HOUSE BILL No. 6079

 

May 7, 2008, Introduced by Reps. Alma Smith, Kathleen Law, Jackson, Young, Byrnes, Green, Gonzales, Clack, Garfield and Wenke and referred to the Committee on Health Policy.

 

     A bill to amend 1974 PA 258, entitled

 

"Mental health code,"

 

(MCL 330.1001 to 330.2106) by adding section 709.

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

     Sec. 709. (1) The department shall establish a policy

 

directive on local grievance procedures that all community mental

 

health services programs shall be required to follow.

 

     (2) The department's policy directive shall require a

 

community mental health services program to reach a decision on a

 

local grievance within 35 calendar days from the date a grievance

 

is filed by an applicant, a recipient, a guardian of an applicant

 

or recipient, or an authorized representative of the applicant,

 

recipient, or guardian.

 


     (3) If a mental health professional communicates orally or in

 

writing to a community mental health services program that the

 

applicant or recipient is experiencing an emergency situation, the

 

community mental health services program is required to reach a

 

decision within 72 hours of receiving that communication.

 

     (4) If the filing applicant, recipient, guardian, or

 

authorized representative is dissatisfied with the decision of the

 

community mental health services program under the local grievance

 

process, he or she may request within 60 calendar days of that

 

decision, or within 10 calendar days if the grievance represented

 

an emergency situation, that the department arrange for an external

 

review of the grievance if both of the following apply:

 

     (a) The grievance involves a community mental health services

 

program determination that an admission, availability of care,

 

continued stay, or other specialty mental health service or support

 

is denied, reduced, suspended, or terminated due to lack of medical

 

necessity.

 

     (b) The applicant or recipient does not have legal recourse to

 

participate in the medicaid fair hearing process regarding the

 

determination of the community mental health services program.

 

     (5) Upon receipt of a request for an external review, the

 

department shall provide written notification of receipt to the

 

involved community mental health services program.

 

     (6) Not later than 5 business days after receiving a request

 

for an external review, or not later than 24 hours if the grievance

 

represented an emergency situation, the department shall determine

 

whether external review is warranted. The person filing the

 


grievance and the involved community mental health services program

 

shall receive written notification of the determination according

 

to 1 of the following:

 

     (a) If external review is not warranted, the department shall

 

attempt to mediate the disagreement between the person filing the

 

grievance and the involved community mental health services

 

program.

 

     (b) If external review is warranted and the service in

 

question is solely or primarily of a treatment nature, the

 

department shall arrange for the review to be conducted by a

 

psychiatrist who has no employment, contractual, or other

 

relationship with the department or any community mental health

 

services program.

 

     (c) If external review is warranted and the service in

 

question is solely or primarily of a support nature, the department

 

shall arrange for the external review to be conducted by a mental

 

health professional who has experience with the service in

 

question, and who has no employment, contractual, or other

 

relationship with the department or any community mental health

 

services program.

 

     (7) In arranging for an external review, the department shall

 

forward immediately to the external reviewer written material

 

submitted to the department by the person filing the grievance. The

 

external reviewer may request that the person filing the grievance

 

provide additional information within 7 business days or within 1

 

business day if the grievance represented an emergency situation.

 

     (8) Upon receiving notification that an external review is to

 


be conducted, the involved community mental health services program

 

has 7 business days to provide the external reviewer with all

 

documents and information utilized by the community mental health

 

services program in making its local grievance decision. If the

 

grievance represented an emergency situation, the material shall be

 

provided within 1 business day. Initial notification of the 1-day

 

requirement may be verbal. Failure of a community mental health

 

services program to provide the required material within the

 

prescribed time frame shall result in the department ordering an

 

immediate reversal of the local grievance decision.

 

     (9) An external reviewer shall make a recommendation to the

 

department within 10 business days after receipt of information

 

under subsections (7) and (8) or within 48 hours from the receipt

 

of that information if the grievance represented an emergency

 

situation.

 

     (10) Upon receipt of a recommendation from an external

 

reviewer, the department shall make a binding administrative

 

decision about the case within 7 business days or within 24 hours

 

if the grievance represented an emergency situation. Initial notice

 

of the decision may be provided orally to the person filing the

 

grievance and the involved community mental health services

 

program. In all cases, both parties shall be provided written

 

notification that shall minimally include both of the following:

 

     (a) The recommendation made by the external reviewer and the

 

rationale for that recommendation.

