HOUSE BILL No. 5736 April 2, 1998, Introduced by Reps. Law, Palamara and Profit and referred to the Committee on Health Policy. 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 1997 PA 184 and section 502a as amended by 1994 PA 440. THE PEOPLE OF THE STATE OF MICHIGAN ENACT: 1 Sec. 502. (1) A health care corporation may enter into par- 2 ticipating contracts for reimbursement with professional health 3 care providers practicing legally in this state for health care 4 services that the professional health care providers may legally 5 perform. A participating contract may cover all members or may 6 be a separate and individual contract on a per claim basis, as 7 set forth in the provider class plan, if, in entering into a 8 separate and individual contract on a per claim basis, the 9 participating provider certifies to the health care corporation: 05853'98 DKH 2 1 (a) That the provider will accept payment from the 2 corporation as payment in full for services rendered for the 3 specified claim for the member indicated. 4 (b) That the provider will accept payment from the corpora- 5 tion as payment in full for all cases involving the procedure 6 specified, for the duration of the calendar year. As used in 7 this subdivision, provider does not include a person licensed as 8 a dentist under part 166 of the public health code, 1978 PA 368, 9 MCL 333.16601 to 333.16648. 10 (c) That the provider will not determine whether to partici- 11 pate on a claim on the basis of the race, color, creed, marital 12 status, sex, national origin, residence, age, handicap, or lawful 13 occupation of the member entitled to health care benefits. 14 (2) A contract entered into pursuant to subsection (1) shall 15 provide that the private provider-patient relationship shall be 16 maintained to the extent provided for by law. A health care cor- 17 poration shall continue to offer a reimbursement arrangement to 18 any class of providers with which it has contracted prior to 19 August 27, 1985 and that continues to meet the standards set by 20 the corporation for that class of providers. 21 (3) A health care corporation shall not restrict the methods 22 of diagnosis or treatment of professional health care providers 23 who treat members. Except as otherwise provided in section 502a, 24 each member of the health care corporation shall at all times 25 have a choice of professional health care providers. This sub- 26 section does not apply to limitations in benefits contained in 27 certificates, to the reimbursement provisions of a provider 05853'98 3 1 contract or reimbursement arrangement, or to standards set by the 2 corporation for all contracting providers. A health care corpo- 3 ration may refuse to reimburse a health care provider for health 4 care services that are overutilized, including those services 5 rendered, ordered, or prescribed to an extent that is greater 6 than reasonably necessary. 7 (4) A health care corporation may provide to a member, upon 8 request, a list of providers with whom the corporation contracts, 9 for the purpose of assisting a member in obtaining a type of 10 health care service. However, except as otherwise provided in 11 section 502a, an employee, agent, or officer of the corporation, 12 or an individual on the board of directors of the corporation, 13 shall not make recommendations on behalf of the corporation with 14 respect to the choice of a specific health care provider. Except 15 as otherwise provided in section 502a, an employee, agent, or 16 officer of the corporation, or a person on the board of directors 17 of the corporation who influences or attempts to influence a 18 person in the choice or selection of a specific professional 19 health care provider on behalf of the corporation, is guilty of a 20 misdemeanor. 21 (5) A health care corporation shall provide a symbol of par- 22 ticipation, which can be publicly displayed, to providers who 23 participate on all claims for covered health care services 24 rendered to subscribers. 25 (6) This section does not impede the lawful operation of, or 26 lawful promotion of, a health maintenance organization owned by a 27 health care corporation. 05853'98 4 1 (7) Contracts entered into under this sectionshall beARE 2 subject to the provisions of sections 504 to 518. 