SB-1308, As Passed Senate, November 29, 2012

SENATE BILL No. 1308

September 25, 2012, Introduced by Senator MARLEAU and referred to the Committee on Insurance.

     A bill to amend 1956 PA 218, entitled

"The insurance code of 1956,"

by amending section 2213 (MCL 500.2213), as amended by 2002 PA 707.

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

     Sec. 2213. (1) Except as otherwise provided in subsection (4),

each insurer and health maintenance organization shall establish an

internal formal grievance procedure for approval by the

commissioner for persons covered under a policy, certificate, or

contract issued under chapter 34, 35, or 36 that includes provides

for all of the following:

     (a) Provides for a A designated person responsible for

administering the grievance system.

     (b) Provides a A designated person or telephone number for

receiving complaints grievances.

     (c) Ensures A method that ensures full investigation of a

complaint grievance.

     (d) Provides for timely Timely notification in plain English

to the insured or enrollee as to the progress of an investigation

of a grievance.

     (e) Provides The right of an insured or enrollee the right to

appear before the board of directors or a designated person or

committee or the right to a managerial-level conference to present

a grievance.

     (f) Provides for notification Notification in plain English to

the insured or enrollee of the results of the insurer's or health

maintenance organization's investigation of the grievance and for

advisement of the insured's or enrollee's right to review have the

grievance reviewed by the commissioner or by an independent review

organization under the patient's right to independent review act,

2000 PA 251, MCL 550.1901 to 550.1929.

     (g) Provides A method for providing summary data on the number

and types of complaints and grievances filed under this section.

Beginning April 15, 2001, this The insurer or health maintenance

organization shall annually file the summary data for the prior

calendar year shall be filed annually with the commissioner on

forms provided by the commissioner.

     (h) Provides for periodic Periodic management and governing

body review of the data to assure that appropriate actions have

been taken.

     (i) Provides for That copies of all complaints and responses

to be are available at the principal office of the insurer or

health maintenance organization for inspection by the commissioner

for 2 years following the year the complaint grievance was filed.

     (j) That when an adverse determination is made, a written

statement in plain English containing the reasons for the adverse

determination is provided to the insured or enrollee along with

written notifications as required under the patient's right to

independent review act, 2000 PA 251, MCL 550.1901 to 550.1929.

     (k) That a final determination will be made in writing by the

insurer or health maintenance organization not later than 35

calendar days after a formal grievance is submitted in writing by

the insured or enrollee. The timing for the 35-calendar-day period

may be tolled, however, for any period of time the insured or

enrollee is permitted to take under the grievance procedure and for

a period of time that shall not exceed 10 business days if the

insurer or health maintenance organization has not received

requested information from a health care facility or health

professional.

     (l) That a determination will be made by the insurer or health

maintenance organization not later than 72 hours after receipt of

an expedited grievance. Within 10 days after receipt of a

determination, the insured or enrollee may request a determination

of the matter by the commissioner or his or her designee or by an

independent review organization under the patient's right to

independent review act, 2000 PA 251, MCL 550.1901 to 550.1929. If

the determination by the insurer or health maintenance organization

is made orally, the insurer or health maintenance organization

shall provide a written confirmation of the determination to the

insured or enrollee not later than 2 business days after the oral

determination. An expedited grievance under this subdivision

applies if a grievance is submitted and a physician, orally or in

writing, substantiates that the time frame for a grievance under

subdivision (k) would seriously jeopardize the life or health of

the insured or enrollee or would jeopardize the insured's or

enrollee's ability to regain maximum function.

     (m) That the insured or enrollee has the right to a

determination of the matter by the commissioner or his or her

designee or by an independent review organization under the

patient's right to independent review act, 2000 PA 251, MCL

550.1901 to 550.1929.

     (2) An insured or enrollee may authorize in writing any

person, including, but not limited to, a physician, to act on his

or her behalf at any stage in a grievance proceeding under this

section.

     (3) This section does not apply to a provider's complaint

concerning claims payment, handling, or reimbursement for health

care services.

     (4) This section does not apply to a policy, certificate,

care, coverage, or insurance listed in section 5(2) of the

patient's right to independent review act, 2000 PA 251, MCL

550.1905, as not being subject to the patient's right to

independent review act, 2000 PA 251, MCL 550.1901 to 550.1929.

     (5) As used in this section:

     (a) "Adverse determination" means a determination that an

admission, availability of care, continued stay, or other health

care service has been reviewed and denied, reduced, or terminated.

Failure to respond in a timely manner to a request for a

determination constitutes an adverse determination.

     (b) "Grievance" means a complaint on behalf of an insured or

enrollee submitted by an insured or enrollee concerning any of the

following:

     (i) The availability, delivery, or quality of health care

services, including a complaint regarding an adverse determination

made pursuant to utilization review.

     (ii) Benefits or claims payment, handling, or reimbursement for

health care services.

     (iii) Matters pertaining to the contractual relationship between

an insured or enrollee and the insurer or health maintenance

organization.