Bill Text: MI HB6240 | 2009-2010 | 95th Legislature | Introduced
Bill Title: Insurance; health; health benefit plans; extend age of dependent coverage, prohibit restriction on lifetime and certain annual limits on benefits, include certain preventive health services, prohibit rescinding coverage, and provide for general amendments. Amends secs. 3406f, 3503 & 3539 of 1956 PA 218 (MCL 500.3406f et seq.) & adds ch. 37A. TIE BAR WITH: HB 6241'10
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2010-12-01 - Referred To Committee On Health Policy [HB6240 Detail]
Download: Michigan-2009-HB6240-Introduced.html
HOUSE BILL No. 6240
June 8, 2010, Introduced by Reps. Corriveau and Ball and referred to the Committee on Health Policy.
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
by amending sections 3406f, 3503, and 3539 (MCL 500.3406f,
500.3503, and 500.3539), section 3406f as added by 1996 PA 517,
section 3503 as amended by 2006 PA 366, and section 3539 as amended
by 2005 PA 306, and by adding chapter 37A.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec.
3406f. (1) An Except as
otherwise provided in section
3763, an insurer may exclude or limit coverage for a condition as
follows:
(a) For an individual covered under an individual policy or
certificate or any other policy or certificate not covered under
subdivision (b) or (c), only if the exclusion or limitation relates
to a condition for which medical advice, diagnosis, care, or
treatment was recommended or received within 6 months before
enrollment and the exclusion or limitation does not extend for more
than 12 months after the effective date of the policy or
certificate.
(b) For an individual covered under a group policy or
certificate covering 2 to 50 individuals, only if the exclusion or
limitation relates to a condition for which medical advice,
diagnosis, care, or treatment was recommended or received within 6
months before enrollment and the exclusion or limitation does not
extend for more than 12 months after the effective date of the
policy or certificate.
(c) For an individual covered under a group policy or
certificate covering more than 50 individuals, only if the
exclusion or limitation relates to a condition for which medical
advice, diagnosis, care, or treatment was recommended or received
within 6 months before enrollment and the exclusion or limitation
does not extend for more than 6 months after the effective date of
the policy or certificate.
(2) As used in this section, "group" means a group health plan
as
defined in section 2791(a)(1) and (2) of part C of title XXVII
of
the public health service act, chapter 373, 110 Stat. 1972, 42
U.S.C.
300gg-91 42 USC 300gg-91, and includes government plans that
are not federal government plans.
(3) This section applies only to an insurer that delivers,
issues for delivery, or renews in this state an expense-incurred
hospital, medical, or surgical policy or certificate. This section
does not apply to any policy or certificate that provides coverage
for specific diseases or accidents only, or to any hospital
indemnity, medicare supplement, long-term care, disability income,
or 1-time limited duration policy or certificate of no longer than
6 months.
(4)
The commissioner and the director of community health
shall
examine the issue of crediting prior continuous health care
coverage
to reduce the period of time imposed by preexisting
condition
limitations or exclusions under subsection (1)(a), (b),
and
(c) and shall report to the governor and the senate and the
house
of representatives standing committees on insurance and
health
policy issues by May 15, 1997. The report shall include the
commissioner's
and director's findings and shall propose
alternative
mechanisms or a combination of mechanisms to credit
prior
continuous health care coverage towards the period of time
imposed
by a preexisting condition limitation or exclusion. The
report
shall address at a minimum all of the following:
(a)
Cost of crediting prior continuous health care coverages.
(b)
Period of lapse or break in coverage, if any, permitted in
a
prior health care coverage.
(c)
Types and scope of prior health care coverages that are
permitted
to be credited.
(d)
Any exceptions or exclusions to crediting prior health
care
coverage.
(e)
Uniform method of certifying periods of prior creditable
coverage.
Sec. 3503. (1) All of the provisions of this act that apply to
a domestic insurer authorized to issue an expense-incurred
hospital, medical, or surgical policy or certificate, including,
but
not limited to, sections 223 and 7925 and chapters 34, and
36,
and 37A apply to a health maintenance organization under this
chapter unless specifically excluded, or otherwise specifically
provided for in this chapter.
