HOUSE BILL No. 5720


     May 2, 2000, Introduced by Reps. Reeves, Hardman, Scott, Schauer, Clark, Garza, Spade, Jamnick, Minore, Jacobs,
Woodward, Clarke, Hansen, Wojno, Callahan, Dennis, Gieleghem, Rison, Daniels, Hale, Vaughn 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 21052c.

               THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

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           SEC. 21052C.  (1) IF REQUESTED BY AN ENROLLEE, A HEALTH

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      MAINTENANCE ORGANIZATION SHALL PROVIDE OR AUTHORIZE A SECOND

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      OPINION BY AN APPROPRIATELY QUALIFIED HEALTH PROFESSIONAL FOR ANY

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      OF THE FOLLOWING REASONS:

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           (A) IF THE ENROLLEE QUESTIONS THE REASONABLENESS OR NECES-

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      SITY OF A RECOMMENDED SURGICAL PROCEDURE.

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           (B) IF THE ENROLLEE QUESTIONS A DIAGNOSIS OR PLAN OF CARE

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      FOR A CONDITION THAT THREATENS LOSS OF LIFE, LOSS OF LIMB, LOSS

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      OF BODILY FUNCTION, OR SUBSTANTIAL IMPAIRMENT, INCLUDING, BUT NOT

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      LIMITED TO, A SERIOUS CHRONIC CONDITION.




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           (C) IF THE CLINICAL INDICATIONS ARE NOT CLEAR OR ARE COMPLEX

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      AND CONFUSING, A DIAGNOSIS IS IN DOUBT DUE TO CONFLICTING TEST

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      RESULTS, OR THE TREATING HEALTH PROFESSIONAL IS UNABLE TO DIAG-

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      NOSE THE CONDITION.

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           (D) IF THE TREATMENT PLAN IN PROGRESS IS NOT IMPROVING THE

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      ENROLLEE'S MEDICAL CONDITION WITHIN AN APPROPRIATE PERIOD OF TIME

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      GIVEN THE DIAGNOSIS AND PLAN OF CARE.

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           (2) IF THE HEALTH MAINTENANCE ORGANIZATION APPROVES A

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      REQUEST FOR A SECOND OPINION TO BE GIVEN BY A NONAFFILIATED QUAL-

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      IFIED HEALTH PROFESSIONAL, THE HEALTH MAINTENANCE ORGANIZATION IS

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      RESPONSIBLE TO PAY FOR THE SECOND OPINION ONLY WHAT THE HEALTH

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      MAINTENANCE ORGANIZATION WOULD PAY FOR A SECOND OPINION BY AN

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      AFFILIATED QUALIFIED HEALTH PROFESSIONAL.

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           (3) AS USED IN THIS SECTION, "APPROPRIATELY QUALIFIED HEALTH

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      PROFESSIONAL" MEANS A PRIMARY CARE PHYSICIAN OR A SPECIALIST WHO

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      IS ACTING WITHIN HIS OR HER SCOPE OF PRACTICE AND WHO POSSESSES A

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      CLINICAL BACKGROUND, INCLUDING TRAINING AND EXPERTISE, RELATED TO

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      THE PARTICULAR ILLNESS, DISEASE, OR CONDITION ASSOCIATED WITH THE

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      REQUEST FOR A SECOND OPINION.



















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