Bill Text: MI SB0692 | 2013-2014 | 97th Legislature | Introduced
Bill Title: Insurance; prudent purchaser agreements; reimbursement for physical therapy services; allow insurance companies to withhold unless patient has a prescription from a licensed health professional. Amends sec. 3 of 1984 PA 233 (MCL 550.53). TIE BAR WITH: SB 0690'13
Spectrum: Moderate Partisan Bill (Republican 7-1)
Status: (Passed) 2014-07-16 - Assigned Pa 0262'14 With Immediate Effect [SB0692 Detail]
Download: Michigan-2013-SB0692-Introduced.html
SENATE BILL No. 692
November 14, 2013, Introduced by Senators CASPERSON, HILDENBRAND, MOOLENAAR, PAPPAGEORGE, WARREN, GREEN, MEEKHOF and BRANDENBURG and referred to the Committee on Insurance.
A bill to amend 1984 PA 233, entitled
"Prudent purchaser act,"
by amending section 3 (MCL 550.53), as amended by 2009 PA 224.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 3. (1) An organization may enter into a prudent purchaser
agreement with 1 or more health care providers of a specific
service to control health care costs, assure appropriate
utilization of health care services, and maintain quality of health
care. The organization may limit the number of prudent purchaser
agreements
entered into pursuant to under
this section if the
number of agreements is sufficient to assure reasonable levels of
access to health care services for recipients of those services.
The number of prudent purchaser agreements authorized by this
section that are necessary to assure reasonable levels of access to
health care services for recipients shall be determined by the
organization. However, the organization shall offer a prudent
purchaser agreement, comparable to those agreements with other
members of the provider panel, to at least 1 health care provider
that provides the applicable health care services and is located
within a reasonable distance from the recipients of those health
care services, if a health care provider that provides the
applicable health care services is located within that reasonable
distance.
(2) An organization shall give all health care providers that
provide the applicable health care services and are located in the
geographic area served by the organization an opportunity to apply
to the organization for membership on the provider panel.
(3) A prudent purchaser agreement shall be based upon the
following written standards, which shall be filed by the
organization with the commissioner on a form and in a manner that
is uniformly developed and applied by the commissioner before the
initial provider panel is formed:
(a) Standards for maintaining quality health care.
(b) Standards for controlling health care costs.
(c) Standards for assuring appropriate utilization of health
care services.
(d) Standards for assuring reasonable levels of access to
health care services.
(e) Other standards considered appropriate by the
organization.
(4) An organization shall develop and institute procedures
that are designed to notify health care providers located in the
geographic area served by the organization of the acceptance of
applications for a provider panel. The procedures shall include the
giving of notice to providers of the service upon request and shall
include publication in a newspaper with general circulation in the
geographic area served by the organization at least 30 days before
the initial provider application period. An organization shall
provide for an initial 60-day provider application period during
which providers of the service may apply to the organization for
membership on the provider panel. An organization that has entered
into a prudent purchaser agreement concerning a particular health
care service shall provide, at least once every 4 years, for a 60-
day provider application period during which providers of that
service may apply to the organization for membership on the
provider panel. Notice of this provider application period shall be
given to providers of the service upon request and shall be
published in a newspaper with general circulation in the geographic
area served by the organization at least 30 days before the
commencement of the provider application period. The initial 60-day
provider application period and procedures and the 4-year 60-day
provider application periods and procedures required under this
subsection do not apply to organizations whose provider panels are
open to application for membership at any time. Upon receipt of a
request by a health care provider, the organization shall provide
the written standards described in subsection (3) to the health
care provider. Within 90 days after the close of a provider
application period, or within 30 days following the completion of
the applicable physician credentialing process, whichever is later,
an organization shall notify an applicant in writing as to whether
the applicant has been accepted or rejected for membership on the
provider panel. If an applicant has been rejected, the organization
shall state in writing the reasons for rejection, citing 1 or more
of the standards.
(5) A health care provider whose membership on an
organization's provider panel is terminated shall be provided upon
request with a written explanation by the organization of the
reasons for the termination.
(6) An organization that enters into a prudent purchaser
agreement shall institute a program for the professional review of
the quality of health care, performance of health care personnel,
and utilization of services and facilities under the prudent
purchaser agreement. At least every 2 years, the organization shall
provide for an evaluation of its professional review program by a
professionally recognized independent third party.
(7) If 2 or more classes of health care providers may legally
provide the same health care service, the organization shall offer
each class of health care providers the opportunity to apply to the
organization for membership on the provider panel.
(8) Each prudent purchaser agreement shall state that the
health care provider may be removed from the provider panel before
the expiration of the agreement if the provider does not comply
with the requirements of the contract.
(9) This act does not preclude a health care provider or
health care facility from being a member of more than 1 provider
panel.
(10) A provider panel may include health care providers and
facilities
outside Michigan this
state if necessary to assure
reasonable levels of access to health care services under coverage
authorized by this act.
(11) When coverage authorized by this act is offered to a
person, the organization shall give or cause to be given to the
person the following information:
(a) The identity of the organization contracting with the
provider panel.
(b) The identity of the party sponsoring the coverage
including, but not limited to, the employer.
(c) The identity of the collective bargaining agent if the
coverage is offered pursuant to a collective bargaining agreement.
(12) If a person who has coverage authorized by this act is
entitled to receive a health care service when rendered by a health
care provider who is a member of the provider panel, the person is
entitled to receive the health care service from a health care
provider who is not a member of the provider panel for an emergency
episode of illness or injury that requires immediate treatment
before it can be obtained from a health care provider who is on the
provider panel.
(13) Subsections (2) to (12) do not limit the authority of
organizations to limit the number of prudent purchaser agreements.
(14) If coverage under a prudent purchaser agreement provides
for benefits for services that are within the scope of practice of
optometry, this act does not require that coverage or reimbursement
be
provided for a practice of optometric optometry service unless
that service was included in the definition of practice of
optometry under section 17401 of the public health code, 1978 PA
368, MCL 333.17401, as of May 20, 1992.
(15) If coverage under a prudent purchaser agreement provides
for benefits for services that are within the scope of practice of
chiropractic, this act does not require that coverage or
reimbursement be provided for a practice of chiropractic service
unless that service was included in the definition of practice of
chiropractic under section 16401 of the public health code, 1978 PA
368, MCL 333.16401, as of January 1, 2009.
(16) If coverage under a prudent purchaser agreement provides
for benefits for services provided by a licensed physical therapist
or physical therapist assistant under the supervision of a licensed
physical therapist, this act does not require that coverage or
reimbursement be provided for a practice of physical therapy
service or practice as a physical therapist assistant service,
unless that service was provided by a licensed physical therapist
or physical therapist assistant under the supervision of a licensed
physical therapist pursuant to a prescription from a health
professional as that term is defined in section 17801 of the public
health code, 1978 PA 368, MCL 333.17801.
Enacting section 1. This amendatory act does not take effect
unless Senate Bill No.690
of the 97th Legislature is enacted into law.