(2) Sections 408, 410, 411, 901, and 5208, chapter 77, and,
except as otherwise provided in subsection (1), chapter 79 do not
apply to a health maintenance organization.
Sec.
3539. (1) For Except as
otherwise provided in section
3763, for an individual covered under a nongroup contract or under
a contract not covered under subsection (2), a health maintenance
organization may exclude or limit coverage for a condition only if
the exclusion or limitation relates to a condition for which
medical advice, diagnosis, care, or treatment was recommended or
received within 6 months before enrollment and the exclusion or
limitation does not extend for more than 6 months after the
effective date of the health maintenance contract.
(2) A health maintenance organization shall not exclude or
limit coverage for a preexisting condition for an individual
covered under a group contract or as provided in section 3763.
(3) Except as provided in subsection (5), a health maintenance
organization that has issued a nongroup contract shall renew or
continue in force the contract at the option of the individual.
(4) Except as provided in subsection (5), a health maintenance
organization that has issued a group contract shall renew or
continue in force the contract at the option of the sponsor of the
plan.
(5) Guaranteed renewal is not required in cases of fraud,
intentional misrepresentation of material fact, lack of payment, if
the health maintenance organization no longer offers that
particular type of coverage in the market, or if the individual or
group moves outside the service area.
(6) A health maintenance organization is not required to
continue a healthy lifestyle program or to continue any incentive
associated with a healthy lifestyle program, including, but not
limited to, goods, vouchers, or equipment.
(7) As used in this section, "group" means a group of 2 or
more subscribers.
CHAPTER 37A
HEALTH BENEFIT PLANS
Sec. 3751. As used in this chapter:
(a) "Carrier" means a person that provides health benefits,
coverage, or insurance under a health benefit plan in this state.
For the purposes of this chapter, carrier includes a health
insurance company authorized to do business in this state, a health
care corporation, a health maintenance organization, a multiple
employer welfare arrangement, or any other person providing a plan
of health benefits, coverage, or insurance subject to state
insurance regulation.
(b) "Enrollee" means an insured, enrollee, member,
participant, or subscriber under a health benefit plan.
(c) "Health benefit plan" or "plan" means a group, individual,
or nongroup expense-incurred hospital, medical, or surgical policy
or certificate, health care corporation certificate, or health
maintenance organization contract. Health benefit plan does not
include accident-only, credit, or disability income insurance;
long-term care insurance; medicare supplmental coverage; coverage
issued as a supplement to liability insurance; coverage only for a
specified disease or illness; dental-only or vision-only insurance;
worker's compensation or similar insurance; or automobile medical-
payment insurance.
(d) "Health care corporation" means a nonprofit health care
corporation operating pursuant to the nonprofit health care
corporation reform act, 1980 PA 350, MCL 550.1101 to 550.1704.
(e) "Patient protection and affordable care act" means the
patient protection and affordable care act, Public Law 111-148.
(f) "Secretary" means the secretary of the United States
department of health and human services.
Sec. 3755. (1) A carrier shall not establish lifetime limits
or unreasonable annual limits on the dollar value of benefits for
an enrollee, other than as permitted in section 2711 of the patient
protection and affordable care act.
(2) Subsection (1) does not prevent a carrier that is not
required to provide essential health benefits under section 1302(b)
of the patient protection and affordable care act from placing
lifetime limits or annual limits per insured, enrollee, member, or
participant on specific covered benefits to the extent that those
limits are otherwise permitted under federal or state law.
Sec. 3757. (1) A carrier shall not rescind a health benefit
plan for an individual once the individual is covered under the
health benefit plan.
(2) Subsection (1) does not apply to a covered individual who
has committed an act or practice that constitutes fraud or makes an
intentional misrepresentation of material fact. A health benefit
plan shall not be rescinded without prior notice to the covered
individual and only as permitted under section 2702(c) or 2742(b)
of the public health service act, 42 USC 300gg-1 and 400 USC 300gg-
42.
