HOUSE BILL No. 5702 May 2, 2000, Introduced by Reps. Jacobs, Dennis, Woodward, Baird, Martinez, Spade, Schermesser, Mans, Switalski, Brater, Vaughn, Cherry, Schauer, Thomas, Prusi, DeHart, Daniels, Quarles, Brewer, Frank, Pestka, Bob Brown, Reeves, Hardman, Clark, Garza, Gieleghem, Basham, Jamnick, Hansen, Clarke, LaForge, Callahan, Hale, Rivet, Scott and Lemmons and referred to the Committee on Insurance and Financial Services. A bill to amend 1978 PA 368, entitled "Public health code," (MCL 333.1101 to 333.25211) by adding section 21052b. THE PEOPLE OF THE STATE OF MICHIGAN ENACT: 1 SEC. 21052B. (1) IF AN AFFILIATION BETWEEN A PRIMARY CARE 2 PHYSICIAN AND A HEALTH MAINTENANCE ORGANIZATION TERMINATES, THE 3 PHYSICIAN MAY PROVIDE WRITTEN NOTICE OF THIS TERMINATION WITHIN 4 15 DAYS AFTER THE PHYSICIAN BECOMES AWARE OF THE TERMINATION TO 5 EACH ENROLLEE WHO HAS CHOSEN THE PHYSICIAN AS HIS OR HER PRIMARY 6 CARE PHYSICIAN. IF AN ENROLLEE IS IN AN ONGOING COURSE OF TREAT- 7 MENT WITH ANY OTHER PHYSICIAN WHO IS AFFILIATED WITH THE HEALTH 8 MAINTENANCE ORGANIZATION AND THE AFFILIATION BETWEEN THE PHYSI- 9 CIAN AND THE HEALTH MAINTENANCE ORGANIZATION TERMINATES, THE 10 PHYSICIAN MAY PROVIDE WRITTEN NOTICE OF THIS TERMINATION TO THE 11 ENROLLEE WITHIN 15 DAYS AFTER THE PHYSICIAN BECOMES AWARE OF THE 00906'99 DKH 2 1 TERMINATION. THE NOTICES UNDER THIS SUBSECTION MAY ALSO DESCRIBE 2 THE PROCEDURE FOR CONTINUING CARE UNDER SUBSECTIONS (2) AND (3). 3 (2) IF AN AFFILIATION BETWEEN AN ENROLLEE'S CURRENT PHYSI- 4 CIAN AND A HEALTH MAINTENANCE ORGANIZATION TERMINATES, THE HEALTH 5 MAINTENANCE ORGANIZATION SHALL PERMIT THE ENROLLEE TO CONTINUE AN 6 ONGOING COURSE OF TREATMENT WITH THAT PHYSICIAN AS FOLLOWS: 7 (A) FOR 90 DAYS FROM THE DATE OF NOTICE TO THE ENROLLEE BY 8 THE PHYSICIAN OF THE PHYSICIAN'S TERMINATION WITH THE HEALTH 9 MAINTENANCE ORGANIZATION. 10 (B) IF THE ENROLLEE IS PREGNANT AT THE TIME OF THE 11 PHYSICIAN'S TERMINATION, THROUGH POSTPARTUM CARE DIRECTLY RELATED 12 TO THE PREGNANCY. 13 (C) IF THE ENROLLEE IS DETERMINED TO BE TERMINALLY ILL PRIOR 14 TO A PHYSICIAN'S TERMINATION OR KNOWLEDGE OF THE TERMINATION AND 15 THE PHYSICIAN WAS TREATING THE TERMINAL ILLNESS BEFORE THE DATE 16 OF TERMINATION OR KNOWLEDGE OF THE TERMINATION, FOR THE REMAINDER 17 OF THE ENROLLEE'S LIFE FOR CARE DIRECTLY RELATED TO THE TREATMENT 18 OF THE TERMINAL ILLNESS. 19 (D) IF AN ENROLLEE HAS A SERIOUS CHRONIC ILLNESS PRIOR TO A 20 PHYSICIAN'S TERMINATION OR KNOWLEDGE OF THE TERMINATION AND THE 21 PHYSICIAN WAS TREATING THE SERIOUS CHRONIC ILLNESS BEFORE THE 22 DATE OF TERMINATION OR KNOWLEDGE OF THE TERMINATION, FOR THE 23 REMAINDER OF THE ENROLLEE'S LIFE FOR CARE DIRECTLY RELATED TO THE 24 TREATMENT OF THE SERIOUS CHRONIC ILLNESS. 