HB 6133

HOUSE BILL NO. 6133
A bill to amend 1939 PA 280, entitled
"The social welfare act,"
by amending sections 105d, 109, 111i, and 111j (MCL
400.105d, 400.109, 400.111i, and 400.111j), section 105d as amended by 2023 PA
98, section 109 as amended by 2025 PA 45, section 111i as added by 2000 PA 187,
and section 111j as added by 1988 PA 445, and by adding sections 111o, 111p,
and 111q.
the people of the state of michigan enact:
Sec. 105d. (1) The department shall seek
approval from the United States Department of Health and Human Services to do,
without jeopardizing federal match dollars or otherwise incurring federal
financial penalties, and upon on approval shall do, all of the following:
(a) Enroll
individuals eligible under section 1396a(a)(10)(A)(i)(VIII) of title XIX who
meet the citizenship provisions of 42 CFR 435.406 and who are otherwise
eligible for the medical assistance program under this act into a contracted
health plan.
(b) Give enrollees
described in subdivision (a) a choice in choosing among contracted health
plans.
(c) Ensure that all
enrollees described in subdivision (a) have access to a primary care
practitioner who is licensed, registered, or otherwise authorized to engage in
the primary care practitioner's health care profession in this state and to
preventive services. The department shall require that all new enrollees be
assigned and have scheduled an initial appointment with their primary care
practitioner within 60 days of initial enrollment. The department shall monitor
and track contracted health plans for compliance in
this area with this subdivision and
consider that compliance in any health plan incentive programs. The department
shall ensure that the contracted health plans have procedures to ensure that
the privacy of the enrollees' personal information is protected in accordance
with the health insurance portability and accountability act of 1996, Public
Law 104-191.
(d) Establish cost
sharing requirements for enrollees described in subsection
(1)(a) subdivision (a) as approved by
the United States Department of Health and Human Services.
(e) Implement a
plan to encourage use of high-value services, while discouraging low-value
services such as nonurgent emergency department use.
(f) Develop
incentives for enrollees and providers who assist the department in detecting
fraud and abuse in the medical assistance program. The department shall provide
an annual report that includes the type of fraud detected, the amount saved,
and the outcome of the investigation to the legislature.
(g) Allow for
services provided by telemedicine from a practitioner who is licensed,
registered, or otherwise authorized under section 16171 of the public health
code, 1978 PA 368, MCL 333.16171, to engage in the practitioner's health care
profession in the state where the patient is located.
(2) For services
rendered to an uninsured individual, a hospital that participates in the
medical assistance program under this act shall accept 115% of Medicare rates
as payments in full from an uninsured individual with an annual income level up
to 250% of the federal poverty guidelines.
(3) The department
shall develop and implement a plan to enroll all existing fee-for-service
enrollees into contracted health plans if allowable by law, if the medical
assistance program is the primary payer and if that enrollment is
cost-effective. This includes all newly eligible enrollees as described in
subsection (1)(a). The department shall include contracted health plans as the
mandatory delivery system in its waiver request. The department shall identify
all remaining populations eligible for managed care, develop plans for their
integration into managed care, and provide recommendations for a performance
bonus incentive plan mechanism for long-term care managed care providers that
are consistent with other managed care performance bonus incentive plans. The
department shall make recommendations for a performance bonus incentive plan
for long-term care managed care providers of up to 3% of their Medicaid
capitation payments, consistent with other managed care performance bonus
incentive plans. These payments shall must comply with federal requirements and shall be based on measures that identify the
appropriate use of long-term care services and that focus on consumer
satisfaction, consumer choice, and other appropriate quality measures
applicable to community-based and nursing home services. Beginning on the effective date of the amendatory act that
added section 111o, the department shall disenroll an individual in a skilled
nursing facility who is enrolled under the Michigan coordinated health plan after
45 days of care in the skilled nursing facility. The department shall
automatically enroll the individual disenrolled under this subsection into a
fee-for-service plan under the medical assistance program.
(4) The department
shall implement a pharmaceutical benefit to encourage the use of high-value,
low-cost prescriptions, such as generic prescriptions when such an alternative
exists for a branded product and 90-day prescription supplies, as recommended by
the enrollee's prescribing provider and as is consistent with section 109h and
sections 9701 to 9709 of the public health code, 1978 PA 368, MCL 333.9701 to
333.9709.