 

     (b) If applicable, the rationale for why the department did

 

not follow the external reviewer's recommendation.

 


     (11) At any time before the binding administrative decision

 

from the department, the external review process is abrogated if

 

the person filing the grievance makes a written request for

 

withdrawal or if the involved community mental health services

 

program provides written notification that it has elected to

 

authorize the action sought by the person filing the grievance.

 

     (12) In making a determination under subsection (6) or (10),

 

the department may consider all information it considers relevant,

 

including, but not limited to, all of the following:

 

     (a) The applicant's or recipient's diagnosis, prognosis, and

 

case history.

 

     (b) The severity of the applicant's or recipient's condition

 

and the degree to which the applicant's or recipient's

 

circumstances meet the criteria described in section 208 for

 

priority services.

 

     (c) The financial resources available to the involved

 

community mental health services program.

 

     (d) The degree to which the community mental health services

 

program utilized appropriate person-centered planning procedures.

 

     (e) The quality of the written individualized plan of service

 

and the degree of consumer participation in developing it.

 

     (f) The availability of the service desired by the person

 

filing the grievance.

 

     (g) The existence of co-occurring medical conditions.

 

     (h) The degree of involvement required from any provider who

 

is not a mental health human service provider in addressing the

 

situation.

 


     (13) The department shall provide the legislature annually

 

with a report for each community mental health services program and

 

the state in aggregate that includes the following details:

 

     (a) The number of local grievances filed, categorized

 

according to emergent or nonemergent status and whether or not the

 

person filing the grievance had legal recourse to the medicaid fair

 

hearing process.

 

     (b) The number of filed local grievances, categorized

 

according to subdivision (a), in which agreement between the

 

parties negated a need for a local grievance decision by the

 

community mental health services program.

 

     (c) The number of local grievance decisions, categorized

 

according to subdivision (a), upholding the initial determination

 

of the community mental health services program.

 

     (d) The number of local grievance decisions, categorized

 

according to emergent or nonemergent status, resulting in requests

 

for external review.

 

     (e) The number of requests for external review, categorized

 

according to subdivision (d), that were not honored by the

 

department, and the outcomes of the department's mediation efforts

 

for those cases.

 

     (f) The number of requests for external review, categorized

 

according to subdivision (d), honored by the department.

 

     (g) The number of external review cases, categorized according

 

to subdivision (d), in which the community mental health services

 

program's failure to provide required material within prescribed

 

time frames resulted in default judgment for the person filing the

 


grievance.

 

     (h) The number of external review cases, categorized according

 

to subdivision (d), withdrawn before final administrative decision

 

at the request of community mental health services programs.

 

     (i) The number of external review cases, categorized according

 

to subdivision (d), withdrawn before final administrative decision

 

at the request of a person filing a grievance.

 

     (j) The number of external review cases, categorized according

 

to subdivision (d), in which the external review recommendation

 

respectively favored community mental health services programs and

 

parties filing grievances.

 

     (k) The number of external review cases, categorized according

 

to subdivision (d), in which the department overturned the external

 

reviewer recommendation, and the numbers of those overturned

 

external reviewer recommendations that respectively favored

 

community mental health services programs and parties filing

 

grievances.

 

     (14) As used in this section:

 

     (a) "Grievance" means a written communication from or on

 

behalf of the applicant or recipient, reflecting disagreement with

 

a community mental health services program or its provider network

 

over 1 or more of the following:

 

     (i) The denial, reduction, suspension, or termination of

 

services.

 

     (ii) The timeliness of responses to requests for services.

 

     (iii) The clinical, cultural, or linguistic appropriateness of

 

services offered or rendered.

 


     (iv) The availability of services offered or rendered.

 

     (v) The performance and behavior of individual service

 

providers and employees.

 

     (b) "Medical necessity" means screening, assessment, treatment

 

or support that is consistent with generally accepted mental health

 

and health care practices, addresses symptoms or the existence of

 

serious mental illness, serious emotional disturbance,

 

developmental disability, or substance use disorder, as well as

 

impairments in daily functioning related to these disorders, and is

 

for the purpose of preventing either the need for more intensive

 

levels of treatment or relapses and deterioration of an

 

individual's mental, emotional, developmental, or behavioral

 

condition.