Bill Summary – FastDemocracy

HOUSE BILL NO. 4922
     July 19, 2023, Introduced by Rep. Brenda Carter and referred to the Committee on Insurance and
        Financial Services.
          A bill to amend 1978 PA 368, entitled
    "Public health code,"
    by amending sections 24502, 24503, 24504, 24507, 24509, 24510,
    24511, and 24513 (MCL 333.24502, 333.24503, 333.24504, 333.24507,
24509, 333.24510, 333.24511, and 333.24513), sections 24502,
    24503, 24504, 24507, 24510, 24511, and 24513 as added by 2020 PA
and section 24509 as added by 2020 PA 235.
                      THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
       Sec. 24502. (1) "Carrier" means any of the following:
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       (a) A person that issues a health benefit plan in this state,
 including an insurer, health maintenance organization, or any other
 person providing a plan of health benefits, coverage, or insurance
 subject to state insurance regulation.
       (b) An entity that contracts with this state or a local unit
 of government to provide, deliver, arrange for, pay for, or
 reimburse any of the costs of health care services provided under a
 self-funded plan established or maintained by the state or local
 unit of government for its employees.
       (2) "Department" means the department of insurance and
 financial services.
       (3) "Director" means the director of the department or his or
 her designee.
       (4) "Emergency medical services operation" means any of the
 following:
       (a) A medical first response service as that term is defined
 in section 20906.
       (b) A nontransport prehospital life support operation as that
 term is defined in section 20908.
       (c) An ambulance operation as that term is defined in section
 20902 if the ambulance operation is transporting any of the
 following by an ambulance that is a motor vehicle:
       (i) A nonemergency patient.
       (ii) An emergency patient.
       (5) (4) "Emergency patient" means an individual with a
 physical or mental condition that manifests itself by acute
 symptoms of sufficient severity, including, but not limited to,
 pain such that a prudent layperson, possessing average knowledge of
 health and medicine, could reasonably expect to result in 1 or more
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 of the following:
       (a) Placing the health of the individual or, in the case of a
 pregnant woman, the health of the woman or the unborn child, or
 both, in serious jeopardy.
       (b) Serious impairment of bodily function.
       (c) Serious dysfunction of a body organ or part.
       (6) (5) "Health benefit plan" means an individual or group
 expense-incurred hospital, medical, or surgical policy or
 certificate, an individual or group health maintenance organization
 contract, or a self-funded plan established or maintained by this
 state or a local unit of government for its employees. Health
 benefit plan does not include accident-only, credit, dental, or
 disability income insurance; long-term care insurance; coverage
 issued as a supplement to liability insurance; coverage only for a
 specified disease or illness; worker's compensation or similar
 insurance; or automobile medical-payment insurance.
       (7) (6) "Health care service" means a diagnostic procedure,
 medical or surgical procedure, examination, or other treatment or
 service, or a service delivered through an emergency medical
 services operation.
       (8) (7) "Health facility" means any of the following:
       (a) A hospital.
       (b) A freestanding surgical outpatient facility as that term
 is defined in section 20104.
       (c) A skilled nursing facility as that term is defined in
 section 20109.
       (d) A physician's office or other outpatient setting, that is
 not otherwise described in this subsection.
       (e) A laboratory.
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       (f) A radiology or imaging center.
       (9) (8) "Health maintenance organization" means that term as
 defined in section 3501 of the insurance code of 1956, 1956 PA 218,
 MCL 500.3501.
       (10) (9) "Hospital" means that term as defined in section
 20106.
       (11) (10) "Insurer" means that term as defined in section 106
 of the insurance code of 1956, 1956 PA 218, MCL 500.106.
       Sec. 24503. (1) "Local unit of government" means that term as
 defined in section 1 of 2006 PA 495, MCL 550.1951.
       (2) "Nonemergency patient" means an individual whose physical
 or mental condition is such that the individual may reasonably be
 suspected of not being in imminent danger of loss of life or of
 significant health impairment.
       (3) "Nonparticipating emergency medical services operation"
 means an emergency medical services operation that is not a
 participating emergency medical services operation.
       (4) (3) "Nonparticipating health facility" means a health
 facility that is not a participating health facility.
       (5) (4) "Nonparticipating provider" means a provider who is
 not a participating provider.
