Bill Text: MI HB4752 | 2011-2012 | 96th Legislature | Engrossed

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Bill Title: Labor; public service employment; claims data provided to policyholder of school district's health insurance plans; clarify. Amends secs. 5 & 15 of 2007 PA 106 (MCL 124.75 & 124.85).

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2011-06-28 - Referred To Committee On Education [HB4752 Detail]

Download: Michigan-2011-HB4752-Engrossed.html

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HB-4752, As Passed House, June 23, 2011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOUSE BILL No. 4752

 

June 14, 2011, Introduced by Rep. Shaughnessy and referred to the Committee on Education.

 

     A bill to amend 2007 PA 106, entitled

 

"Public employees health benefit act,"

 

by amending sections 5 and 15 (MCL 124.75 and 124.85).

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

     Sec. 5. (1) Subject to collective bargaining requirements, a

 

public employer may provide medical, optical, or dental benefits to

 

public employees and their dependents by any of the following

 

methods:

 

     (a) By establishing and maintaining a plan on a self-insured

 

basis. A plan under this subdivision does not constitute doing the

 

business of insurance in this state and is not subject to the

 

insurance laws of this state.

 

     (b) By joining with other public employers and establishing

 

and maintaining a public employer pooled plan to provide medical,

 

optical, or dental benefits to not fewer than 250 public employees

 

on a self-insured basis as provided in this act. A pooled plan

 

shall accept any public employer that applies to become a member of

 

the pooled plan, agrees to make the required payments, agrees to

 

remain in the pool for a 3-year period, and satisfies the other

 

reasonable provisions of the pooled plan. A public employer that

 

leaves a pooled plan may not rejoin the pooled plan for 2 years

 

after leaving the plan. A pooled plan under this subdivision does

 

not constitute doing the business of insurance in this state and,

 

except as provided in this act, is not subject to the insurance

 

laws of this state. A pooled plan under this subdivision may enter

 

into contracts and sue or be sued in its own name.

 

     (c) By procuring coverage or benefits from 1 or more carriers,

 

either on an individual basis or with 1 or more other public

 

employers.

 

     (2) A public employer or pooled plan procuring coverage or

 

benefits from 1 or more carriers shall solicit from independent

 

entities 4 or more bids when establishing a medical benefit plan,

 

including at least 1 bid from a voluntary employees' beneficiary

 

association described in section 501(c)(9) of the internal revenue

 

code, 26 USC 501(c)(9). A public employer or pooled plan procuring

 

coverage or benefits from 1 or more carriers shall solicit from

 

independent entities 4 or more bids every 3 years when renewing or

 

continuing a medical benefit plan, including at least 1 bid from a

 

voluntary employees' beneficiary association described in section

 

501(c)(9) of the internal revenue code, 26 USC 501(c)(9). A public

 

employer or pooled plan that provides for administration of a

 

medical benefit plan using an authorized third party administrator,

 

an insurer, a nonprofit health care corporation, or other entity

 

authorized to provide services in connection with a noninsured

 

medical benefit plan shall solicit from independent entities 4 or

 

more bids for those administrative services when establishing a

 

medical benefit plan. A public employer or pooled plan that

 

provides for administration of a medical benefit plan using an

 

authorized third party administrator, an insurer, a nonprofit

 

health care corporation, or other entity authorized to provide

 

services in connection with a noninsured medical benefit plan shall

 

solicit from independent entities 4 or more bids for those

 

administrative services every 3 years when renewing or continuing a

 

medical benefit plan.

 

     (3) This act does not prohibit a public employer from

 

participating, for the payment of medical benefits and claims, in a

 

purchasing pool or coalition to procure insurance, benefits, or

 

coverage, or health care plan services or administrative services.

 

     (4) A public university may establish a medical benefit plan

 

to provide medical, dental, or optical benefits to its employees

 

and their dependents by any of the methods set forth in this

 

section.