Sec. 3759. (1) A carrier shall, at a minimum, provide for and
not impose any cost sharing requirements on all of the following:
(a) Evidence-based items or services that have in effect a
rating of "A" or "B" in the current recommendations of the United
States preventive services task force.
(b) Immunizations that have in effect a recommendation from
the advisory committee on immunization practices of the centers for
disease control and prevention for the individual involved.
(c) For infants, children, and adolescents, evidence-informed
preventive care and screenings provided for in comprehensive
guidelines supported by the health resources and services
administration for purposes of this section.
(d) For women, any additional preventive care and screenings
not described in subdivision (a) as provided for in comprehensive
guidelines supported by the health resources and services
administration for purposes of this section.
(2) As used in this section, the current recommendations of
the United States preventive services task force concerning breast
cancer screening, mammography, and prevention shall be considered
the most current other than those issued around November 2009.
(3) This section does not prohibit a carrier from providing a
health benefit plan that provides coverage for services in addition
to those recommended by, or that denies coverage for services that
are not recommended by, the United States preventive services task
force.
Sec. 3761. A health benefit plan that provides for dependent
coverage shall permit continuation of that coverage until that
child attains age 26 as provided in section 2714 of the patient
protection and affordable care act and regulations promulgated
under that section. This continuation of coverage does not apply to
any child of a child receiving dependent coverage under this
section.
Sec. 3763. A carrier shall not deny a child who is under 19
years of age access to his or her parent's health benefit plan and
shall not impose any preexisting condition exclusion or limitation
on the child's coverage.
Sec. 3765. By not later than 60 days before a health benefit
plan premium increase goes into effect, a carrier shall submit to
the commissioner notice of, and justification for, the premium
increase. The carrier shall also prominently publish the notice of,
and justification for, the premium increase on the carrier's
internet website.
Sec. 3767. (1) A carrier shall submit to the secretary and the
commissioner a report each calendar year on the ratio of the
incurred loss or incurred claims plus the loss adjustment expense
or change in contract reserves to earned premiums. The report shall
include the percentage of total premium revenue, after accounting
for collections or receipts for risk adjustment and risk corridors
and payments of reinsurance, that such coverage expends on all of
the following:
(a) Reimbursement for clinical services provided to enrollees
under the coverage.
(b) Activities that improve health care quality.
(c) All other nonclaims costs, including an explanation of the
nature of the costs, and excluding federal and state taxes and
licensing or regulatory fees.
(2) Beginning January 1, 2011, a carrier shall provide a
rebate pursuant to subsection (3) if the ratio of the premium
revenue expended by a carrier on costs described in subsection
(1)(a) and (b) to the total amount of premium revenue, excluding
federal and state taxes and licensing or regulatory fees and after
accounting for payments or receipts for risk adjustment, risk
corridors, and reinsurance under sections 1341, 1342, and 1343 of
the patient protection and affordable care act, for the health
benefit plan year is less than the following:
(a) For a large group health benefit plan, 85%.
(b) For a small group health benefit plan or individual health
benefit plan, 80%.
(3) Beginning January 1, 2011, rebates shall be provided
annually, on a pro rata basis, to each enrollee covered under a
health benefit plan for the coverage year in which the plan did not
meet the ratio described in subsection (2). The total amount of an
annual rebate shall be in an amount equal to the product of the
amount by which the percentage in subsection (2)(a) or (b) exceeds
the ratio described in that subsection and the total amount of
premium revenue, excluding federal and state taxes and licensing or
regulatory fees and after accounting for payments or receipts for
risk adjustment, risk corridors, and reinsurance under sections
1341, 1342, and 1343 of the patient protection and affordable care
act, for that plan year.
Enacting section 1. This amendatory act takes effect September
23, 2010.
Enacting section 2. Sections 3755, 3757, and 3761 apply to
health care benefit plans in existence on September 23, 2010
beginning on the plans' next renewal date after September 23, 2010.
Enacting section 3. This amendatory act does not take effect
unless Senate Bill No.____ or House Bill No. 6241(request no.
06726'10) of the 95th Legislature is enacted into law.
