HOUSE BILL No. 4650 April 22, 1997, Introduced by Reps. Schroer, Baird, Gire, Schauer, Martinez and LaForge and referred to the Committee on Health Policy. A bill to amend 1978 PA 368, entitled "Public health code," by amending sections 21004, 21051, and 21053c (MCL 333.21004, 333.21051, and 333.21053c), sections 21004 and 21051 as amended by 1982 PA 354 and section 21053c as added by 1996 PA 515, and by adding sections 21052a, 21052b, 21052c, 21052d, 21052e, 21053d, and 21095. THE PEOPLE OF THE STATE OF MICHIGAN ENACT: 1 Sec. 21004. (1) "EMERGENCY HEALTH SERVICES" MEANS SERVICES 2 PROVIDED TO AN ENROLLEE FOR A MEDICAL CONDITION THAT MANIFESTS 3 ITSELF BY SYMPTOMS OF SUFFICIENT SEVERITY INCLUDING SEVERE PAIN 4 AND THAT A PRUDENT LAYPERSON POSSESSING AN AVERAGE KNOWLEDGE OF 5 HEALTH AND MEDICINE COULD REASONABLY EXPECT TO RESULT IN SERIOUS 6 JEOPARDY, SERIOUS IMPAIRMENT TO BODILY FUNCTIONS, SERIOUS 7 DYSFUNCTION OF ANY BODILY ORGAN OR PART, OR DISFIGUREMENT. 02031'97 DKH 2 1 EMERGENCY HEALTH SERVICES INCLUDE EMERGENCY HEALTH SERVICES 2 PROVIDED WITHOUT PRIOR APPROVAL OR AUTHORIZATION BY A HEALTH 3 MAINTENANCE ORGANIZATION, REGARDLESS OF WHETHER THE HEALTH CARE 4 PROVIDER IS AFFILIATED WITH THE HEALTH MAINTENANCE ORGANIZATION. 5 IN SUCH CASE, ENROLLEES OR PERSONS ACTING ON THEIR BEHALF SHALL 6 NOTIFY THEIR HEALTH MAINTENANCE ORGANIZATION WITHIN 24 HOURS 7 AFTER CARE WAS PROVIDED OR AS SOON AS PRACTICAL. ACCEPTABLE 8 NOTIFICATION INCLUDES VERBAL COMMUNICATION, INCLUDING THE LEAVING 9 OF A MESSAGE, WITH THE HEALTH MAINTENANCE ORGANIZATION. 10 (2) "Enrollee" means an individual who is entitled to 11 receive health maintenance services under a health maintenance 12 contract. 13 Sec. 21051. (1) The governing body of a health maintenance 14 organization shall havea minimum of1/3 of its membership con- 15 sisting of adult enrollees of the organization who are not com- 16 pensated officers, employees, stockholders who own more than 5% 17 of the shares of the organization, or other individuals responsi- 18 ble for the conduct of, or financially interested in, the 19 organization's affairs, 1/3 OF ITS MEMBERSHIP CONSISTING OF 20 AFFILIATED HEALTH CARE PROVIDERS, AND 1/3 OF ITS MEMBERSHIP CON- 21 SISTING OF NONAFFILIATED HEALTH CARE PROVIDERS. The enrollee 22 board members shall be elected by a simple plurality of the 23 voting subscribers. Each subscriber shall have 1 vote. The 24 enrollee board members shall hold office for 3 years after their 25 election, except that the terms of office following the first 26 enrollee election may be adjusted to allow the terms of enrollee 27 board members to expire on a staggered basis. A vacancy among 02031'97 3 1 enrollee board members shall be filled by appointment by a simple 2 majority of the remaining enrollee members of the board from 3 individuals meeting the qualifications of this section. A 4 vacancy shall be filled only for the unexpired portion of the 5 original term, at which time the enrollee member shall be elected 6 in the manner prescribed by this part. During the first 12 7 months of operation the requirements of this section are waived. 