(5) The department
in collaboration with the contracted health plans shall create financial
incentives for enrollees who demonstrate improved health outcomes, practice
healthy behaviors, or complete screenings or procedures that improve health
outcomes.
(6) The performance
bonus incentive pool for contracted health plans shall
must include targets established for at
least 3 and no more than 5 objectives established by the department in
collaboration with the contracted health plans. Targets should focus on key
current health priorities, improve health equity, utilize established
measurements to set a baseline for performance improvement, and be determined
at least 6 months before the measurement period to support planning and
execution necessary for achievement of desired outcomes.
(7) The department
shall ensure that all capitated payments made to contracted health plans are
actuarially sound. This subsection applies whether or not either or both of the
waivers requested under this section are approved, the patient protection and affordable
care act is repealed, or the state terminates or opts out of the program
established under this section.
(8) The department
shall withhold, at a minimum, 0.75% of payments to contracted health plans,
except for specialty prepaid health plans, for the purpose of expanding the
existing performance bonus incentive pool. Distribution of funds from the
performance bonus incentive pool is contingent on the contracted health plan's
completion of the required performance or compliance metrics.
(9) The department
may measure contracted health plan or specialty prepaid health plan performance
metrics, as applicable, on application of standards of care as that relates to
appropriate treatment of substance use disorders and efforts to reduce substance
use disorders.
(10) The department
shall make available at least 3 years of state medical assistance program data,
without charge, to any vendor considered qualified by the department who
indicates interest in submitting proposals to contracted health plans in order
to implement cost savings and population health improvement opportunities
through the use of innovative information and data management technologies. Any
program or proposal to the contracted health plans must be consistent with the
state's goals of improving health, increasing the quality, reliability,
availability, and continuity of care, and reducing the cost of care of the
eligible population of enrollees described in subsection (1)(a). The use of the
data described in this subsection for the purpose of assessing the potential
opportunity and subsequent development and submission of formal proposals to
contracted health plans is not a cost or contractual obligation to the
department or the state.
(11) For the
purposes of submitting reports and other information or data required under
this section only, "legislature" means the senate majority leader,
the speaker of the house of representatives, the chairs of the senate and house
of representatives appropriations committees, the chairs of the senate and
house of representatives appropriations subcommittees on the department budget,
and the chairs of the senate and house of representatives standing committees
on health policy.
(12) As used in
this section:
(a) "Patient
protection and affordable care act" means the patient protection and
affordable care act, Public Law 111-148, as amended by the federal health care
and education reconciliation act of 2010, Public Law 111-152.
(b)
"Telemedicine" means that term as defined in section 3476 of the
insurance code of 1956, 1956 PA 218, MCL 500.3476.
Sec. 109. (1) An eligible individual may receive the
following medical services under this act:
(a) Hospital
services that an eligible individual may receive consist of medical, surgical,
or obstetrical care, together with necessary drugs, X-rays, physical therapy,
prosthesis, transportation, and nursing care incident to the medical, surgical,
or obstetrical care. The period of inpatient hospital service must be the minimum period necessary in this
type of facility for the proper care and treatment of the individual. Necessary
hospitalization to provide dental care must be provided if certified by the
attending dentist with the approval of the department. An individual who is
receiving medical treatment as an inpatient because of a diagnosis of mental
disease may receive service under this section, notwithstanding the mental
health code, 1974 PA 258, MCL 330.1001 to 330.2106. The department must pay for
hospital services according to the state plan for medical assistance adopted
under section 10 and approved by the United States Department of Health and
Human Services.
(b) Physician Physician's services
authorized by the department. The services may be furnished in the physician's
office, the eligible individual's home, a medical institution, or elsewhere in
case of emergency. A physician must be paid a reasonable charge for the service
rendered. The department must determine reasonable charges. Reasonable charges
must not be more than those paid in this state for services rendered under
title XVIII.