       Sec. 24504. (1) "Participating emergency medical services
 operation" means an emergency medical services operation that,
 under contract with a carrier, or with the carrier's contractor or
 subcontractor, agrees to provide health care services to
 individuals who are covered by health benefit plans issued or
 administered by the carrier and to accept payment by the carrier,
 contractor, or subcontractor for the services covered by the health
 benefit plans as payment in full, other than coinsurance,
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 copayments, or deductibles.
       (2) (1) "Participating health facility" means a health
 facility that, under contract with a carrier, or with the carrier's
 contractor or subcontractor, agrees to provide health care services
 to individuals who are covered by health benefit plans issued or
 administered by the carrier and to accept payment by the carrier,
 contractor, or subcontractor for the services covered by the health
 benefit plans as payment in full, other than coinsurance,
 copayments, or deductibles.
       (3) (2) "Participating provider" means a provider who, under
 contract with a carrier, or with the carrier's contractor or
 subcontractor, agrees to provide health care services to
 individuals who are covered by health benefit plans issued or
 administered by the carrier and to accept payment by the carrier,
 contractor, or subcontractor for the services covered by the health
 benefit plans as payment in full, other than coinsurance,
 copayments, or deductibles.
       (4) (3) "Patient's representative" means any of the following:
       (a) A person to whom a nonemergency patient has given express
 written consent to represent the patient.
       (b) A person authorized by law to provide consent for a
 nonemergency patient.
       (c) A provider who is treating a nonemergency patient, but
 only if the patient is unable to provide consent.
       (5) (4) "Provider" means an any of the following:
       (a) An individual who is licensed, registered, or otherwise
 authorized to engage in a health profession under article 15, but
 does not include a dentist licensed under part 166.
       (b) A medical first responder, emergency medical technician,
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 emergency medical technician specialist, or paramedic licensed
 under article 17.
       Sec. 24507. (1) Subsection (2) applies to a nonparticipating
 provider who or a nonparticipating emergency medical services
 operation that is providing a health care service if any of the
 following apply:
       (a) The health care service is provided to an emergency
 patient, is covered by the emergency patient's health benefit plan,
 and is provided to the emergency patient by the nonparticipating
 provider at a participating health facility or nonparticipating
 health facility.
       (b) The health care service is provided to a nonemergency
 patient, is covered by the nonemergency patient's health benefit
 plan, and is provided to the nonemergency patient by an emergency
 medical services operation as defined in section 24502(4)(c) that
 is a nonparticipating emergency medical services operation.
       (c) (b) All of the following apply:
       (i) The health care service is provided to a nonemergency
 patient.
       (ii) The health care service is covered by the nonemergency
 patient's health benefit plan.
       (iii) The health care service is provided to the nonemergency
 patient by the nonparticipating provider at a participating health
 facility.
       (iv) Either of the following:
       (A) The nonemergency patient does not have the ability or
 opportunity to choose a participating provider.
       (B) The nonemergency patient has not been provided the
 disclosure required under section 24509.
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       (d) (c) The health care service is provided by the
 nonparticipating provider at a hospital that is a participating
 health facility to an emergency patient who was admitted to the
 hospital within 72 hours after receiving a health care service in
 the hospital's emergency room.
       (2) Except as otherwise provided in section 24511 or 24513 and
 subject to subsection (4), if any of the circumstances described in
 subsection (1) apply, the nonparticipating provider or the
 nonparticipating emergency medical services operation shall submit
 a claim to the patient's carrier within 60 days after the date of
 the health care service and shall accept from the patient's
 carrier, as payment in full, the greater of the following:
       (a) Subject to section 24510, the median amount negotiated by
 the patient's carrier for the region and provider specialty,
 excluding any in-network coinsurance, copayments, or deductibles.
 The patient's carrier shall determine the region and provider
 specialty for purposes of this subdivision.
       (b) One hundred and fifty percent of the Medicare fee for
 service fee schedule for the health care service provided,
 excluding any in-network coinsurance, copayments, or deductibles.
       (3) If the circumstance described in subsection (1)(c) (1)(d)
 applies, this section applies to any health care service provided
 by a nonparticipating provider to the emergency patient during his
 or her hospital stay.
