SENATE BILL No. 950
February 1, 2000, Introduced by Senators KOIVISTO, A. SMITH, DINGELL, EMERSON,
DE BEAUSSAERT, BYRUM and MURPHY and referred to the Committee on Health Policy.
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
by amending section 2213 (MCL 500.2213), as added by 1996
PA 517.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
1 Sec. 2213. (1) By
October 1, 1997, an AN insurer shall
2 establish an internal formal grievance procedure for approval by
3 the insurance bureau for persons covered under a policy or cer-
4 tificate issued under chapter 34 or 36 that includes all of the
5 following:
6 (a) Provides for a designated person responsible for admin-
7 istering the grievance system.
8 (b) Provides a designated person or telephone number for
9 receiving complaints.
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1 (c) Ensures full investigation of a complaint.
2 (d) Provides for timely notification to the insured as to
3 the progress of an investigation.
4 (e) Provides an insured the right to appear before the board
5 of directors or designated committee or the right to a
6 managerial-level conference to present a grievance.
7 (f) Provides for notification to the insured of the results
8 of the insurer's investigation and for advisement of the
9 insured's right to review the grievance by the commissioner.
10 (g) Provides summary data on the number and types of com-
11 plaints filed.
12 (h) Provides for periodic management and governing body
13 review of the data to assure that appropriate actions have been
14 taken.
15 (i) Provides for copies of all complaints and responses to
16 be available at the principal office of the insurer for inspec-
17 tion by the insurance bureau for 2 years following the year the
18 complaint was filed.
19 (j) That when an adverse determination is made, a written
20 statement containing the reasons for the adverse determination
21 will be provided to the insured
person . (k) That ALONG WITH a
22 written notification IN PLAIN ENGLISH of the grievance procedures
23 will be provided to the
insured person when the insured person
24 contests an adverse
determination INCLUDING THE RIGHT TO A
25 REVIEW BY THE COMMISSIONER.
26 (K)
(l)
That a final determination will be made in writing
27 by the insurer not later than
90 30 calendar days after a
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1 formal grievance is submitted in writing by the insured person.
2 The timing for the
90-calendar-day 30-CALENDAR-DAY period may
3 be tolled, however, for any period of time the insured person is
4 permitted to take under the grievance procedure.
5 (l)
(m) That an initial determination will be made by the
6 insurer not later than 72 hours after receipt of an expedited
7 grievance. Within 3 business days after the initial determina-
8 tion by the insurer, the insured
or a person, including, but not
9 limited to, a physician,
authorized in writing to act on behalf
10 of the insured
may request further review by the insurer or for
11 a determination of the matter by the commissioner or his or her
12 designee. If further review is requested, a final determination
13 by the insurer shall be made not later than 30 days after receipt
14 of the request for further review. Within 10 days after receipt
15 of a final determination, the insured
or a person, including,
16 but not limited to, a
physician, authorized in writing to act on
17 behalf of the insured
may request a determination of the matter
18 by the commissioner or his or her designee. If the initial or
19 final determination by the insurer is made orally, the insurer
20 shall provide a written confirmation of the determination to the
21 insured not later than 2 business days after the oral
22 determination. An expedited grievance under this subdivision
23 applies if a grievance is submitted and a physician, orally or in
24 writing, substantiates that the time frame for a grievance under
25 subdivision
(l)
(K) would acutely jeopardize the life of the
26 insured.
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1 (M) (n)
That the insured person has the right to a
2 determination of the matter by the commissioner or his or her
3 designee.
4 (2) The commissioner shall establish a procedure for a
5 determination of a grievance under this section which shall be
6 reasonably calculated to resolve these matters informally and as
7 rapidly as possible, while protecting the interests of both the
8 insured and the insurer. This procedure is not a contested case
9 under the administrative procedures
act of 1969, Act No. 306 of
10 the Public Acts of 1969,
being sections 24.201 to 24.328 of the
11 Michigan Compiled
Laws 1969 PA 306, MCL 24.201 TO 24.328, and is
12 not appealable under
Act No. 306 of the Public Acts of 1969 THE
13 ADMINISTRATIVE PROCEDURES ACT OF 1969, 1969 PA 306, MCL 24.201 TO
14 24.328.
15 (3) AN INSURED MAY AUTHORIZE IN WRITING ANY PERSON, INCLUD-
16 ING, BUT NOT LIMITED TO, A PHYSICIAN, TO ACT ON HIS OR HER BEHALF
17 AT ANY STAGE IN A GRIEVANCE PROCEEDING UNDER THIS SECTION.
18 (4) (3)
This section does not apply to a provider's com-
19 plaint concerning claims payment, handling, or reimbursement for
20 health care services.
21 (5) (4)
As used in this section:
22 (a) "Adverse determination" means a determination that an
23 admission, availability of care, continued stay, or other health
24 care service has been reviewed and denied. Failure to respond in
25 a timely manner to a request for a determination constitutes an
26 adverse determination.
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1 (b) "Grievance" means a complaint on behalf of an insured
2 person submitted by an insured
person or a person, including,
3 but not limited to, a
physician, authorized in writing to act on
4 behalf of the insured
person regarding CONCERNING ANY OF THE
5 FOLLOWING:
6 (i) The availability, delivery, or quality of health care
7 services, including a complaint regarding an adverse determina-
8 tion made pursuant to utilization review.
9 (ii) Benefits or claims payment, handling, or reimbursement
10 for health care services.
11 (iii) Matters pertaining to the contractual relationship
12 between an insured and the insurer.
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