services provided by a case manager with a health professional degree and current license or national certification in a health or human services profession. Case Management includes, but is not limited to, assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required to meet the injured person's health and human service needs.
(c) (b) "Consumer Price Index" means the most comprehensive index of consumer prices available for this state from the United States Department of Labor, Bureau of Labor Statistics.
(d) "Day treatment" means daytime programs that provide educational, prevocational, or vocational or therapeutic activity services and that are supervised by paraprofessional staff with program design and oversight by health care professionals.
(e) "Day Treatment - 15 minute" means day treatment for which 15-minute units are used and reimbursed for services rendered that are not otherwise covered by full day or half day codes.
(f) "Day Treatment - Full Day" means day treatment provided for 5 to 7 hours per day.
(g) "Day Treatment - Half Day" means day treatment provided for 2.5 to 3.5 hours per day.
(h) (c) "Emergency medical condition" means that term as defined in section 1395dd of the social security act, 42 USC 1395dd.
(i) "Enclave Work Site – Group" means a community-based work site of a competitive employer external to a residential services program where a group of injured persons works under the supervision of staff from the program.
(j) "HHA/CNA Basic Care Level Services" means services generally performed at the care level of a home health aide or certified nursing assistant for the purpose of providing personal care or assisting an injured person with the performance of BADLs or IADLs in the home or other place of residence.
(k) "HHA/CNA High-Tech Care Level Services" means services generally performed at the care level of a home health aide or certified nursing assistant for the purpose of providing personal care, assisting with the performance of BADLs and IADLs, and providing additional interventions for an injured person, including, but not limited to, basic bowel and bladder program management, complex transfers, basic behavior and cognitive management, vital sign monitoring, orthopedic brace care, basic skin integrity care, pediatric patient care, and other forms of monitoring and care that do not require direct care or oversight by a licensed nurse, in the home or other place of residence.
(l) "HHA/CNA Supervision Level Services" means services generally performed at the care level of a home health aide or certified nursing assistant for the purpose of providing direct supervision to ensure the health and safety of an injured person in the home or other place of residence.
(m) "Home- and Community-Based Therapies" means those services that are performed by licensed, registered, or certified professionals, using current procedural terminology codes within their scope of practice, and performing services in the home or community setting, as an extension of an outpatient rehabilitation program or community-based private practice model.
(n) "Home care" means home health aide, nursing, and other similar services provided to an injured person in the home or place of residence, other than in a hospital, nursing home, or county medical facility, unless ordered by a physician for safety reasons.
(o) "IADLs" means instrumental activities of daily living and may include health and medication management, money and financial management, menu planning, grocery shopping, cooking, cleaning, laundry, transportation, community mobility or access, planning and organization, and other similar activities.
(p) "In-Home Occupational Therapy" means occupational therapy services performed in the home or other place of residence.
(q) "In-Home Physical Therapy" means physical therapy services performed in the home or other place of residence.
(r) "In-Home Speech Language Pathology" means speech language pathology services performed in the home or other place of residence.
(s) "Job Coaching" means services performed to assist an injured person with learning, accommodating, or performing specific job tasks and developing interpersonal and other employment-related skills.
(t) "Job Development/Job Placement" means services performed by an individual with a bachelor's degree or higher with additional vocational training for the purpose of assisting an injured person with job placement and development of interpersonal and other employment-related skills.
(u) (d) "Level I or level II trauma center" means a hospital that is verified as a level I or level II trauma center by the American College of Surgeons Committee on Trauma.
(v) "Licensed Practical Nurse Home Health Care Level Services" means skilled nursing services performed at the care level of a licensed practical nurse in the home or place of residence.
(w) (e) "Medicaid" means a program for medical assistance established under subchapter XIX of the social security act, 42 USC 1396 to 1396w-5.1396w-7.
(x) (f) "Medicare" means fee for service payments under part A, B, or D of the federal Medicare program established under subchapter XVIII of the social security act, 42 USC 1395 to 1395lll, without regard to the limitations unrelated to the rates in the fee schedule such as limitation or supplemental payments but does not include adjustments related to utilization, readmissions, recaptures, bad debt adjustments, or sequestration. Medicare includes payments to providers reimbursed under a prospective payment system, including the inpatient acute, inpatient psychiatric, inpatient rehabilitation, long-term acute care, skilled nursing, hospice, and outpatient prospective payment systems and any other hospital payment system designated by the United States Department of Health and Human Services. Medicare includes all facility adjustments, including, but not limited to, adjustments for acuity, area wage index, capital, direct and indirect graduate medical education, disproportionate share components, new technology, low volume, organ acquisition cost, routine and ancillary cost for allied health programs, and outlier. For sole community hospitals, rural referral centers, rural emergency hospitals, and critical access hospitals, Medicare means the equivalent hospital-specific payment for providing inpatient or outpatient services to Medicare beneficiaries.