8 (2) A HEALTH MAINTENANCE ORGANIZATION SHALL DEDICATE NOT 9 LESS THAN 10% OF THE ORGANIZATION'S ADMINISTRATIVE COSTS TO SUP- 10 PORT THE ENROLLEE MEMBERS ON THE HEALTH MAINTENANCE 11 ORGANIZATION'S GOVERNING BODY BY PROVIDING STAFF RESOURCES, FUNDS 12 FOR OUTSIDE TECHNICAL ASSISTANCE, AND REIMBURSEMENT FOR ACTUAL 13 EXPENSES. 14 SEC. 21052A. (1) EACH HEALTH MAINTENANCE ORGANIZATION SHALL 15 INCLUDE A SUFFICIENT NUMBER OF EACH CATEGORY OF HEALTH PROVIDER, 16 INCLUDING SPECIALISTS WITHIN EACH CATEGORY, THROUGHOUT THE SERV- 17 ICE AREA, TO MEET THE NEEDS OF ITS ENROLLEES AND TO PROVIDE ITS 18 ENROLLEES WITH A MEANINGFUL CHOICE AMONG HEALTH PROVIDERS WITHIN 19 EACH CATEGORY. ENROLLEE NEEDS SHALL BE DETERMINED FOR EACH 20 HEALTH MAINTENANCE ORGANIZATION BY THE DEPARTMENT WITH ADVICE 21 FROM THE OFFICE OF HEALTH CARE CONSUMER ADVOCATE CREATED IN 22 SECTION 21095 BASED ON THE CHARACTERISTICS OF THE ORGANIZATION'S 23 ENROLLEE POPULATION, TAKING INTO ACCOUNT SUCH FACTORS AS AGE, 24 GENDER, AND HEALTH STATUS, INCLUDING ACUTE AND CHRONIC CONDITIONS 25 AND SPECIAL NEEDS. 26 (2) ENROLLEES MAY DESIGNATE THEIR OWN CARE COORDINATOR FROM 27 A LIST OF HEALTH PROVIDERS WHO SERVE AS CARE COORDINATORS. THE 02031'97 4 1 LIST OF HEALTH PROVIDERS SHALL BE SUPPLIED BY THE HEALTH 2 MAINTENANCE ORGANIZATION AND SHALL INCLUDE A SUFFICIENT NUMBER OF 3 HEALTH PROVIDERS IN EACH CATEGORY WHO ARE ACCEPTING NEW 4 PATIENTS. THE LIST OF HEALTH PROVIDERS SUPPLIED BY THE HEALTH 5 MAINTENANCE ORGANIZATION SHALL INCLUDE, BUT IS NOT LIMITED TO, 6 THE FOLLOWING INFORMATION ABOUT EACH HEALTH PROVIDER: SPECIALTY, 7 BOARD CERTIFICATION, YEARS IN PRACTICE, HOSPITAL AFFILIATION, 8 LOCATION OF OFFICE, OFFICE HOURS, AND WHETHER THE SPECIALIST IS 9 ACCEPTING NEW PATIENTS. 10 (3) ENROLLEES UNDER THE AGE OF 18 MAY DESIGNATE A PEDIATRI- 11 CIAN AS THEIR CARE COORDINATOR. WOMEN ENROLLEES MAY DESIGNATE A 12 SPECIALIST IN OBSTETRICS/GYNECOLOGY AS THEIR CARE COORDINATOR. 13 ENROLLEES WHO HAVE A DEGENERATIVE, DISABLING, OR LIFE-THREATENING 14 DISEASE OR CONDITION, OR ANY OTHER CONDITION THAT THE DEPARTMENT 15 WITH ADVICE FROM THE OFFICE OF HEALTH CARE CONSUMER ADVOCATE CRE- 16 ATED IN SECTION 21095 SHALL DESIGNATE AS REQUIRING THE REGULAR 17 CARE OF A SPECIALIST, MAY DESIGNATE AN APPROPRIATE SPECIALIST AS 18 THEIR CARE COORDINATOR. 19 (4) AN ENROLLEE DOES NOT HAVE THE RIGHT TO SELECT A PROVIDER 20 WHO IS NOT AFFILIATED WITH THE HEALTH MAINTENANCE ORGANIZATION AS 21 THE ENROLLEE'S CARE COORDINATOR. 22 (5) AN ENROLLEE MAY CHANGE THE DESIGNATION OF CARE COORDINA- 23 TOR WITHIN 30 DAYS OF THE FIRST VISIT TO THE CARE COORDINATOR, 24 ONCE EVERY 6 MONTHS, AND AT ANY TIME WHEN THE ENROLLEE SHOWS GOOD 25 CAUSE. 