       (4) A patient's carrier shall pay the amount described in
 subsection (2) to the nonparticipating provider or nonparticipating
 emergency medical services operation within 60 days after receiving
 the claim from the nonparticipating provider or nonparticipating
 emergency medical services operation under subsection (2). The
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 nonparticipating provider or nonparticipating emergency medical
 services operation shall not collect or attempt to collect from the
 patient any amount other than the applicable in-network
 coinsurance, copayment, or deductible.
          Sec. 24509. (1) Subject to subsection (2), a nonparticipating
 provider who is providing a health care service to a nonemergency
 patient shall provide the disclosure described in subsection (3) to
 the nonemergency patient at the earliest of the following:
          (a) If the health care service was scheduled and is being
 provided in a health facility described in section 24502(7)(a),
 24502(8)(a), (b), (c), (e), or (f), at least 14 days before
 providing the health care service or, if the health care service
 will be provided within 14 days after scheduling the health care
 service, within 14 days.
          (b) If the health care service is being provided in a health
 facility described in section 24502(7)(d), 24502(8)(d), at the time
 of the nonparticipating provider's first contact with the
 nonemergency patient regarding the health care service.
          (c) During 1 of the following:
          (i) A presurgical consultation for the health care service.
          (ii) A scheduling or intake call for the health care service.
          (iii) A preoperative review for the health care service.
          (iv) Any other contact occurring before a health care service
 that is similar to a contact described in subparagraph (i), (ii), or
 (iii).
          (2) A nonparticipating provider shall not provide the
 disclosure described in subsection (3) to a nonemergency patient at
 the time of the nonemergency patient's admittance to a health
 facility described in section 24502(7)(a), 24502(8)(a), (b), (c),
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 (e), or (f), or at the time of preparing the nonemergency patient
 for a surgery or another medical procedure.
         (3) The disclosure required under subsection (1) must be in
 not less than 12-point type and in substantially the following
 form:
         "Your health benefit plan may or may not provide coverage for
 all of the health care services you are scheduled to receive or the
 providers providing those services. You may be responsible for the
 costs of the services that are not covered by your health benefit
 plan.
         The nonparticipating provider must provide a good-faith
 estimate of the cost of the health care services to be provided. A
 good-faith estimate does not take into account unforeseen
 circumstances, which may affect the cost of the health care
 services provided.
         You also have a right to request that the health care services
 be performed by a provider that participates with your health
 benefit plan, and may contact your carrier to arrange for those
 services to be provided at a lower cost and to receive information
 on in-network providers who can perform the health care services
 that you need.
         I have received, read, and understand this disclosure.
         __________________________________________________   _________
         (Patient or patient's representative's signature)     (Date)
         __________________________________________________
         (Type or print name of patient or patient's representative)".
         (4) A nonparticipating provider shall do all of the following:
         (a) Complete the disclosure described in subsection (3) and,
 after completing the disclosure, obtain on the disclosure the
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 signature of the nonemergency patient, or that patient's
 representative, acknowledging that the nonemergency patient, or
 that patient's representative, has received, has read, and
 understands the disclosure.
       (b) Retain a copy of the disclosure required under this
 section for not less than 7 years.
       (c) Provide the nonemergency patient or that patient's
 representative with a good-faith estimate of the cost of the health
 care services to be provided to the nonemergency patient.
       (5) Except as otherwise provided in section 24513 and subject
 to subsection (6), a nonparticipating provider who fails to provide
 the disclosure as required under this section shall submit a claim
 to the nonemergency patient's carrier within 60 days after the date
 of the health care service and shall accept from the nonemergency
 patient's carrier, as payment in full, the greater of the
 following:
       (a) Subject to section 24510, the median amount negotiated by
 the nonemergency patient's carrier for the region and provider
 specialty, excluding any in-network coinsurance, copayments, or
 deductibles. The nonemergency patient's carrier shall determine the
 region and provider specialty for purposes of this subdivision.
       (b) One hundred and fifty percent of the Medicare fee for
 service fee schedule for the health care service provided,
 excluding any in-network coinsurance, copayments, or deductibles.
       (6) A nonemergency patient's carrier shall pay the amount
 described in subsection (5) to the nonparticipating provider within
 60 days after receiving the claim from the nonparticipating
 provider under subsection (5). The nonparticipating provider shall
 not collect or attempt to collect from the nonemergency patient any
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 amount other than the applicable in-network coinsurance, copayment,
 or deductible.
       (7) This section does not apply to a nonparticipating
 emergency medical services operation.
       Sec. 24510. (1) Beginni