(c) Nursing home
services in a state licensed nursing home, a medical care facility, or other
facility or identifiable unit of that facility, certified by the appropriate
authority as meeting established standards for a nursing home under the laws
and rules of this state and the United States Department of Health and Human
Services, to the extent found necessary by the attending physician, dentist, or
certified Christian Science practitioner. An eligible individual may receive
nursing home services in an extended care services program established under
section 22210 of the public health code, 1978 PA 368, MCL 333.22210, to the
extent found necessary by the attending physician when the combined length of
stay in the acute care bed and short-term nursing care bed exceeds the average
length of stay for Medicaid hospital diagnostic related group reimbursement.
The department shall not make a final payment under title XIX for benefits
available under title XVIII without documentation that title XVIII claims have
been filed and denied. The department must pay for nursing home services
according to the state plan for medical assistance adopted according to section
10 and approved by the United States Department of Health and Human Services. A
county must reimburse a county maintenance of effort rate determined on an
annual basis for each patient day of Medicaid nursing home services provided to
eligible individuals in long-term care facilities owned by the county and
licensed to provide nursing home services. For purposes of determining rates
and costs described in this subdivision, all of the following apply:
(i) For county-owned facilities with per
patient day updated variable costs exceeding the variable cost limit for the
county facility, county maintenance of effort rate means 45% of the difference
between per patient day updated variable cost and the concomitant nursing
home-class variable cost limit, the quantity offset by the difference between
per patient day updated variable cost and the concomitant variable cost limit
for the county facility. The county rate must not be less than zero.
(ii) For county-owned facilities with per
patient day updated variable costs not exceeding the variable cost limit for
the county facility, county maintenance of effort rate means 45% of the
difference between per patient day updated variable cost and the concomitant
nursing home class variable cost limit.
(iii) For county-owned facilities with per
patient day updated variable costs not exceeding the concomitant nursing home
class variable cost limit, the county maintenance of effort rate must equal
zero.
(iv) For the purposes of this section:
"per patient day updated variable costs and the variable cost limit for
the county facility" must be determined according to the state plan for
medical assistance; for freestanding county facilities the "nursing home
class variable cost limit" must be determined according to the state plan
for medical assistance and for hospital attached county facilities the
"nursing class variable cost limit" must be determined according to
the state plan for medical assistance plus $5.00 per patient day; and
"freestanding" and "hospital attached" must be determined
according to the federal regulations.
(v) If the county maintenance of effort rate
computed under this section exceeds the county maintenance of effort rate in
effect as of September 30, 1984, the rate in effect as of September 30, 1984
must remain in effect until a time that the rate computed under this section is
less than the September 30, 1984 rate. This limitation remains in effect until
December 31, 2030 or until a new reimbursement system determined by the
department replaces the current system, whichever is sooner. For each
subsequent county fiscal year, the maintenance of effort rate may not increase
by more than $1.00 per patient day each year.
(vi) For county-owned facilities,
reimbursement for plant costs must continue to be based on interest expense and
depreciation allowance unless otherwise provided by law.
(d) Pharmaceutical
services from a licensed pharmacist of the individual's choice as prescribed by
a licensed physician or dentist and approved by the department. In an
emergency, but not routinely, the individual may receive pharmaceutical
services rendered personally by a licensed physician or dentist on the same
basis as approved for pharmacists.
(e) Other medical
and health services as authorized by the department.
(f) Psychiatric care
provided according to the guidelines established by the department to the
extent of appropriations made available by the legislature for the fiscal year.
(g) Screening,
laboratory services, diagnostic services, early intervention services, and
treatment for chronic kidney disease under guidelines established by the
department. A clinical laboratory performing a creatinine test on an eligible
individual under this subdivision must include in the lab report the glomerular
filtration rate (eGFR) of the individual and must report it as a percentage of
kidney function remaining.
(h) Medically
necessary acute medical detoxification for opioid use disorder, medically
necessary inpatient care at an approved facility, or care in an appropriately
licensed substance use disorder residential treatment facility.
(i) Mental health
screenings during the postpartum period as described in section 9137 of the
public health code, 1978 PA 368, MCL 333.9137.
(2) The director
must provide notice to the public, according to applicable federal regulations,
and must obtain the approval of the committees on appropriations of the house
of representatives and senate of the state legislature, of a proposed change in
the statewide method or level of reimbursement for a service, if the proposed
change is expected to increase or decrease payments for that service by 1% or
more during the 12 months after the effective date of the change.