26 (6) AN ENROLLEE'S CARE COORDINATOR SHALL, WHEN REFERRING THE 27 ENROLLEE TO A SPECIALIST, PROVIDE THE ENROLLEE WITH A CHOICE OF A 02031'97 5 1 SUFFICIENT NUMBER OF SPECIALISTS TO OFFER THE ENROLLEE A 2 MEANINGFUL CHOICE AMONG SPECIALISTS. 3 (7) ENROLLEES WHO ARE NEWLY ENROLLED IN A HEALTH MAINTENANCE 4 ORGANIZATION, AND WHO AT THE TIME OF ENROLLMENT, OR IN THE 1 YEAR 5 PREVIOUS TO ENROLLMENT, HAVE BEEN RECEIVING TREATMENT FROM A 6 HEALTH PROVIDER WHO IS NOT AN AFFILIATED PROVIDER WITH THE HEALTH 7 MAINTENANCE ORGANIZATION FOR A DEGENERATIVE, DISABLING, OR 8 LIFE-THREATENING DISEASE OR CONDITION, OR ANY OTHER CONDITION 9 THAT HAS BEEN DESIGNATED BY THE DEPARTMENT WITH ADVICE FROM THE 10 OFFICE OF HEALTH CARE CONSUMER ADVOCATE CREATED IN SECTION 21095 11 AS REQUIRING THE REGULAR CARE OF A SPECIALIST, MAY CONTINUE TO 12 RECEIVE TREATMENT FROM THAT HEALTH PROVIDER FOR A REASONABLE 13 PERIOD OF TIME, TO BE DETERMINED BY THE DEPARTMENT, WITHOUT BEING 14 SUBJECT TO THE AMOUNT CHARGED BY THE PROVIDER THAT IS NOT COMPEN- 15 SATED BY THE HEALTH MAINTENANCE ORGANIZATION. THE HEALTH MAINTE- 16 NANCE ORGANIZATION SHALL REIMBURSE THE NONAFFILIATED PROVIDER FOR 17 CARE RECEIVED BY THE ENROLLEE AT THE REASONABLE AND CUSTOMARY 18 RATE PAID BY THE ORGANIZATION FOR THAT CARE BY AN AFFILIATED 19 PROVIDER. 20 SEC. 21052B. (1) ENROLLEES HAVE THE RIGHT TO SEEK HEALTH 21 CARE SERVICES COVERED BY THE HEALTH MAINTENANCE ORGANIZATION CON- 22 TRACT FROM HEALTH PROVIDERS WHO ARE NOT AFFILIATED PROVIDERS WITH 23 THE HEALTH MAINTENANCE ORGANIZATION. THE HEALTH MAINTENANCE 24 ORGANIZATION SHALL REIMBURSE THESE PROVIDERS WHEN AN ENROLLEE 25 ELECTS TO SEEK THEIR SERVICES, WITH REIMBURSEMENT TO BE AT RATES 26 THAT ARE REASONABLE AND CUSTOMARY. 02031'97 6 1 (2) THE HEALTH MAINTENANCE ORGANIZATION MAY CHARGE AN 2 ENROLLEE A REASONABLE, AFFORDABLE, AND APPROPRIATE DEDUCTIBLE AND 3 COPAYMENT, SUBJECT TO A REASONABLE, APPROPRIATE, AND AFFORDABLE 4 OUT-OF-POCKET LIMIT, IF AN ENROLLEE SEEKS CARE FROM A PROVIDER 5 WHO IS NOT AFFILIATED WITH THE HEALTH MAINTENANCE ORGANIZATION. 6 THE DEPARTMENT WITH ADVICE FROM THE OFFICE OF HEALTH CARE CON- 7 SUMER ADVOCATE CREATED IN SECTION 21095 SHALL DETERMINE THE PER- 8 MITTED LEVELS OF SUCH DEDUCTIBLES, COPAYMENTS, AND OUT-OF-POCKET 9 COSTS. THE DEPARTMENT SHALL ESTABLISH LOWER OUT-OF-POCKET COSTS 10 BASED ON A SLIDING FEE SCALE FOR LOWER-INCOME ENROLLEES IF THE 11 DEPARTMENT FINDS THAT SO DOING WILL AVOID IMPEDING ACCESS OF THE 12 ENROLLEES TO NEEDED SERVICES. 13 SEC. 21052C. PROVIDERS WHO ARE NOT AFFILIATED WITH THE 14 HEALTH MAINTENANCE ORGANIZATION AND WHO PROVIDE EMERGENCY HEALTH 15 SERVICES TO AN ENROLLEE SHALL BE REIMBURSED AT REASONABLE AND 16 CUSTOMARY RATES. 17 SEC. 21052D. A HEALTH MAINTENANCE ORGANIZATION SHALL NOT 18 PROHIBIT OR DISCOURAGE A HEALTH PROFESSIONAL FROM ADVOCATING FOR 19 THE ENROLLEE PURSUANT TO SECTION 21034 OR 21035 OR FROM DISCUSS- 20 ING WITH AN ENROLLEE OR PROVIDER ANY OF THE FOLLOWING: 21 (A) HEALTH CARE TREATMENTS AND SERVICES. 