SECOND OPINIONS AT HMOs
House Bill 4978
Sponsor: Rep. Triette Reeves
Committee: Insurance and Financial Services
Complete to 7-12-01
A SUMMARY OF HOUSE BILL 4978 AS INTRODUCED 6-19-01
The bill would amend the Insurance Code (MCL 500.3518) to require a health maintenance organization to provide or authorize a second opinion by an appropriately qualified health professional under certain circumstances.
Upon the request of an enrollee, an HMO would have to allow a second opinion for any of the following reasons:
* the enrollee questioned the reasonableness or necessity of a recommended surgical procedure;
* the enrollee questioned a diagnosis or plan of care for a condition that threatened loss of life, loss of limb, loss of bodily function, or substantial impairment, including a serious chronic condition;
* the clinical indications were not clear or were complex and confusing, a diagnosis was in doubt due to conflicting test results, or the treating health professional was unable to diagnose the condition; or
* the treatment plan in progress was not improving the enrollee's medical condition within an appropriate period of time, given the diagnosis and plan of care.
If a second opinion was given by a non-affiliated qualified health professional, an HMO would be responsible to pay for the second opinion only what it would pay for a second opinion by an affiliated qualified health professional.
The term "appropriately qualified health professional" would mean a primary care physician or a specialist who was acting within his or her scope of practice and who possessed a clinical background, including training and expertise, related to the particular illness, disease, or condition associated with the request for a second opinion.
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This analysis was prepared by nonpartisan House staff for use by House members in their deliberations, and does not constitute an official statement of legislative intent.