SENATE BILL No. 68

February 1, 2001, Introduced by Senators SCHWARZ, SHUGARS, BYRUM,

HAMMERSTROM and EMERSON and referred to the Committee on Health

Policy.

A bill to amend 1956 PA 218, entitled

"The insurance code of 1956,"

by amending section 3406k (MCL 500.3406k), as added by 1998

PA 125.

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

1 Sec. 3406k. (1) An expense-incurred hospital, medical, or

2 surgical policy or certificate delivered, issued for delivery, or

3 renewed in this state that provides coverage for emergency health

4 services AND A HEALTH MAINTENANCE ORGANIZATION CONTRACT shall

5 provide coverage for medically necessary services provided to an

6 insured OR ENROLLEE for the sudden onset of a medical condition

7 that manifests itself by signs and symptoms of sufficient severi-

8 ty, including severe pain, such that the absence of immediate

9 medical attention could reasonably be expected to result in

10 serious jeopardy to the individual's health or to a pregnancy in

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1 the case of a pregnant woman, serious impairment to bodily

2 functions, or serious dysfunction of any bodily organ or part.

3 An insurer AND A HEALTH MAINTENANCE ORGANIZATION shall not deny

4 payment for emergency health services up to the point of stabili-

5 zation provided to an insured OR ENROLLEE under this subsection

6 because of either of the following:

7 (a) The final diagnosis.

8 (b) Prior authorization was not given by the insurer OR

9 HEALTH MAINTENANCE ORGANIZATION before emergency health services

10 were provided.

11 (2) AN INSURER SUBJECT TO THIS SECTION AND A HEALTH MAINTE-

12 NANCE ORGANIZATION SHALL NOT ENCOURAGE OR DIRECT AN INSURED OR

13 ENROLLEE TO AN EMERGENCY HEALTH SERVICES RESPONSE AND TRANSPORTA-

14 TION SYSTEM IN COMPETITION WITH OR IN SUBSTITUTION FOR THE 9-1-1

15 EMERGENCY HEALTH SERVICES SYSTEM OR OTHER STATE OR LOCAL UNIT OF

16 GOVERNMENT EMERGENCY HEALTH SERVICES SYSTEM.

17 (3) SUBSECTION (2) DOES NOT PROHIBIT AN INSURER AND A HEALTH

18 MAINTENANCE ORGANIZATION FROM USING OR REQUIRING TRANSPORTATION

19 OUTSIDE THE 9-1-1 EMERGENCY HEALTH SERVICES SYSTEM OR OTHER STATE

20 OR LOCAL UNIT OF GOVERNMENT EMERGENCY HEALTH SERVICES SYSTEM FOR

21 NONEMERGENCY HEALTH SERVICES.

22 (4) AN INSURER AND A HEALTH MAINTENANCE ORGANIZATION SHALL

23 NOT REQUIRE AN INSURED OR ENROLLEE TO OBTAIN PRIOR AUTHORIZATION

24 BEFORE ACCESSING THE 9-1-1 SYSTEM OR OTHER STATE OR LOCAL UNIT OF

25 GOVERNMENT EMERGENCY HEALTH SERVICES SYSTEM FOR EMERGENCY HEALTH

26 SERVICES.

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1 (5) AN INSURER AND A HEALTH MAINTENANCE ORGANIZATION SHALL

2 NOT USE FALSE OR MISLEADING LANGUAGE IN ANY MATERIALS PROVIDED TO

3 INSUREDS OR ENROLLEES TO DISCOURAGE OR PROHIBIT AN INSURED OR

4 ENROLLEE FROM ACCESSING THE 9-1-1 SYSTEM FOR EMERGENCY HEALTH

5 SERVICES OR OTHER STATE OR LOCAL UNIT OF GOVERNMENT EMERGENCY

6 HEALTH SERVICES SYSTEM.

7 (6) (2) As used in this section, "stabilization" means the

8 point at which no material deterioration of a condition is

9 likely, within reasonable medical probability, to result from or

10 occur during transfer of the patient.

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