(3) At the time of enrollment, a Medicaid managed care organization
shall make the following information available to an enrolled individual:
(a) Identity, location, qualifications, and availability of
participating providers.
(b) Enrollee rights and responsibilities.
(c) Grievance and appeal procedures.
(d) Covered items and services.
(4) (3) As
used in this act:
(a) "Medicaid managed care organization" means a Medicaid
contracted health plan.
(b) (a) "Title
XVIII" means title XVIII of the social security act, 42 USC 1395 to 1395lll.1395mmm.
(c) (b) "Title
XIX" means title XIX of the social security act, 42 USC 1396 to 1396w-7.1396w-9.
(d) (c) "Title
XX" means title XX of the social security act, 42 USC 1397 to 1397n-13.
Sec. 111i. (1) The commissioner director of
office the
department of insurance and financial and insurance services shall establish a timely
claims processing and payment procedure to be used by health professionals and
facilities in billing for, and qualified health plans in processing and paying
claims for, medicaid Medicaid services rendered. The commissioner director of the
department of insurance and financial services shall consult with the
department, of
community health, health professionals and facilities, and qualified
health plans in establishing this the timely payment procedure
established under this subsection.
(2) The timely
claims processing and payment procedure established by the commissioner director of
the department of insurance and financial services under subsection (1) shall must provide
for all of the following:
(a) That a
"clean claim", for the purposes of this section, means a claim that
does, at a minimum,
all of the following:
(i) Identifies the health professional or
health facility that provided treatment or service, including a matching
identifying number.
(ii) Identifies the patient and plan.
(iii) Lists the date and place of service.
(iv) Is for covered services.
(v) Is certified pursuant to under section
111b(17) and has the identifying information required under section 111b(21).
(vi) If necessary, substantiates the medical
necessity and appropriateness of the care or service provided.
(vii) If prior authorization is required for
certain patient care or services, includes any applicable authorization number,
as appropriate.
(viii) Includes additional documentation based upon on services
rendered as reasonably required by the payer.
(b) A universal
system of coding to be used on all medicaid Medicaid claims submitted to qualified health plans.
(c) That a claim
must be transmitted electronically or as otherwise specified by the
commissioner and a qualified health plan must be able to receive a claim
transmitted electronically.
(d) That a health
professional and facility must bill a qualified health plan within 1 year after
the date of service or date of discharge from the health facility.
(e) That after a
health professional or facility has submitted a claim to a qualified health
plan, the health professional or facility shall not resubmit the same claim to
the qualified health plan unless the time frame in subdivision (f) has passed
or as provided in subdivision (h).
(f) Except as
otherwise provided in this subdivision, that a clean claim must be paid within
45 days after receipt of the claim by the qualified health plan. For a
pharmaceutical clean claim, the clean claim must be paid within the industry
standard time frame for paying the claim as of the
effective date of this subdivision June 20,
2000, or within 45 days after receipt of the claim by the qualified
health plan, whichever is sooner. A clean claim that is not paid within this
time frame shall must
bear simple interest at a rate of 12% per annum.
(g) That a
qualified health plan must state in writing to the health professional or
facility any defect in the claim within 30 days after receipt of the claim.
(h) That a health
professional and a health facility have 30 days after receipt of a notice that
a claim or a portion of a claim is defective within which to correct the
defect. The qualified health plan shall pay the claim within 30 days after the
defect is corrected.
(i) That a
qualified health plan must notify the health professional or facility and the
commissioner of the defect if a claim or a portion of a claim is returned from
a health professional or facility under subdivision (h) and remains defective
for the original reason or a new reason.
(j) An external
review procedure for adverse determinations of payment as provided in
subsections (4) and (5). The costs for the external review procedure shall must be
assessed as determined by the commissioner.director of the department of insurance and financial
services.
(k) Penalties to be
applied to health professionals, health facilities, and qualified health plans
for failing to adhere to the timely claims processing and payment procedure
established under this section.
(l) A system for notifying the licensing
entity for health maintenance organizations, qualified health plans, and other
health care insurers if a penalty is incurred under subdivision (k).
