SENATE BILL NO. 675


   June 17, 1999, Introduced by Senator BYRUM and referred to the
        Committee on Health Policy.



        A bill to amend 1956 PA 218, entitled

   "The insurance code of 1956,"

   (MCL 500.100 to 500.8302) by adding section 2212b.

               THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 1         SEC. 2212B.  (1) AS USED IN THIS SECTION:

 2         (A) "UTILIZATION REVIEW" MEANS A SYSTEM FOR PROSPECTIVE AND

 3    CONCURRENT REVIEW OF THE MEDICAL NECESSITY AND APPROPRIATENESS IN

 4    THE ALLOCATION OF HEALTH CARE RESOURCES AND SERVICES GIVEN OR

 5    PROPOSED TO BE GIVEN TO AN INSURED UNDER A POLICY OR CERTIFICATE

 6    ISSUED UNDER SECTION 3405 OR 3631.  UTILIZATION REVIEW DOES NOT

 7    INCLUDE ELECTIVE REQUESTS FOR CLARIFICATION OF COVERAGE.

 8         (B) "UTILIZATION REVIEW ACCREDITATION COMMISSION" MEANS THE

 9    AMERICAN ACCREDITATION HEALTHCARE COMMISSION/UTILIZATION REVIEW

10    ACCREDITATION COMMISSION.




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 1         (2) THIS SECTION APPLIES TO A POLICY OR CERTIFICATE ISSUED

 2    UNDER SECTION 3405 OR 3631.

 3         (3) AN INSURER SHALL ESTABLISH A POLICY GOVERNING TERMINA-

 4    TION OF HEALTH CARE PROVIDERS.  THE POLICY SHALL INCLUDE, BUT IS

 5    NOT LIMITED TO, ALL OF THE FOLLOWING:

 6         (A) NOTICE TO THE PROVIDER OF THE TERMINATION IN THE TIME

 7    AND MANNER SPECIFIED IN THE PROVIDER'S CONTRACT.

 8         (B) METHODS BY WHICH THE TERMINATION POLICY WILL BE MADE

 9    KNOWN TO PROVIDERS AND INSUREDS AT THE TIME OF ENROLLMENT AND ON

10    A PERIODIC BASIS.

11         (C) WRITTEN NOTIFICATION TO EACH INSURED AT LEAST 30 BUSI-

12    NESS DAYS PRIOR TO THE TERMINATION OR WITHDRAWAL FROM THE

13    INSURER'S PROVIDER NETWORK OF AN INSURED'S PRIMARY CARE PROVIDER

14    AND ANY OTHER PROVIDER FROM WHICH THE INSURED IS CURRENTLY

15    RECEIVING A COURSE OF TREATMENT.  THE 30-DAY PRIOR NOTICE TO

16    INSUREDS MAY BE WAIVED IN CASES OF IMMEDIATE TERMINATION OF A

17    PROVIDER WHERE IT WAS NECESSARY FOR THE PROTECTION OF THE HEALTH,

18    SAFETY, AND WELFARE OF INSUREDS.

19         (4) AN INSURER SHALL NOT TERMINATE A HEALTH CARE PROVIDER'S

20    PARTICIPATION WITH THE INSURER BECAUSE OF THE UTILIZATION OF

21    SERVICES CAUSED BY 1 OR MORE HIGH UTILIZATION INSUREDS.

22         (5) AN INSURER THAT WISHES TO PERFORM UTILIZATION REVIEW

23    IN-HOUSE SHALL DO SO ONLY UNDER EITHER OF THE FOLLOWING

24    CIRCUMSTANCES:

25         (A) IF THE UTILIZATION REVIEW STANDARDS TO BE USED HAVE BEEN

26    APPROVED OR ACCREDITED BY THE UTILIZATION REVIEW ACCREDITATION

27    COMMISSION.



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 1         (B) THE PLAN HAS DEMONSTRATED TO THE COMMISSIONER THAT IT

 2    ADHERES TO UTILIZATION REVIEW STANDARDS THAT ARE SUBSTANTIALLY

 3    SIMILAR TO STANDARDS APPROVED OR ACCREDITED BY THE UTILIZATION

 4    REVIEW ACCREDITATION COMMISSION AND THE STANDARDS PROVIDE THE

 5    SAME OR GREATER PROTECTION TO THE RIGHTS OF INSUREDS WHOSE CARE

 6    IS REVIEWED.

 7         (6) AN INSURER SHALL ONLY CONTRACT WITH A UTILIZATION REVIEW

 8    COMPANY FOR THE PERFORMANCE OF UTILIZATION REVIEW SERVICES IF THE

 9    UTILIZATION REVIEW COMPANY SHOWS EITHER OF THE FOLLOWING:

10         (A) THE UTILIZATION REVIEW COMPANY HAS BEEN APPROVED OR

11    ACCREDITED BY THE UTILIZATION REVIEW ACCREDITATION COMMISSION.

12         (B) THE UTILIZATION REVIEW COMPANY HAS DEMONSTRATED TO THE

13    COMMISSIONER THAT IT ADHERES TO UTILIZATION REVIEW STANDARDS THAT

14    ARE SUBSTANTIALLY SIMILAR TO STANDARDS APPROVED OR ACCREDITED BY

15    THE UTILIZATION REVIEW ACCREDITATION COMMISSION AND THE STANDARDS

16    PROVIDE THE SAME OR GREATER PROTECTION TO THE RIGHTS OF INSUREDS

17    WHOSE CARE IS REVIEWED.

18         Enacting section 1.  This amendatory act takes effect

19    January 1, 2000.



















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