22 (B) QUALITY ASSURANCE PLANS REQUIRED BY LAW, IF APPLICABLE. 23 (C) THE FINANCIAL RELATIONSHIPS BETWEEN THE HEALTH MAINTE- 24 NANCE ORGANIZATION AND THE HEALTH PROFESSIONAL INCLUDING ALL OF 25 THE FOLLOWING AS APPLICABLE: 02031'97 7 1 (i) WHETHER A FEE-FOR-SERVICE ARRANGEMENT EXISTS, UNDER 2 WHICH THE PROVIDER IS PAID A SPECIFIED AMOUNT FOR EACH COVERED 3 SERVICE RENDERED TO THE PARTICIPANT. 4 (ii) WHETHER A CAPITATION ARRANGEMENT EXISTS, UNDER WHICH A 5 FIXED AMOUNT IS PAID TO THE PROVIDER FOR ALL COVERED SERVICES 6 THAT ARE OR MAY BE RENDERED TO EACH COVERED INDIVIDUAL OR 7 FAMILY. 8 (iii) WHETHER PAYMENTS TO PROVIDERS ARE MADE BASED ON STAN- 9 DARDS RELATING TO COST, QUALITY, OR PATIENT SATISFACTION. 10 SEC. 21052E. A HEALTH MAINTENANCE ORGANIZATION SHALL PRO- 11 VIDE COVERAGE AND REIMBURSEMENT FOR CARE THAT IT CONSIDERS INVES- 12 TIGATIONAL OR EXPERIMENTAL UNDER THE SAME TERMS AS IT WOULD FOR 13 CARE THAT IS NOT CONSIDERED INVESTIGATIONAL OR EXPERIMENTAL SO 14 LONG AS ALL OF THE FOLLOWING APPLY: 15 (A) THE TREATMENT IS FOR LIFE-THREATENING, DEGENERATIVE, OR 16 PERMANENTLY DISABLING CONDITIONS, OR A CHRONIC CONDITION ASSOCI- 17 ATED WITH A COMPLICATION OF SUCH A CONDITION. 18 (B) THE TREATMENT IS PROVIDED WITH THERAPEUTIC OR PALLIATIVE 19 INTENT. 20 (C) THE PROPOSED TREATMENT HAS BEEN REVIEWED AND APPROVED BY 21 THE HEALTH MAINTENANCE ORGANIZATION GOVERNING BODY ESTABLISHED 22 PURSUANT TO SECTION 21051. 23 (D) THE FACILITY AND PERSONNEL PROVIDING THE TREATMENT ARE 24 CAPABLE OF DOING SO BY VIRTUE OF THEIR EXPERIENCE AND TRAINING. 25 (E) THERE IS NO CLEARLY SUPERIOR, NONINVESTIGATIONAL ALTER- 26 NATIVE TO THE TREATMENT. 02031'97 8 1 Sec. 21053c. (1) This section applies if a health 2 maintenance organization contracts with health care providers to 3 become affiliated providers or offers a prudent purchaser 4 contract. 5 (2) A health maintenance organization may enter into a con- 6 tract with 1 or more health care providers to control health care 7 costs, assure appropriate utilization of health maintenance serv- 8 ices, and maintain quality of health care. The health mainte- 9 nance organizationmay limit the number of contracts entered10into pursuant to this section if the number of contracts is suf-11ficient to assure reasonable levels of access to health mainte-12nance services for recipients of those services. The number of13contracts authorized by this section that are necessary to assure14reasonable levels of access to health maintenance services for15recipients shall be determined by the health maintenance organi-16zation as approved by the department pursuant to this part.17However, the health maintenance organizationshall offer a con- 18 tract, comparable to those contracts entered into with other 19 affiliated providers, to at least 1 health care provider that 20 provides the applicable health maintenance services and is 21 located within a reasonable distance from the recipients of those 22 health maintenance services, if a health care provider that pro- 23 vides the applicable health maintenance services is located 24 within that reasonable distance. 