December 4, 2014, Introduced by Senator KAHN and referred to the Committee on Appropriations.
A bill to amend 2012 PA 101, entitled
"Autism coverage reimbursement act,"
by amending section 3 (MCL 550.1833).
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 3. As used in this act:
(a) "Autism coverage reimbursement program" or "program" means
the autism coverage reimbursement program created under section 5.
(b) "Autism diagnostic observation schedule", "autism spectrum
disorders", "diagnosis of autism spectrum disorders", and
"treatment of autism spectrum disorders" mean those terms as
defined under section 416e of the nonprofit health care corporation
reform act, 1980 PA 350, MCL 550.1416e, and section 3406s of the
insurance code of 1956, 1956 PA 218, MCL 500.3406s.
(c) "Carrier" means any of the following:
(i) An insurer or health maintenance organization regulated
under the insurance code of 1956, 1956 PA 218, MCL 500.100 to
500.8302.
(ii) A health care corporation regulated under the nonprofit
health care corporation reform act, 1980 PA 350, MCL 550.1101 to
550.1704.
(iii) A specialty prepaid health plan.
(iv) A group health plan sponsor including, but not limited to,
1 or more of the following:
(A) An employer if a group health plan is established or
maintained by a single employer.
(B) An employee organization if a plan is established or
maintained by an employee organization.
(C) If a plan is established or maintained by 2 or more
employers or jointly by 1 or more employers and 1 or more employee
organizations, the association, committee, joint board of trustees,
or other similar group of representatives of the parties that
establish or maintain the plan.
(d)
"Department" means the department of licensing and
regulatory
affairs.insurance and
financial services.
(e) "Excess loss" or "stop loss" means coverage that provides
insurance protection against the accumulation of total claims
exceeding a stated level for a group as a whole or protection
against a high-dollar claim on any 1 individual.
(f) "Federal act" means the federal patient protection and
affordable care act, Public Law 111-148, as amended by the federal
health care and education reconciliation act of 2010, Public Law
111-152, and any regulations promulgated under those acts.
(g) "Federal employee health benefit program" means the
program of health benefits plans, as defined in 5 USC 8901,
available to federal employees under 5 USC 8901 to 8914.
(h) "Fund" means the autism coverage fund created in section
7.
(i) "Group health plan" means an employee welfare benefit plan
as defined in section 3(1) of subtitle A of title I of the employee
retirement income security act of 1974, Public Law 93-406, 29 USC
1002, to the extent that the plan provides medical care, including
items and services paid for as medical care to employees or their
dependents as defined under the terms of the plan directly or
through insurance, reimbursement, or otherwise.
(j) "Medicaid" means the program of medical assistance
established under title XIX of the social security act, 42 USC 1396
to 1396w-5.
(k) "Medicare" means the federal medicare program established
under title XVIII of the social security act, 42 USC 1395 to
1395kkk-1.1395lll.
(l) "Medicare advantage plan" means a plan of coverage for
health benefits under part C of title XVIII of the social security
act, 42 USC 1395w-21 to 1395w-28.
(m) "Medicare part D" means a plan of coverage for
prescription drug benefits under part D of title XVIII of the
social security act, 42 USC 1395w-101 to 1395w-154.
(n) "Paid claims" means actual payments, net of recoveries,
made for the diagnosis of autism spectrum disorders and treatment
of autism spectrum disorders whether made to a provider or
reimbursed to an individual by a carrier, third party
administrator, or excess loss or stop loss carrier. Paid claims do
not include any of the following:
(i) Claims paid for services rendered to a nonresident of this
state.
(ii) Claims paid for services rendered to a person covered
under a health benefit plan for federal employees.
(iii) Claims paid for services rendered outside of this state to
a person who is a resident of this state.
(iv) Claims paid under a federal employee health benefit
program, medicare, a medicare advantage plan, medicare part D,
tricare, by the United States veterans administration, and for
high-risk pools established pursuant to the federal act.
(v) Costs paid by an individual for cost-sharing requirements,
including deductibles, coinsurance, or copays.
(vi) Claims paid by, or on behalf of, this state.
(vii) Claims paid that are covered by medicaid.
(viii) Claims paid for which the carrier or third party
administrator has already been reimbursed or compensated, in whole
or in part, through any increase in premiums or rates or from any
other source.
(ix) Beginning January 1, 2014, claims paid for
services that
are
included in the essential health benefits as required pursuant
to
the federal act.
(o) "Specialty prepaid health plan" means that term as
described in section 109f of the social welfare act, 1939 PA 280,
MCL 400.109f.
(p) "Third party administrator" means an entity that processes
claims under a service contract and that may also provide 1 or more
other administrative services under a service contract.