(3) If a qualified
health plan determines that 1 or more covered services listed on a claim are
payable, the qualified health plan shall pay for those services and shall not
deny the entire claim because 1 or more other covered services listed on the
claim are defective or because 1 or more other services listed on the claim are
not covered services.
(4) The commissioner director of
the department of insurance and financial services shall establish an
external review procedure as provided in this subsection and subsection (5). A
health professional or facility may request an external review by the commissioner director of
the department of insurance and financial services of a qualified health
plan's adverse determination if the health professional or facility makes the
request not later than 30 days after receipt of a the notice required under
subsection (2)(i). Within 10 days after a request for an external review, the commissioner director of
the department of insurance and financial services shall complete a
preliminary review to determine whether the external review may proceed or
request more information from the health professional, facility, or the qualified health plan. The health
professional, facility, or the qualified
health plan shall supply the commissioner director of the department of insurance and financial
services with the requested information not later than 10 business days
after receipt of the request for information from the commissioner. director of
the department of insurance and financial services. Not later than 5
business days after receipt of any information requested by the commissioner, director of
the department of insurance and financial services, the commissioner director of
the department of insurance and financial services shall complete a
preliminary review to determine whether the external review may proceed. If the
commissioner director
of the department of insurance and financial services determines the
external review may not proceed, the commissioner director of the department of insurance and financial
services shall notify in writing the health professional or facility of
the specific reasons for the determination and may permit the health
professional or facility to reapply for a preliminary review by the
commissioner. If the commissioner determines the external review may proceed,
the commissioner shall notify in writing the health professional or facility
and the qualified health plan and shall require the qualified health plan to
provide, not later than 7 business days after receipt of the notice,
any information used by the qualified health plan in making the adverse
determination. Failure by a health professional,
or facility,
or qualified health plan to provide the commissioner
director of the department of insurance and
financial services with requested information permits the commissioner director of
the department of insurance and financial services to terminate a review
and issue a decision reversing or affirming an adverse determination.
(5) If the commissioner director of
the department of insurance and financial services determines that an
external review may proceed, the commissioner director of the department of insurance and financial
services shall immediately assign an independent review organization to
conduct the external review. Only an independent review organization meeting
qualifications established by the commissioner shall
director of the department of insurance and
financial services may be assigned to conduct an external review. The
independent review organization may request the health professional or facility
and the qualified health plan to provide information and shall review all
pertinent information submitted by the health professional or facility and the
qualified health plan along with the terms of coverage under the medicaid Medicaid plan.
The independent review organization shall make a written recommendation that
includes the rationale and supporting documentation and any recommendation for
an assessment of interest to the commissioner supporting documentation not later than 30 days after
being assigned as the review organization. The commissioner
director of the department of insurance and
financial services shall notify in writing the health professional or
facility and the qualified health plan of his or her
 the decision of
the director of the department of insurance and financial services reversing
or affirming the qualified health plan's adverse determination and shall include the principal reasons for the
decision not later than 15 days after receipt of the assigned independent
review organization's recommendation. If an adverse determination is reversed,
the qualified health plan shall immediately pay the claim and any interest
assessed by the commissioner. director of the department of insurance and financial
services.
(6) Beginning not
later than October 1, 2000 and continuing thereafter, the department of community health shall not enter into or renew
a contract with a qualified health plan unless the qualified health plan agrees
to follow the timely claims processing and payment procedure established under
this section and requires health professionals and facilities under contract
with the qualified health plan to follow the timely claims processing and
payment procedure established under this section. The department of community health shall not enter into or renew
a contract with a qualified health plan unless the commissioner
director of the department of insurance and
financial services determines that the qualified health plan satisfies
all of the following:
(a) Is a health
maintenance organization licensed or issued a certificate of authority in this
state.
(b) Uses
standardized claims as outlined in the provider contract and accepts claims
submitted electronically in a generally accepted format.
(c) Demonstrates
the ability to provide all required or covered medicaid
Medicaid services including covered
specialty care to the estimated number of enrollees on a regional basis.
(d) Meets the
criteria for delivering the comprehensive package of services under the department of community health's department's comprehensive health plan.