25 (3) A health maintenance organization shall give all health 26 care providers that provide the applicable health maintenance 27 services and are located in the geographic area served by the 02031'97 9 1 health maintenance organization an opportunity to apply to the 2 health maintenance organization to become an affiliated 3 provider. A HEALTH MAINTENANCE ORGANIZATION SHALL CONTRACT WITH 4 ALL HEALTH CARE PROVIDERS WHO APPLY TO BECOME AFFILIATED PROVID- 5 ERS OR TO BE ON A PRUDENT PURCHASER PANEL AND WHO MEET THE 6 ORGANIZATION'S WRITTEN STANDARDS DESCRIBED IN SUBSECTION (4). 7 (4) A contract shall be based upon the following written 8 standards which shall be filed by the health maintenance organi- 9 zation with the department or commissioner on a form and in a 10 manner that is uniformly developed and applied by the department 11 or commissioner: 12 (a) Standards for maintaining quality health care. 13 (b) Standards for controlling health care costs. 14 (c) Standards for assuring appropriate utilization of health 15 care services. 16 (d) Standards for assuring reasonable levels of access to 17 health care services. 18 (e) Other standards considered appropriate by the health 19 maintenance organization. 20 (5) If the department or commissioner determines that stan- 21 dards under subsection (4) are duplicative of standards already 22 filed by the health maintenance organization, those duplicative 23 standards need not be filed under subsection (4). 24 (6) A health maintenance organization shall develop and 25 institute procedures that are designed to notify health care pro- 26 viders that provide the applicable health maintenance services 27 and are located in the geographic area served by the organization 02031'97 10 1 of the acceptance of applications for a provider panel. The 2 procedures shall include the giving of notice to those providers 3 upon request and shall include publication in a newspaper with 4 general circulation in the geographic area served by the organi- 5 zation at least 30 days before the initial provider application 6 period. A health maintenance organization shall provide for an 7 initial 60-day provider application period during which providers 8 may apply to the health maintenance organization to become affil- 9 iated providers. A health maintenance organization that has 10 entered into a contract with an affiliated provider shall pro- 11 vide, at least once every 4 years, for a 60-day provider applica- 12 tion period during which a provider may apply to the organization 13 to become an affiliated provider. Notice of this provider appli- 14 cation period shall be given to providers upon request and shall 15 be published