3 (8) A health care corporation shall not deny participation 4 to a freestanding medical or surgical outpatient facility on the 5 basis of ownership if the facility meets the reasonable standards 6 set by the health care corporation for similar facilities, is 7 licensed under part 208 of the public health code, 1978 PA 368, 8 MCL 333.20801 to 333.20821, and complies with part 222 of the 9 public health code, 1978 PA 368, MCL 333.22201 to 333.22260. 10 (9) Notwithstanding any other provision of this act, if a 11 certificate provides for benefits for services that are within 12 the scope of practice of optometry, a health care corporation is 13 not required to provide benefits or reimburse for a practice of 14 optometric service unless that service was included in the defi- 15 nition of practice of optometry under section 17401 of the public 16 health code, 1978 PA 368, MCL 333.17401, as of May 20, 1992. 17 (10) NOTWITHSTANDING ANY OTHER PROVISION OF THIS ACT, IF A 18 CERTIFICATE PROVIDES FOR BENEFITS FOR SERVICES THAT ARE WITHIN 19 THE DEFINITION OF A REGISTERED ATHLETIC TRAINER UNDER SECTION 20 17901 OF THE PUBLIC HEALTH CODE, 1978 PA 368, MCL 333.17901, A 21 HEALTH CARE CORPORATION IS NOT REQUIRED TO PROVIDE BENEFITS OR 22 REIMBURSE FOR SERVICES PERFORMED BY AN ATHLETIC TRAINER REGIS- 23 TERED UNDER PART 179 OF THE PUBLIC HEALTH CODE, 1978 PA 368, MCL 24 333.17901 TO 333.17907. 25 Sec. 502a. (1) For the purpose of doing business as an 26 organization under the prudent purchaser act,Act No. 233 of the27Public Acts of 1984, being sections 550.51 to 550.63 of the05853'98 5 1Michigan Compiled Laws1984 PA 233, MCL 550.51 TO 550.63, a 2 health care corporation may enter into prudent purchaser agree- 3 ments with health care providers pursuant to this section and 4Act No. 233 of the Public Acts of 1984THE PRUDENT PURCHASER 5 ACT, 1984 PA 233, MCL 550.51 TO 550.63. 6 (2) A health care corporation may offer group contracts 7 under which subscribers shall be required, as a condition of cov- 8 erage, to obtain services exclusively from health care providers 9 who have entered into prudent purchaser agreements. 10 (3) An individual who is a member of a group who is offered 11 the option of being a subscriber under a contract pursuant to 12 subsection (2) shall also be offered the option of being a sub- 13 scriber under a contract pursuant to subsection (4). This sub- 14 section applies only if the group in which the individual is a 15 member has 25 or more members or if the provider panel that is 16 providing the services under the contract is limited by the 17 organization to a specific number pursuant to section 3(1) of 18Act No. 233 of the Public Acts of 1984, being section 550.53 of19the Michigan Compiled LawsTHE PRUDENT PURCHASER ACT, 1984 PA 20 233, MCL 550.53. 21 (4) A health care corporation may offer group contracts 22 under which subscribers who elect to obtain services from health 23 care providers who have entered into prudent purchaser agreements 24 shall realize a financial advantage or other advantage by select- 25 ing such providers. Contracts offered pursuant to this subsec- 26 tion shall not, as a condition of coverage, require subscribers 05853'98 6 1 to obtain services exclusively from health care providers who 2 have entered into prudent purchaser agreements. 3 (5) An individual who is a member of a group who is offered 4 the option of being a subscriber under a contract pursuant to 5 subsection (2) or (4) shall also be offered the option of being a 6 subscriber under a contract that: 7 (a) Does not, as a condition of coverage, require subscrib- 8 ers to obtain services exclusively from health care providers who 9 have entered into prudent purchaser agreements. 10 (b) Does not give a financial advantage or other advantage 11 to a subscriber who elects to obtain services from health care 12 providers who have entered into prudent purchaser agreements. 13 (6) Subsection (5) applies only if the group in which the 14 individual is a member has 25 or more members and if the group on 15 December 20, 1984 had health care coverage through the group 16 sponsor. 17 (7) A health care corporation may offer individual contracts 18 under which subscribers shall be required, as a condition of cov- 19 erage, to obtain services exclusively from health care providers 20 who have entered into prudent purchaser agreements. A person to 21 whom such a contract is offered shall also be offered a contract 22 that: 23 (a) Does not, as a condition of coverage, require subscrib- 24 ers to obtain services exclusively from health care providers who 25 have entered into prudent purchaser agreements. 