 

     (5) A medical benefit plan that provides medical benefits

 

shall provide to covered individuals case management services that

 

meet the case management accreditation standards established by the

 

national committee on quality assurance, the joint commission on

 

health care organizations, or the utilization review accreditation

 

commission.

 

     Sec. 15. (1) Notwithstanding subsection (2), a public employer

 

that has 100 or more employees in a medical benefit plan shall be

 

provided with claims utilization and cost information as provided

 

in subsection (3).

 

     (2) A public employer who that is in an arrangement with 1 or

 

more other public employers, and together have 100 or more

 

employees in a medical benefit plan or have signed a letter of

 

intent to enter together 100 or more public employees into a

 

medical benefit plan, shall be provided with claims utilization and

 

cost information as provided in subsection (3) that is aggregated

 

for all the public employees together of those public employers,

 

and, except as otherwise permitted under subsection (1), shall not

 

be separated out for any of those public employers.

 

     (3) All medical benefit plans in this state shall compile, and

 

shall make available electronically as provided in subsections (1)

 

and (2), complete and accurate claims utilization and cost

 

information for the medical benefit plan in the aggregate and for

 

each public employer as follows:

 

     (a) For persons covered under the medical benefit plan, census

 

information, including date of birth, gender, zip code, and medical

 

tier, such as single, dependent, or family.

 

     (b) Monthly claims by provider type and service category

 

reported by the total number and dollar amounts of claims paid and

 

reported separately for in-network and out-of-network providers.

 

     (c) The number of claims paid over $50,000.00 and the total

 

dollar amount of those claims.

 

     (d) The dollar amounts paid for specific and aggregate stop-

 

loss insurance.

 

     (e) The dollar amount of administrative expenses incurred or

 

paid, reported separately for medical, pharmacy, dental, and

 

vision.

 

     (f) The total dollar amount of retentions and other expenses.

 

     (g) The dollar amount for all service fees paid.

 

     (h) The dollar amount of any fees or commissions paid to

 

agents, consultants, or brokers by the medical benefit plan or by

 

any public employer or carrier participating in or providing

 

services to the medical benefit plan, reported separately for

 

medical, pharmacy, stop-loss, dental, and vision.

 

     (i) Other information as may be required by the commissioner.

 

     (a) A census of all covered employees, including all of the

 

following:

 

     (i) Year of birth.

 

     (ii) Gender.

 

     (iii) Zip code.

 

     (iv) The contract coverage type for the employee, such as

 

single, dependent, or family, and number of individuals covered by

 

contract.

 

     (iv) Employee job classification.

 

     (b) Claims data for the employee group covered by the medical

 

benefit plan, including at least all of the following:

 

     (i) For a plan that provides health benefits, information

 

concerning hospital and medical claims under the plan, presented in

 

a manner that clearly shows all of the following for each of the 3

 

most recent experience years:

 

     (A) Number and total expenditures for hospital claims.

 

     (B) Number and total expenditures for medical claims.

 

     (C) Number of hospital claims exceeding $50,000.00.

 

     (D) Number of medical claims exceeding $50,000.00.

 

     (E) Total expenditures for claims exceeding $50,000.00.

 

     (F) Provider discounts received versus charged amount.

 

     (G) Network access fee.

 

     (ii) For a plan that provides prescription drug benefits,

 

information concerning prescription drugs claims under the plan,

 

presented in a manner that clearly shows all of the following:

 

     (A) Amount charged and amount paid for prescription drugs

 

claims for each of the 3 most recent experience years.

 

     (B) Total amount charged and amount paid for brand

 

prescription drugs claims for each of the 3 most recent experience

 

years.

 

     (C) Total amount charged and amount paid for generic

 

prescription drugs claims for each of the 3 most recent experience

 

years.

 

     (D) Top 50 brand prescriptions for which claims were made for

 

the most recent experience period.

 

     (E) Top 50 generic prescriptions for which claims were made

 

for the most recent experience period.