in a newspaper with general circulation in the geo- 16 graphic area served by the organization at least 30 days before 17 the commencement of the provider application period. Upon 18 receipt of a request by a health care provider, the organization 19 shall provide the written standards required under this act to 20 the health care provider. Within 90 days after the close of a 21 provider application period, or within 30 days following the com- 22 pletion of the applicable physician credentialing process, which- 23 ever is later, a health maintenance organization shall notify an 24 applicant in writing as to whether the application to become an 25 affiliated provider has been accepted or rejected. If an appli- 26 cant has been rejected, the health maintenance organization shall 02031'97 11 1 state in writing the reasons for rejection, citing 1 or more of 2 the standards. 3 (7) A health care provider whose contract as an affiliated 4 provider is terminated shall be provided upon request with a 5 written explanation by the organization of the reasons for the 6 termination. 7 (8) A health maintenance organization that is providing pru- 8 dent purchaser agreement services to an insurer shall provide the 9 insurer on a timely basis with information requested by the 10 insurer that the organization has and that the insurer needs to 11 comply with section 2212 of the insurance code of 1956,Act12No. 218 of the Public Acts of 1956, being section 500.2212 of the13Michigan Compiled Laws1956 PA 218, MCL 500.2212. 14 SEC. 21053D. (1) EACH HEALTH MAINTENANCE ORGANIZATION SHALL 15 ESTABLISH AND IMPLEMENT AN INTERNAL QUALITY ASSURANCE SYSTEM ADE- 16 QUATE TO IDENTIFY, EVALUATE, AND REMEDY PROBLEMS RELATING TO 17 ACCESS, CONTINUITY, AND QUALITY OF CARE. THE SYSTEM SHALL 18 INCLUDE ALL OF THE FOLLOWING: 19 (A) THE DESIGNATION OF THE APPROPRIATE BOARD, COMMITTEE, OR 20 EXECUTIVE STAFF RESPONSIBLE FOR IMPLEMENTATION AND CONTINUOUS 21 MONITORING OF THE SYSTEM. 22 (B) A DETAILED SET OF QUALITY ASSURANCE OBJECTIVES, WITH 23 TIMETABLES, INCLUDING ASSURANCE OF ADEQUATE RESOURCES TO DELIVER 24 A FULL CONTINUUM OF CARE AND GUARANTEE GEOGRAPHIC AVAILABILITY, 25 CULTURAL SENSITIVITY, AND PLANNING FOR SPECIAL NEEDS 26 POPULATIONS. 02031'97 12 1 (C) HEALTH SERVICE DELIVERY STANDARDS OR PRACTICE GUIDELINES 2 AIMED AT CURE, MAINTAINING FUNCTION, AND IMPROVING QUALITY OF 3 LIFE, WHICH ARE UPDATED CONTINUOUSLY WITH HEALTH PROVIDER INPUT, 4 DEVELOPED FOR THE FULL SPECTRUM OF PLAN POPULATIONS, BASED ON 5 REASONABLE SCIENTIFIC KNOWLEDGE, FOCUSED ON OUTCOMES AND ACCESS, 6 AND SUPPLIED TO INDIVIDUAL PROVIDERS. 7 (D) A METHODOLOGY FOR IDENTIFYING QUALITY INDICATORS RELAT- 8 ING TO SPECIFIC CLINICAL OR HEALTH SERVICE DELIVERY AREAS THAT 9 ARE OBJECTIVE, MEASURABLE, AND BASED ON CURRENT KNOWLEDGE AND 10 CLINICAL EXPERIENCE. 11 (E) METHODS TO ENSURE COMPLIANCE WITH ALL QUALITY ASSURANCE 12 STANDARDS BY ANY PROVIDER PROVIDING SERVICES UNDER ANY CONTRAC- 13 TUAL AGREEMENTS. 