(g) "Neurological rehabilitation clinic" means a person that provides post-acute brain and spinal rehabilitation care.
(y) "Metro Detroit" means services provided in the county of Wayne, Washtenaw, Oakland, or Macomb.
(z) "One-on-One Staffing – Aide Services" means direct supervision of a single injured person by an aide or other caregiver to ensure the injured person's health, safety, or adherence to medical recommendations or to enable the injured person to participate in therapeutic activities or other treatment.
(aa) (h) "Person", as provided in section 114, includes, but is not limited to, an agency or institution.
(bb) "Personal caregiver" means an individual who is any of the following:
(i) An individual who is related to the injured person.
(ii) An individual who is domiciled in the household of the injured person.
(iii) An individual with whom the injured person had a business or social relationship before the injury.
(iv) An individual who is employed or contracted to perform home care services directly by an injured person or the injured person's legal representative.
(v) An individual who is not employed or contracted to perform home care services by any agency or other organization.
(cc) "Provider" means a physician, hospital, clinic, or other person that renders treatment or training to an injured person.
(dd) "Registered Nurse Home Health Care Level Services" means skilled nursing services generally performed at the level of a registered nurse, in the home or other place of residence.
(ee) "Residential services" means post-acute brain or spinal cord rehabilitation treatment or training rendered in an accredited residential program that may include direct assistance with BADLs or IADLs on a continual or intermittent basis, direct supervision for health and safety, and medical or behavioral oversight or intervention. Residential services does not include one-on-one staffing or supervision beyond program-level supervision, nursing treatment or intervention, medical supplies, durable medical equipment, individualized interventions and therapeutic services, individual or group therapy services, vocational services and supports, day programs, or transportation to appointments or activities not sponsored by the program.
(ff) "Residential Services Bed Hold" means a temporary leave of absence for an injured person from the accredited residential program in which the injured person permanently resides. The first 2 consecutive days of any leave of absence must be reimbursed at the applicable residential services level rate, and any consecutive day or days of leave after the first 2 days must be reimbursed at the Residential Services Bed Hold rate.
(gg) "Residential Services Level 1" means residential services provided to an injured person who generally requires 1 or more of the following:
(i) Minimal assistance on a routine basis to perform at least some BADLs.
(ii) Minimal to moderate assistance to perform at least some IADLs.
(iii) Ongoing supervision in a structured living environment.
(iv) Minimal assistance on a routine basis to manage 1 or more medical conditions.
(v) Intermittent support to manage mood or promote behavioral stability.
(hh) "Residential Services Level 2" means residential services provided to an injured person who may require any of the services identified in subdivision (gg) and who generally requires 1 or more of the following:
(i) Minimal to moderate assistance or supervision to perform most BADLs.
(ii) Minimal to moderate assistance or supervision for functional mobility.
(iii) Moderate to maximum assistance to perform most IADLs.
(iv) Direct care on a routine basis to monitor and manage 1 or more medical conditions.
(v) One or more impromptu specialized interventions to address behavioral concerns, including mild to moderate verbal aggression.
(ii) "Residential Services Level 3" means residential services provided to an injured person who may require any of the services identified in subdivision (gg) or (hh) and who generally requires 1 or more of the following:
(i) Maximum to total assistance to perform most BADLs.
(ii) Maximum to total assistance for functional mobility.
(iii) Moderate to maximum assistance to perform most IADLs.
(iv) Daily direct care and/or oversight by a licensed health care professional to manage 1 or more medical conditions.
(v) One or more impromptu specialized interventions or individualized behavioral plans for consistent therapeutic response to address behavioral or mental health concerns, including verbal or physical aggression.
(jj) "Rest of State" means services provided in any location, including a location in or outside of this state, other than in the counties of Wayne, Washtenaw, Oakland, and Macomb in this state.
(kk) (i) "Stabilized" means that term as defined in section 1395dd of the social security act, 42 USC 1395dd.
(ll) (j) "Transfer" means that term as defined in section 1395dd of the social security act, 42 USC 1395dd.
(mm) (k) "Treatment" includes, but is not limited to, products, services, and accommodations.
Enacting section 1. This amendatory act does not take effect unless Senate Bill No. 531 of the 102nd Legislature is enacted into law.