 

     (F) Rebates received by the carrier or pharmacy benefits

 

manager for each of the 3 most recent experience years.

 

     (iii) For a plan that provides dental benefits, information

 

concerning dental claims and total expenditures for these claims

 

under the plan, presented in a manner that clearly shows at least

 

all of the following for each of the 3 most recent experience

 

years:

 

     (A) Number of claims submitted and total charged.

 

     (B) Number of and total expenditures for claims paid.

 

     (C) Total expenditures for claims submitted to network

 

providers.

 

     (D) Total savings realized by network providers.

 

     (E) Network access fee.

 

     (iv) For a plan that provides optical benefits, information

 

concerning optical claims and total expenditures for these claims

 

under the plan, presented in a manner that clearly shows at least

 

all of the following for each of the 3 most recent experience

 

years:

 

     (A) Number of claims submitted and total charged.

 

     (B) Number of and total expenditures for claims paid.

 

     (C) Total expenditures for claims submitted to network

 

providers.

 

     (D) Total savings realized by network providers.

 

     (E) Network access fee.

 

     (c) Fees and administrative expenses for the most recent

 

experience year, reported separately for health, dental, and

 

optical plans, and presented in a manner that clearly shows at

 

least all of the following:

 

     (i) Total dollar amount of fees and administrative expenses for

 

the current rating year.

 

     (ii) Commissions or fees paid to agents, brokers, or

 

consultants. In addition to all other commissions or fees, this

 

information shall include any stop loss insurance commission.

 

     (iii) Administration fees charged by an insurance carrier or

 

third party administrator, including, but not limited to, claim

 

administration, risk, nongroup conversion subsidy, and taxes.

 

     (iv) Specific stop loss insurance charges and attachment point.

 

     (v) Aggregate stop loss insurance charges and attachment

 

point.

 

     (vi) Additional fees for case management, precertification, or

 

other claim services.

 

     (vii) Other fees.

 

     (d) For health, dental, and optical plans, a summary plan

 

description or certificate for the current year's plan and, if

 

benefits have changed during any of the 3 most recent experience

 

years, a brief benefit summary for each of those experience years

 

for which the benefits were different.

 

     (4) The Except as otherwise provided in subsection (3), claims

 

utilization and cost information required to be compiled under this

 

section shall be compiled on an annual basis and shall cover a

 

relevant period. For purposes of this subsection, the term

 

"relevant period" means the 36-month period ending no more than 120

 

days prior to the effective date or renewal date of the medical

 

benefit plan under consideration. However, if the medical benefit

 

plan has been in effect for a period of less than 36 months, the

 

relevant period shall be that shorter period.

 

     (5) A public employer or combination of public employers shall

 

disclose the claims utilization and cost information required to be

 

provided under subsections (1) and (2) to any carrier or

 

administrator it solicits to provide benefits or administrative

 

services for its medical benefit plan, and to the employee

 

representative of employees covered under the medical benefit plan,

 

and upon request to any carrier or administrator who requests the

 

opportunity to submit a proposal to provide benefits or

 

administrative services for the medical benefit plan at the time of

 

the request for bids. The public employer shall make the claims

 

utilization and cost information required under this section

 

available at cost and within a reasonable period of time.

 

     (6) The claims utilization and cost information required under

 

this section shall include only de-identified health information as

 

permitted under the health insurance portability and accountability

 

act of 1996, Public Law 104-191, or regulations promulgated under

 

that act, 45 CFR parts 160 and 164, and shall not include any

 

protected health information as defined in the health insurance

 

portability and accountability act of 1996, Public Law 104-191, or

 

regulations promulgated under that act, 45 CFR parts 160 and 164.

 

     (7) All claims utilization and cost information described in

 

this section is required to be compiled beginning 60 days after the

 

effective date of this act. However, claims utilization and cost

 

information already being compiled on the effective date of this

 

act is subject to this section on the effective date of this act.