14 (F) METHODS REQUIRING VERIFICATION OF HEALTH PROVIDERS' 15 LICENSES, EDUCATION, WORK HISTORY, HISTORY OF LIABILITY CLAIMS, 16 AND HISTORY OF REVOCATION OR SUSPENSION OF LICENSES, CLINICAL 17 PRIVILEGES, AND OTHER SANCTIONS. 18 (2) ONCE EVERY 3 YEARS, THE DEPARTMENT SHALL CONDUCT AN 19 AUDIT OR CONTRACT WITH 1 OR MORE INDEPENDENT QUALITY ASSURANCE 20 ORGANIZATIONS TO MONITOR AND EVALUATE THE QUALITY OF CARE AND 21 SERVICES FURNISHED BY THE HEALTH MAINTENANCE ORGANIZATION. THE 22 RESULTS OF THIS AUDIT SHALL BE REPORTED TO THE PUBLIC, THE GOVER- 23 NOR, AND THE SENATE AND HOUSE OF REPRESENTATIVES STANDING COMMIT- 24 TEES ON HEALTH AND INSURANCE ISSUES. 25 SEC. 21095. (1) THE OFFICE OF HEALTH CARE CONSUMER ADVOCATE 26 IS CREATED WITHIN THE DEPARTMENT. 02031'97 13 1 (2) THE OFFICE OF HEALTH CARE CONSUMER ADVOCATE SHALL 2 CONSIST OF THE FOLLOWING 8 MEMBERS: 3 (A) THREE CONSUMER REPRESENTATIVES, 1 SELECTED BY THE GOVER- 4 NOR, 1 SELECTED BY THE SENATE MAJORITY LEADER, AND 1 SELECTED BY 5 THE SPEAKER OF THE HOUSE OF REPRESENTATIVES. 6 (B) THREE HEALTH CARE PROVIDER REPRESENTATIVES, 1 SELECTED 7 BY THE GOVERNOR, 1 SELECTED BY THE SENATE MAJORITY LEADER, AND 1 8 SELECTED BY THE SPEAKER OF THE HOUSE OF REPRESENTATIVES. 9 (C) TWO HEALTH MAINTENANCE ORGANIZATION REPRESENTATIVES 10 SELECTED BY THE DEPARTMENT. 11 (3) THE MEMBERS FIRST APPOINTED TO THE OFFICE OF HEALTH CARE 12 CONSUMER ADVOCATE SHALL BE APPOINTED WITHIN 60 DAYS AFTER THE 13 EFFECTIVE DATE OF THIS SECTION. 14 (4) MEMBERS OF THE OFFICE OF HEALTH CARE CONSUMER ADVOCATE 15 SHALL SERVE FOR TERMS OF 2 YEARS, OR UNTIL A SUCCESSOR IS 16 APPOINTED, WHICHEVER IS LATER, EXCEPT THAT OF THE MEMBERS FIRST 17 APPOINTED, 4 SHALL SERVE FOR 1 YEAR AND 4 SHALL SERVE FOR 2 18 YEARS. 19 (5) IF A VACANCY OCCURS IN THE OFFICE OF HEALTH CARE CON- 20 SUMER ADVOCATE, THE POSITION SHALL BE FILLED BY APPOINTMENT FOR 21 THE UNEXPIRED TERM IN THE SAME MANNER AS THE ORIGINAL 22 APPOINTMENT. 23 (6) THE FIRST MEETING OF THE OFFICE OF HEALTH CARE CONSUMER 24 ADVOCATE SHALL BE HELD 90 DAYS AFTER THE EFFECTIVE DATE OF THIS 25 SECTION. AT THE FIRST MEETING, THE OFFICE OF HEALTH CARE CON- 26 SUMER ADVOCATE SHALL ELECT FROM AMONG ITS MEMBERS A CHAIRPERSON 27 AND OTHER OFFICERS AS IT CONSIDERS NECESSARY OR APPROPRIATE. 02031'97 14 1 AFTER THE FIRST MEETING, THE OFFICE OF HEALTH CARE CONSUMER 2 ADVOCATE SHALL MEET AT LEAST MONTHLY, OR MORE FREQUENTLY AT THE 3 CALL OF THE CHAIRPERSON OR IF REQUESTED BY 4 OR MORE MEMBERS. 4 (7) FIVE OF THE MEMBERS OF THE OFFICE OF HEALTH CARE CON- 5 SUMER ADVOCATE CONSTITUTE A QUORUM FOR THE TRANSACTION OF BUSI- 6 NESS AT A MEETING OF THE OFFICE OF HEALTH CARE CONSUMER 7 ADVOCATE. FIVE OF THE MEMBERS PRESENT AND SERVING ARE REQUIRED 8 FOR OFFICIAL ACTION OF THE OFFICE OF HEALTH CARE CONSUMER 9 ADVOCATE. 