(7) The commissioner director of
the department of insurance and financial services shall report to the
senate and house of representatives appropriations subcommittees on community
health by October 1, 2001 on the timely claims processing and payment procedure
established under this section.
(8) It is not a
fraudulent act for a health professional or facility to submit a claim under
this section that includes 1 or more rendered services that are determined not to constitute covered services.
(9) Beginning January 1, 2027, a Medicaid managed care organization
shall ensure that 99% of clean claims from providers are adjudicated within 14
calendar days after receipt of the claims, and 100% are adjudicated within 30
calendar days after receipt of the claims, for covered services rendered to
covered individuals in skilled nursing facilities who are enrolled with the
Medicaid managed care organization at the time the service was delivered. A
clean claim that is not paid within 14 calendar days must bear a simple
interest payment of 12% per annum.
(10) A managed care plan shall initiate administrative action and
recover improper payments or overpayments related to claims paid by the managed
care plan within 6 months after the date the claim was paid or after the date
of any applicable reconciliation, whichever is later. Except for overpayments
identified under a credible allegation of fraud, the managed care plan shall
confer with the applicable state agency before pursuing overpayment recoveries
for claims where more than 6 months have passed since the claims were paid or
adjudicated. The managed care plan shall not subject these claims to repayment
or offset against future claim reimbursements without prior consent from the
applicable state agency. Any claim improperly recovered or offset will be
subject to penalties of up to $1,000.00 per claim.
(11) (9) As
used in this section:
(a)
"Medicaid" means the program of medical
assistance program established under section
105.
(b) "Medicaid managed care organization" means a Medicaid
contracted health plan.
(c) (b) "Qualified
health plan" means, at a minimum, an organization that meets the criteria
for delivering the comprehensive package of services under the department of community health's department's comprehensive health plan.
Sec. 111j. (1) If Except as otherwise
provided in section 111o, if the director requires prior authorization
for any medical services or equipment, a request by a provider for prior
authorization shall must be approved or rejected within 15 working days
after the request is received by the director. If additional information is
needed in support of the prior authorization request, the director shall
request additional information either verbally or in writing not later than 15
working days after receiving the prior authorization request. Upon On receiving
the additional information from the provider, the director shall approve or
deny the completed prior authorization request not later than 10 working days
after receiving the additional information. The time period limitations
specified in this subsection shall does not apply to prior authorization requests for
transplantation and other extraordinary services.
(2) Claims for
routine, ordinary medical services or equipment shall
must not be subject to prior
authorization, and claims for medical supplies shall
must not be subject to prior
authorization.
(3) The director,
by rule, shall do both of the following:
(a) Prescribe, by
category, what information is required from a provider to support a request for
prior authorization.
(b) Prescribe which
medical services or equipment are subject to prior authorization and list, by
category, those medical services or equipment.
(4) The director
shall establish a reimbursement system for medical services or equipment
receiving prior authorization based upon on reasonable cost up to a maximum reimbursement
screen of acquiring the medical service or equipment, and shall develop an automated payment system,
including at least fee screens and necessary edits. The state department shall
make vendor payments through the automated payment system.
(5) The director
shall waive the requirement for prior authorization if both of the following
conditions exist:
(a) Processing a
request for prior authorization will cause an inpatient hospital stay to be
prolonged.
(b) The cost of the
medical services or equipment is less than the estimated cost of the additional
inpatient hospital stay.
(6) The director,
not later than 180 days after the effective date of
this section, March 30, 1989, shall
maintain and implement automated records of all approved prior authorization
requests according to each medical services recipient involved.
(7) This section
does not authorize the provision of any medical services, supplies, or
equipment that are not otherwise designated to be covered services, supplies,
or equipment under this act.
(8) As used in this
section: ,
"prior authorization" means a requirement imposed by the director, by
which any claim for a particular covered medical service or equipment is
payable only if the director's approval for the provision of that service or
equipment is given before the service or equipment is furnished.
(a) (9) As used in this section, "by category" "By
category" means
using a categorization system containing at least each of the following
categories:
(i) (a) Communication aids.
(ii) (b) Hearing aids.
(iii) (c) Incontinence supplies.
(iv) (d) Orthotic devices.
(v) (e) Ostomy supplies.
