HB 6288

HOUSE BILL NO. 6288
A bill to amend 1939 PA 280, entitled
"The social welfare act,"
by amending section 105d (MCL 400.105d), as amended by
2023 PA 98, and by adding section 105k.
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 require a contracted health plan to spend not less than 12% of
its overall annual health care spending on primary care spending over the
course of 8 years after the effective date of the amendatory act that added
section 105k. 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.
(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. 105k. (1) By
April 1, 2027 and by April 1 of each year thereafter, a contracted health plan
shall submit a report to the department, in the form and manner prescribed by
the department, that includes all of the following information:
(a) The percentage of the contracted health plan's overall annual health
care spending for the immediately preceding calendar year that constituted
primary care spending.
(b) If the
percentage reported under subdivision (a) is less than 12%, 1 of the following:
(i) A plan to increase primary care spending as a percentage
of overall annual health care spending by at least 1% per year.
(ii) If the contracted health plan previously submitted a plan
described in subparagraph (i), both of the following:
(A) Any
modifications to that plan.
(B) A
description of the steps taken to date to increase the contracted health plan's
proportion of primary care spending.
(2) The department
may promulgate rules to implement this section pursuant to the administrative
procedures act of 1969, 1969 PA 306, MCL 24.201 to 24.328.
(3) As used
in this section, "primary care spending" means spending on a
professional service billed by a physician practicing primary care, including,
but not limited to, spending on a professional claim, an evaluation and
management visit, a preventative visit, care transition or coordination of
services, and an in-office preventative service, screening, or counseling, and is
calculated annually in the Medical Expenditure Panel Survey by the Department
of Health and Human Services Agency for Healthcare Research and Quality.