HOUSE BILL NO. 4623

May 23, 2023, Introduced by Reps. Koleszar, Rogers, Wilson, McKinney, Steckloff, Miller, Byrnes, Rheingans, Morgan, Martus, Skaggs, Hope, Brixie, Tyrone Carter, Hood, Paiz, Brenda Carter, Haadsma, Hill, McFall, Morse, Phil Green, Puri, Breen, Farhat and Aiyash and referred to the Committee on Insurance and Financial Services.

A bill to amend 1956 PA 218, entitled

"The insurance code of 1956,"

by amending section 3501 (MCL 500.3501), as amended by 2016 PA 276, and by adding section 3406z.

the people of the state of michigan enact:

Sec. 3406z. (1) An insurer that delivers, issues for delivery, or renews in this state a health insurance policy shall provide coverage for all of the following:

(a) Ambulatory patient services.

(b) Emergency services.

(c) Hospitalization.

(d) Pregnancy, maternity, and newborn care.

(e) Mental health and substance use disorder services, including behavioral health treatment.

(f) Prescription drugs.

(g) Rehabilitative and habilitative services and devices.

(h) Laboratory services.

(i) Preventive and wellness services and chronic disease management, as specified by an annual order of the director. The coverage required under this subdivision, as specified by the director's order, includes, but is not limited to, all of the following:

(i) Evidence-based items or services that are highly recommended for preventive care and wellness purposes. As used in this subparagraph, "highly recommended" means that the director has determined there is a high certainty the net benefit of the item or service is substantial or moderate or there is a moderate certainty the net benefit is moderate to substantial after consideration of the recommendations issued by the United States Preventive Services Task Force, or a similar organization recognized by the director.

(ii) Immunizations that the director determines are recommended with respect to the individual involved after consideration of recommendations from the Advisory Committee on Immunization Practices of the Centers for Disease Control, or a similar organization recognized by the director.

(iii) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings that the director determines are supported by the Health Resources and Services Administration, or a similar organization recognized by the director.

(iv) With respect to women, additional preventive care and screenings not described in subparagraph (i) that the director determines are supported by the Health Resources and Services Administration, or a similar organization recognized by the director.

(j) Pediatric services, including oral and vision care.

(2) An insurer that delivers, issues for delivery, or renews in this state a health insurance policy shall not impose any cost-sharing requirements for benefits provided under subsection (1)(i).

(3) Benefits provided under subsection (1) are subject to all requirements applicable to those benefits under this chapter.

(4) This section does not limit the requirements to provide additional benefits under this chapter.

Sec. 3501. As used in this chapter:

(a) "Affiliated provider" means a health professional, licensed hospital, licensed pharmacy, or any other institution, organization, or person that has entered into a participating provider contract, directly or indirectly, with a health maintenance organization to render 1 or more health services to an enrollee. Affiliated provider includes a person described in this subdivision that has entered into a written arrangement with another person, including, but not limited to, a physician hospital organization or physician organization, that contracts directly with a health maintenance organization.

(b) "Basic health services" means medically necessary health services that health maintenance organizations must offer to large employers in at least 1 health maintenance contract. Basic health services include all of the following:

(i) Physician services including primary care and specialty care.

(ii) Ambulatory patient services.

(iii) Inpatient hospital Hospitalization services.

(iv) Emergency health services.

(v) Mental health and substance use disorder services, including behavioral health treatment.

(vi) Diagnostic laboratory and diagnostic and therapeutic radiological Laboratory services.

(vii) Home health services.

(viii) Preventive, wellness, and chronic disease management health services.

(ix) Pregnancy, maternity, and newborn care.

(x) Prescription drugs.

(xi) Rehabilitative and habilitative services and devices.

(c) "Credentialing verification" means the process of obtaining and verifying information about a health professional and evaluating the health professional when the health professional applies to become a participating provider with a health maintenance organization.

(d) "Health maintenance contract" means a contract between a health maintenance organization and a subscriber or group of subscribers to provide or arrange for the provision of health services within the health maintenance organization's service area. Health maintenance contract includes a prudent purchaser agreement under section 3405.

(e) "Health maintenance organization" means a person that, among other things, does the following:

(i) Delivers health services that are medically necessary to enrollees under the terms of its health maintenance contract, directly or through contracts with affiliated providers, in exchange for a fixed prepaid sum or per capita prepayment, without regard to the frequency, extent, or kind of health services.

(ii) Is responsible for the availability, accessibility, and quality of the health services provided.

(f) "Health professional" means an individual licensed, certified, or authorized in accordance with state law to practice a health profession in his or her the individual's respective state.

(g) "Health services" means services provided to enrollees of a health maintenance organization under their health maintenance contract.

(h) "Service area" means a defined geographical area in which covered health services are generally available and readily accessible to enrollees and where health maintenance organizations may market their contracts.