(vi) (f) Prosthetic devices.
(vii) (g) Respiratory equipment.
(viii) (h) Seating systems.
(ix) (i) Visual aids.
(x) (j) Wheelchairs and mobility aids.
(b) "Prior authorization" means a requirement imposed by the
director, by which any claim for a particular covered medical service or
equipment is payable only if the director's approval for the provision of that
service or equipment is given before the service or equipment is furnished.
Sec. 111o. (1) A
Medicaid managed care organization shall provide a standard prior authorization
decision for a nursing facility within 7 calendar days of submission and an
expedited prior authorization decision within 72 hours of submission.
(2) A Medicaid managed care organization shall provide specific
information about prior authorization denials, regardless of how the prior
authorization request is submitted.
(3) A prior authorization request that is not authorized within the time
frames specified in subsections (1) and (2) must be considered approved.
(4) Beginning not later than January 1, 2027, each Medicaid managed care
organization shall submit to the department quarterly data on all of the
following, disaggregated by provider type, for skilled nursing facilities:
(a) Prior authorization activity, including information regarding all of
the following:
(i) Total number of
prior authorization requests received.
(ii) Number of
requests approved.
(iii) Number of
requests denied.
(iv) Number of
denied requests that were appealed.
(v) Outcome of
appealed decisions, including the number reversed in whole or in part.
(b) Concurrent review activity, including information regarding all of
the following:
(i) Total number of
concurrent review requests received.
(ii) Frequency of
concurrent review requests by service type and provider type.
(iii) Number of
concurrent review requests approved in full.
(iv) Number of
concurrent review requests denied in whole or in part.
(v) Number of
denied requests that were appealed by the enrollee or provider.
(vi) Outcome of
appealed decisions, including the number of denials reversed in full, in part,
or upheld.
(c) Postservice payment activity, including information regarding all of
the following:
(i) Number of
claims denied after services were rendered.
(ii) Number of
denials under subparagraph (i) that involved
services previously authorized or approved.
(iii) Number and
outcome of provider or enrollee appeals related to postservice denials.
(d) Timeliness and delay metrics, including information regarding all of
the following:
(i) Average and
median time to decision for initial prior authorization requests.
(ii) Number and
percentage of delayed authorizations that exceeded the Centers for Medicare and
Medicaid Services timeliness standards. All metrics under this subparagraph must
be reported separately for each provider type in a manner enabling comparative
analysis across provider categories.
(5) The department shall make the data submitted under subsection (4)
available to the public on its website in a format that comports with all of
the following:
(a) Enables beneficiaries and providers to compare plans by prior
authorization and denial metrics.
(b) Disaggregates data by provider type, service category, and
geographic region where feasible.
(c) Protects personally identifiable information and proprietary trade
secrets.
(d) Is searchable, downloadable, and updated at least quarterly.
(6) The department shall develop and publish a consumer-facing summary
for each Medicaid managed care organization that includes all of the following
information:
(a) Overall denial rate for prior authorization requests.
(b) Percentage of denials overturned on appeal.
(c) Percentage of postservice payment denials.
(d) Timeliness of decisions.
(e) Any relevant compliance actions or corrective action plans imposed
on the plan by the Centers for Medicare and Medicaid Services relating to
utilization management practices.
(f) Clear indicators showing how the plan performs across different
provider types.
(7) As used in this section:
(a) "Appeal" includes all levels of reconsideration or
review initiated by the beneficiary or provider, including external review
entities.
(b) "Concurrent review" means a utilization management process
conducted by a Medicaid managed care organization or any of its delegated
entities during the course of an enrollee's ongoing receipt of healthcare
services, for the purpose of determining the continued medical necessity,
appropriateness, or level of care of such services in real time or near real
time.
(c) "Medicaid managed care organization" means a Medicaid
contracted health plan.
(d) "Payment denial" means a refusal to pay, in whole or in
part, for services rendered by a provider, regardless of prior authorization
status.
(e) "Prior authorization" means any requirement imposed by a
managed care plan for approval of coverage before a service or item is
furnished to a beneficiary.
(f) "Provider type" means the category of provider furnishing
services, as defined by the Centers for Medicare and Medicaid Services,
including hospitals, skilled nursing facilities, home health agencies, hospice
providers, physicians, and other entities.
