Embed Size (px)
Citation preview
1
MAHP 2015 Summer Conference
Insurance Code Revisions
Judith W HooyengaJuly 17, 2015
2
Goals Process Status Proposed revisions Call to action Questions
Agenda
3
Modernize the Insurance Code with respect to health insurance
Enable faster development of new products Keep Michigan laws strong and relevant
Goals
4
In fall of 2013, MAHP prepared first draft of proposed changes
Throughout 2014, MAHP◦consulted with interested parties – DIFS, Blue
Cross, agents, disability insurers◦identified legislative sponsor◦obtained new draft bill from LSB◦participated in workgroups with legislators, DIFS,
Blue Cross and others
Process
5
2015◦LSB prepared new draft◦MAHP continued to work with proposed
legislative sponsor◦MAHP continued to consult with interested
parties, including DIFS
Process (cont.)
6
Agreement reached on most issues Blue Back prepared Billed to be introduced in July 2015◦HB ____ - Insurance Code◦HB ____ - PRIRA◦HB ____ - Coordination of Benefits
Current Status
7
Chapter 22 – Insurance ContractsChapter 34 – Individual disability
coverageChapter 35 – HMOsChapter 36 – Group disability coverageChapter 37 – Small group coverage
Current regulation of health insurance in Michigan
8
But… Mandate language in Chapter 34 also applies
to group coverage and HMOs Definition of “disability insurance” currently
includes health insurance, resulting in confusion as to which provisions of Chapter 34 apply to disability and which apply to health
Chapter 35 restricts innovation in developing health plans desired by employers
Current regulation (cont.)
9
Definition of “health insurance” included in new Sec 607
Chapter 34 specifies which provisions apply to health, which apply to disability, and which apply to both
Chapter 36 eliminated◦Some provisions moved to Chapter 34◦Unnecessary provisions deleted, including
requirement for conversion coverage
General Revisions
10
Chapter 35 revised◦Provisions that apply only to HMOs remain
in chapter 35◦Some provisions of chapter 35 have been
revised◦Provisions that should apply to all health
insurers moved to either chapters 22 or 34
General revisions (cont.)
11
Sec 3501 – Some definitions moved to other chapters
Sec 3503 – HMOs permitted to operate an ASO Sec 3509 – Service areas not required to be
contiguous Sec 3511 – HMO must make good faith effort for
1/3 of its governing body to be comprised of enrollees or representatives of membership.
Key Chapter 35 revisions
12
Sec 3511 (cont.) If 1/3 not attained, must establish a consumer advisory board. Requirement for election of member representatives by HMO members is eliminated.
Sec 3517 – Payment of cash to members allowed if approved by director. Additional health improvement initiatives allowed.
Sec 3519 – One plan with basic health services must be offered to large employer groups.
Chapter 35 revisions (cont.)
13
Sec 3528 – Credentialing process approved by accrediting agency replaces state requirements.
Sec 3537 – Annual open enrollment period eliminated due to guaranteed issue requirement of ACA.
Sec 3539 – Guaranteed renewal doesn’t apply if employer fails to meet minimum contribution requirements.
Chapter 35 revisions (cont.)
14
Sec 3544 – New section will allow HMOs to process claims for noninsured benefit plans, but only after HMO has received funds to cover claims payment.
Chapter 35 revisions (cont.)
15
Sections clarified as to whether they apply to health insurance, disability insurance or both
Sec 3405 – Removed requirement for insurers and HMOs to offer indemnity plans
Sec 3406k – Adds definition of “prudent layperson” for coverage of emergency services
Sec 3406o – Adds expedited process for approval of experimental drugs
Key Chapter 34 Revisions
16
Sec 3409 – Addresses issue when a person signs up for policy, never pays premium but receives services
Sec 3425 – Eliminates minimum dollar coverage for substance use disorder services
Sec 3426 – Permits rebate for tobacco cessation programs to be equal to 50% of premium; allows insurers to develop new products in response to market demands
Chapter 34 revisions (cont.)
17
Sec 3452 – Coverage excluded for illegal activities that include driving with a blood alcohol level in excess of the legal limit or operating a so-called “meth lab”
Sec 3474 – Incorporates sections 2242 and 3525. Director has 60 days to approve individual or small group rates and forms, with possible 30 day extension. If director withdraws approval of a rate or form, insurer may continue to use it until appeal is completed.
Chapter 34 revisions (cont.)
18
Sec 3474a – Incorporates language from Sec 3519 re development of rates for large groups
Sec 3477 – Sec 3542, which prohibits payment by HMO of an inducement to health professionals, moved to Chapter 34 to apply to all insurers
Chapter 34 revisions (cont.)
19
Sec 2212d – Requirements for contracting with providers applies to all “network plans”
Sec 2213 – Informal grievance procedure revised to conform timelines with federal ERISA law and to incorporate federal definition of adverse determination
Sec 2236 – Readability scoring clarified; new subsection (8) allows delivery of documents electronically under certain conditions
Key Chapter 22 Revisions
20
Coordination of Benefits◦Adopt NAIC Model Act
Patient Right to Independent Review Act◦Update to reflect changes in federal law, which
permit Michigan to operate appeal process Health Benefit Agent Act◦Retain
Cross-references to Insurance Code
Other Laws
21
Supporters should call/email/write their locally elected Representatives and all members of the House Insurance Committee to urge support for the package
Supporters are encouraged to have similar conversations with Senate members, but should hold email/letter communication until after the package passes the House
Call to Action
22
Questions or comments?
Insurance Code Revisions