25 (E) IF AN ENROLLEE IS DIAGNOSED WITH CANCER PRIOR TO A 26 PHYSICIAN'S TERMINATION OR KNOWLEDGE OF THE TERMINATION AND THE 27 PHYSICIAN WAS TREATING THE CANCER BEFORE THE DATE OF TERMINATION 00906'99 3 1 OR KNOWLEDGE OF THE TERMINATION, FOR THE REMAINDER OF THE 2 ENROLLEE'S LIFE FOR CARE DIRECTLY RELATED TO THE TREATMENT OF 3 THAT CANCER. 4 (F) IF AN ENROLLEE IS 65 YEARS OLD OR OLDER, FOR THE REMAIN- 5 DER OF THE ENROLLEE'S LIFE. 6 (3) SUBSECTION (2) APPLIES ONLY IF THE PHYSICIAN AGREES TO 7 ALL OF THE FOLLOWING: 8 (A) TO CONTINUE TO RENDER TREATMENT AND TO ACCEPT AS PAYMENT 9 IN FULL REIMBURSEMENT FROM THE HEALTH MAINTENANCE ORGANIZATION AT 10 THE RATES APPLICABLE PRIOR TO THE TERMINATION. 11 (B) TO ADHERE TO THE HEALTH MAINTENANCE ORGANIZATION'S STAN- 12 DARDS FOR MAINTAINING QUALITY HEALTH CARE AND TO PROVIDE TO THE 13 HEALTH MAINTENANCE ORGANIZATION NECESSARY MEDICAL INFORMATION 14 RELATED TO THE CARE. 15 (C) TO OTHERWISE ADHERE TO THE HEALTH MAINTENANCE 16 ORGANIZATION'S POLICIES AND PROCEDURES, INCLUDING, BUT NOT 17 LIMITED TO, THOSE CONCERNING UTILIZATION REVIEW, REFERRALS, PRE- 18 AUTHORIZATIONS, AND TREATMENT PLANS. 19 (4) A HEALTH MAINTENANCE ORGANIZATION SHALL PROVIDE WRITTEN 20 NOTICE TO EACH AFFILIATED PHYSICIAN THAT IF AN AFFILIATION 21 BETWEEN THE PHYSICIAN AND THE HEALTH MAINTENANCE ORGANIZATION 22 TERMINATES, THE PHYSICIAN MAY DO BOTH OF THE FOLLOWING: 23 (A) NOTIFY THE HEALTH MAINTENANCE ORGANIZATION'S ENROLLEES 24 UNDER THE CARE OF THE PHYSICIAN OF THE TERMINATION IF THE PHYSI- 25 CIAN DOES SO WITHIN 15 DAYS AFTER THE PHYSICIAN BECOMES AWARE OF 26 THE TERMINATION. 00906'99 4 1 (B) INCLUDE IN THE NOTICE UNDER SUBDIVISION (A) A 2 DESCRIPTION OF THE PROCEDURES FOR CONTINUING CARE UNDER 3 SUBSECTIONS (2) AND (3). 4 (5) THIS SECTION DOES NOT CREATE AN OBLIGATION FOR A HEALTH 5 MAINTENANCE ORGANIZATION TO PROVIDE TO AN ENROLLEE COVERAGE 6 BEYOND THE MAXIMUM COVERAGE LIMITS PERMITTED BY THE HEALTH MAIN- 7 TENANCE ORGANIZATION'S CONTRACT WITH THE ENROLLEE. 8 (6) AS USED IN THIS SECTION: 9 (A) "PHYSICIAN" MEANS AN ALLOPATHIC PHYSICIAN OR OSTEOPATHIC 10 PHYSICIAN OR MENTAL HEALTH PROFESSIONAL. 11 (B) "SERIOUS CHRONIC ILLNESS" MEANS A DISEASE OR CONDITION 12 THAT CAN BE MANAGED, BUT NOT CURED, INCLUDING A SERIOUS MENTAL 13 ILLNESS, AND THAT AFFECTS A PERSON'S GENERAL ABILITY TO LEAD HIS 14 OR HER NORMAL LIFE. 15 (C) "TERMINAL ILLNESS" MEANS THAT TERM AS DEFINED IN SECTION 16 5653. 17 (D) "TERMINATES" OR "TERMINATION" INCLUDES THE NONRENEWAL, 18 EXPIRATION, OR ENDING FOR ANY REASON OF AN AFFILIATION BETWEEN A 19 PHYSICIAN AND A HEALTH MAINTENANCE ORGANIZATION, BUT DOES NOT 20 INCLUDE A TERMINATION BY THE HEALTH MAINTENANCE ORGANIZATION FOR 21 FAILURE TO MEET APPLICABLE QUALITY STANDARDS OR FOR FRAUD. 22 Enacting section 1. This amendatory act takes effect July 23 1, 2000. 00906'99 Final page. DKH