Sec. 111p. (1) A Medicaid
managed care organization shall ensure that nursing facilities and long-term
supports and services providers are paid no less than the current Medicaid fee-for-service
rate.
(2) Quality assurance supplement payments must be paid monthly.
Sec. 111q. (1) A Medicaid
managed care organization must always be ready and willing to enter into health
care provider service contracts with a qualified health care provider of the
category or categories that are necessary to provide the health care services
covered by the Medicaid managed care organization if the health care provider
meets all of the following requirements:
(a) Is licensed in this state.
(b) Desires to become a participant health care provider of the Medicaid
managed care organization.
(c) Meets the requirements of the Medicaid managed care organization.
(d) Practices within the general area served by the Medicaid managed
care organization.
(2) This section does not preclude a Medicaid managed care organization
from refusing to contract with a health care provider who is unqualified or
does not meet the terms and conditions of the Medicaid managed care organization's
participating provider contract, or from terminating or refusing to renew the
contract of a health care provider who is unqualified or does not comply with,
or refuses to comply with, the terms and conditions of the participating health
care provider contract, including, but not limited to, practice standards and
quality requirements. The contract must provide for written notice to the
participating health care provider detailing any breach of contract for which
the Medicaid managed care organization proposes that the contract be terminated
or not renewed and provide for a reasonable period of time for the
participating health care provider to cure the breach before termination or
nonrenewal. If the breach has not been cured within that time, the contract may
be terminated or not renewed. Notwithstanding this subsection, if the breach of
contract for which the Medicaid managed care organization proposes that the
contract be terminated or not renewed is a willful breach, fraud, or a breach that
poses an immediate danger to public health or safety, the contract may be
terminated or not renewed immediately.
(3) A Medicaid managed care organization must establish a grievance procedure
for health care providers that provides for arbitration or other grievance
procedures that provide for reasonable due process protections for the
resolution of grievances and the protection of the rights of the parties.
(4) A Medicaid managed care organization may not require, as an element
of any health care provider contract, that the health care provider agree to do
any of the following:
(a) Deny an eligible individual access to services not covered by the Medicaid
managed care plan if the eligible individual is informed that the eligible
individual will be responsible to pay for the noncovered services and the
member nonetheless desires to obtain the services.
(b) Refrain from treating an eligible individual, at the eligible
individual's request and expense, if the health care provider has been, but is
no longer, a contracting health care provider under the Medicaid managed care
plan and the health care provider has notified the eligible individual that the
health care provider is no longer a contracting health care provider under the Medicaid
managed care plan.
(c) Renegotiate adjustment by the Medicaid managed care organization of
the heath care provider's contractual reimbursement rate to equal the lowest
reimbursement rate the health care provider has agreed to charge any other
payor.
(d) Adjust or enter into negotiations to adjust the health care
provider's charges to the Medicaid managed care organization if the health care
provider agrees to charge another payor lower rates.
(e) Disclose the health care provider's contractual reimbursement rates
from other payors.
(5) A Medicaid managed care organization shall not refuse to contract
with or compensate for covered services an otherwise eligible health care provider
or nonparticipating health care provider solely because the provider has in
good faith communicated with 1 or more current, former, or prospective patients
regarding the provisions, terms, or requirements of the Medicaid managed care
organization's products as they relate to the needs of the provider's patients.
(6) As part of a health care provider contract, a Medicaid managed care
organization may require a health care provider to indemnify and hold harmless
the Medicaid managed care organization under certain circumstances if the Medicaid
managed care organization also agrees to indemnify and hold harmless the health
care provider under comparable circumstances.
(7) On request and within a reasonable time, a Medicaid managed care
organization shall make available to any party to a health care provider
contract any documents referred to or adopted by reference in the contract
except for information that is proprietary, a trade secret, or a confidential
personnel record.
(8) A Medicaid managed care organization shall permit a contracting heath
care provider who is practicing in conformity with community standards to
advocate for the health care provider's patient without being subject to
termination or penalty for the sole reason of the advocacy.
(9) Subsections (1) and (2) apply to heath care provider participation
contracts entered into beginning January 1, 2027.