10 (8) THE BUSINESS THAT THE OFFICE OF HEALTH CARE CONSUMER 11 ADVOCATE MAY PERFORM SHALL BE CONDUCTED AT A PUBLIC MEETING HELD 12 IN COMPLIANCE WITH THE OPEN MEETINGS ACT, 1976 PA 267, MCL 15.261 13 TO 15.275. 14 (9) A WRITING PREPARED, OWNED, USED, IN POSSESSION OF, OR 15 RETAINED BY THE OFFICE OF HEALTH CARE CONSUMER ADVOCATE IN THE 16 PERFORMANCE OF AN OFFICIAL FUNCTION IS SUBJECT TO THE FREEDOM OF 17 INFORMATION ACT, 1976 PA 442, MCL 15.231 TO 15.246. 18 (10) MEMBERS OF THE OFFICE OF HEALTH CARE CONSUMER ADVOCATE 19 SHALL SERVE WITHOUT COMPENSATION. HOWEVER, MEMBERS MAY BE REIM- 20 BURSED FOR THEIR ACTUAL AND NECESSARY EXPENSES INCURRED IN THE 21 PERFORMANCE OF THEIR OFFICIAL DUTIES. 22 (11) THE OFFICE OF HEALTH CARE CONSUMER ADVOCATE SHALL DO 23 ALL OF THE FOLLOWING: 24 (A) ASSIST INDIVIDUAL CONSUMERS TO ACCESS HEALTH CARE APPRO- 25 PRIATE TO THEIR NEEDS AND ASSURE THAT THE RIGHTS OF INDIVIDUALS 26 IN RECEIVING HEALTH CARE SERVICES ARE IMPLEMENTED. 02031'97 15 1 (B) EDUCATE HEALTH CARE CONSUMERS ABOUT THEIR RIGHTS AND 2 RESPONSIBILITIES AS CONSUMERS OF HEALTH CARE SERVICES AND HEALTH 3 CARE COVERAGES AND INSURANCE. 4 (C) REPRESENT AND PROMOTE THE INTERESTS OF HEALTH CARE CON- 5 SUMERS AS A CLASS BEFORE ANY LEGISLATIVE, ADMINISTRATIVE, OR 6 JUDICIAL BODY AND INITIATE, MAINTAIN, INTERVENE, OR PARTICIPATE 7 IN ANY PROCEEDING RELATED TO HEALTH CARE OR HEALTH CARE COVERAGES 8 AND INSURANCE THAT REFLECTS THE INTERESTS OF HEALTH CARE 9 CONSUMERS. 10 (D) CONDUCT AND DISSEMINATE PUBLIC INFORMATION CONCERNING 11 HEALTH CARE AND HEALTH CARE COVERAGES AND INSURANCE. 12 (E) DEVELOP PROPOSALS TO IMPROVE THE DELIVERY AND QUALITY OF 13 HEALTH CARE SERVICES AND HEALTH CARE COVERAGES AND INSURANCE. 14 (F) ASSIST AND ADVISE THE DEPARTMENT IN DETERMINING HEALTH 15 MAINTENANCE ORGANIZATIONS' ENROLLEE NEEDS BASED ON THE CHARACTER- 16 ISTICS OF THE HEALTH MAINTENANCE ORGANIZATION'S ENROLLEE POPULA- 17 TION TAKING INTO ACCOUNT SUCH FACTORS AS AGE, GENDER, AND HEALTH 18 STATUS, INCLUDING ACUTE AND CHRONIC CONDITIONS AND SPECIAL NEEDS, 19 PURSUANT TO SECTION 21052A(1). 20 (G) ASSIST AND ADVISE THE DEPARTMENT IN DEVISING A LIST OF 21 DEGENERATIVE, DISABLING, AND LIFE-THREATENING DISEASES AND CONDI- 22 TIONS AND OTHER CONDITIONS THAT REQUIRE THE REGULAR CARE OF A 23 SPECIALIST PURSUANT TO SECTION 21052A(3). 24 (H) ASSIST AND ADVISE THE DEPARTMENT IN DETERMINING PERMIT- 25 TED LEVELS OF DEDUCTIBLES, COPAYMENTS, AND OUT-OF-POCKET COSTS 26 THAT A HEALTH MAINTENANCE ORGANIZATION MAY CHARGE AN ENROLLEE 27 PURSUANT TO SECTION 21052B(2). 02031'97 16 1 (I) ESTABLISH A TOLL-FREE TELEPHONE NUMBER THAT CONSUMERS 2 CAN ACCESS TO RECEIVE ADVICE AND ASSISTANCE FROM THE OFFICE OF 3 HEALTH CARE CONSUMER ADVOCATE. 4 (J) REPORT ANNUALLY ON ISSUES AFFECTING HEALTH CARE SERVICES 5 AND HEALTH CARE COVERAGES AND INSURANCE TO THE GOVERNOR AND THE 6 SENATE AND HOUSE OF REPRESENTATIVES STANDING COMMITTEES ON HEALTH 7 AND INSURANCE ISSUES. 02031'97 Final page. 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