05853'98 7 1 (b) Does not give a financial advantage or other advantage 2 to a subscriber who elects to obtain services from health care 3 providers who have entered into prudent purchaser agreements. 4 (8) A health care corporation may offer individual contracts 5 under which subscribers who elect to obtain services from health 6 care providers who have entered into prudent purchaser agreements 7 shall realize a financial advantage or other advantage by select- 8 ing such providers. Contracts offered pursuant to this subsec- 9 tion shall not, as a condition of coverage, require subscribers 10 to obtain services exclusively from health care providers who 11 have entered into prudent purchaser agreements. A person to whom 12 such a contract is offered shall also be offered a contract 13 that: 14 (a) Does not, as a condition of coverage, require subscrib- 15 ers to obtain services exclusively from health care providers who 16 have entered into prudent purchaser agreements. 17 (b) Does not give a financial advantage or other advantage 18 to a subscriber who elects to obtain services from health care 19 providers who have entered into prudent purchaser agreements. 20 (9) The rates charged by a corporation for coverage under 21 contracts issued under this section shall not be unreasonably 22 lower than what is necessary to meet the expenses of the corpora- 23 tion for providing this coverage and shall not have an anticom- 24 petitive effect or result in predatory pricing in relation to 25 prudent purchaser agreement coverages offered by other 26 organizations. 05853'98 8 1 (10) Contracts entered into under this sectionshallARE 2 notbesubject to the provisions of sections 504 to 518. 3 (11) A corporation shall not discriminate against a class of 4 health care providers when entering into prudent purchaser agree- 5 ments with health care providers for its provider panel. This 6 subsection does not: 7 (a) Prohibit the formation of a provider panel consisting of 8 a single class of providers when a service provided for in the 9 specifications of a purchaser may be legally provided only by a 10 single class of providers. 11 (b) Prohibit the formation of a provider panel that conforms 12 to the specifications of a purchaser of the coverage authorized 13 by this section so long as the specifications do not exclude any 14 class of health care providers who may legally perform the serv- 15 ices included in the coverage. 16 (c) Require an organization that has uniformly applied the 17 standards filed pursuant to section 3(3) ofAct No. 233 of the18Public Acts of 1984THE PRUDENT PURCHASER ACT, 1984 PA 233, MCL 19 550.53, to contract with any individual provider. 20 (12) Nothing in the 1984 amendatory act that added this sec- 21 tion applies to any contract that was in existence before 22 December 20, 1984, or the renewal of such contract. 23 (13) Notwithstanding any other provision of this act, if 24 coverage under a prudent purchaser agreement provides for bene- 25 fits for services that are within the scope of practice of optom- 26 etry, a health care corporation is not required to provide 27 benefits or reimburse for a practice of optometric service unless 05853'98 9 1 that service was included in the definition of practice of 2 optometry under section 17401 of the public health code,Act3No. 368 of the Public Acts of 1978, being section 333.17401 of4the Michigan Compiled Laws1978 PA 368, MCL 333.17401, as of 5 May 20, 1992. 6 (14) Notwithstanding any other provision of this act, if 7 coverage under a prudent purchaser agreement provides for bene- 8 fits for services that are within thescope of practice of9chiropracticDEFINITION OF A REGISTERED ATHLETIC TRAINER UNDER 10 SECTION 17901 OF THE PUBLIC HEALTH CODE, 1978 PA 368, MCL 11 333.17901, a health care corporation is not required to provide 12 benefits or reimburse forthe use of therapeutic sound or elec-13tricity, or both, for the reduction or correction of spinal sub-14luxations in a chiropractic serviceSERVICES PERFORMED BY AN 15 ATHLETIC TRAINER REGISTERED UNDER PART 179 OF THE PUBLIC HEALTH 16 CODE, 1978 PA 368, MCL 333.17901 TO 333.17907.This subsection17shall not take effect unless Senate Bill No. 493 or House Bill18No. 4494 of the 87th Legislature is enacted into law.19 Enacting section 1. This amendatory act does not take 20 effect unless House Bill No. 4789 of the 89th Legislature is 21 enacted into law. 05853'98 Final page. DKH