Michigan Compiled Laws 218-1956-35 Chapter 35 Health Maintenance Organizations (500.3501...500.3580)

• Section 500.3501 Definitions.
  As used in this chapter: (a) “Affiliated provider” means a health professional, licensed hospital, licensed pharmacy, or any other institution, organization, or person having...
• Section 500.3503 Applicability Of Provisions To Health Maintenance Organization.
  (1) All of the provisions of this act that apply to a domestic insurer authorized to issue an expense-incurred hospital, medical, or surgical policy...
• Section 500.3505 Certificate Of Authority; Use Of Descriptive Words; Restrictions.
  (1) A health maintenance organization shall receive a certificate of authority under this chapter before issuing health maintenance contracts. A health maintenance organization license...
• Section 500.3507 Authorizing And Regulating Health Maintenance Organization; Establishment Of System By Commissioner.
  The commissioner shall establish a system of authorizing and regulating health maintenance organizations in this state to protect and promote the public health through...
• Section 500.3508 Quality Assessment Program; Quality Improvement Program.
  (1) A health maintenance organization shall develop and maintain a quality assessment program to assess the quality of health care provided to enrollees that...
• Section 500.3509 Certificate Of Authority; Application; Form; Limitation; Change Of Service Area.
  (1) An application to the commissioner for a certificate of authority shall be on a form prescribed and provided by the commissioner. (2) A...
• Section 500.3511 Governing Body; Election Of Enrollee Board Members; Terms; Vacancy; Meetings.
  (1) By the end of the first 12 months of operation, a health maintenance organization's governing body shall have a minimum of 1/3 of...
• Section 500.3513 Health Delivery And Business And Financial Operations; Regulation By Commissioner.
  (1) The commissioner shall regulate health delivery aspects of health maintenance organization operations for the purpose of assuring that health maintenance organizations are capable...
• Section 500.3515 Additional Health Maintenance Services; Copayments; Limitation; Report On Increase Of Employer And Employee Numbers; "Preventive Health Care Services" Defined; Partial Payment From Government Or Private Person.
  (1) A health maintenance organization may provide additional health maintenance services or any other related health care service or treatment not required under this...
• Section 500.3517 Healthy Lifestyle Programs; Emergency Or Out-of-area Service; Payment Of Expenses Or Fees.
  (1) A health maintenance contract shall not provide for payment of cash or other material benefit to an enrollee, except as stated in this...
• Section 500.3519 Contract And Contract Rates; Fairness; Rate Differential; Basic Health Services Required.
  (1) A health maintenance organization contract and the contract's rates, including any deductibles, copayments, and coinsurances, between the organization and its subscribers shall be...
• Section 500.3521 Prepayment Rates; Filing And Approval Of Methodology; Schedule.
  (1) The methodology used to determine prepayment rates by category rates charged by the health maintenance organization and any changes to either the methodology...
• Section 500.3523 Health Maintenance Contract; Provisions.
  (1) A health maintenance contract shall be filed with and approved by the commissioner. (2) A health maintenance contract shall include any approved riders,...
• Section 500.3525 Proposal To Revise Contract Or Rate; Approval Of Commissioner; Approval With Modifications; Hearing; Disposition; Exception; Notice.
  (1) Except as otherwise provided in subsection (2), if a health maintenance organization desires to change a contract it offers to enrollees or desires...
• Section 500.3527 Health Maintenance Contract; Performance; Violation Of Terms.
  (1) Upon obtaining a certificate of authority, a health maintenance organization may enter into health maintenance contracts and engage in other activities consistent with...
• Section 500.3528 Health Maintenance Organization; Duties.
  (1) A health maintenance organization shall do all of the following: (a) Establish written policies and procedures for credentialing verification of all health professionals...
• Section 500.3529 Affiliated Provider Contracts; Collection Of Payments From Enrollees; Contract Provisions; Waiver Of Requirement Under Subsection (2); Contract Format; Evidence Of Sufficient Number Of Providers.
  (1) A health maintenance organization may contract with or employ health professionals on the basis of cost, quality, availability of services to the membership,...
• Section 500.3530 Availability Of Covered Services; Assurance; Establishment And Maintenance Of Proximity.
  (1) A health maintenance organization shall maintain contracts with those numbers and those types of affiliated providers that are sufficient to assure that covered...
• Section 500.3531 Contracts With Health Care Providers To Become Affiliated Providers; Requirements; Standards; Filing; Duplicative Standards; Notice Procedures; Provider Application Period; Approval Or Rejection As Affiliated Provider; Termination Of Contract; Providing Information To Insurer.
  (1) This section applies if a health maintenance organization contracts with health care providers to become affiliated providers or offers a prudent purchaser contract....
• Section 500.3533 Prudent Purchaser Contracts; Reimbursement For Unauthorized Services Or Services By Nonaffiliated Providers; Rate And Operating Requirements; Maintenance Of Financial Records By Health Maintenance Organization.
  (1) A health maintenance organization may offer prudent purchaser contracts to groups or individuals and in conjunction with those contracts a health maintenance organization...
• Section 500.3535 Solicitation Or Advertising.
  Solicitation of enrollees or advertising of the services, charges, or other nonprofessional aspects of the health maintenance organization's operation under this section shall not...
• Section 500.3537 Open Enrollment Period; Acceptance Of Group Members; Rating Nongroup Membership.
  (1) After the initial 24 months of operation, a health maintenance organization shall have an open enrollment period of not less than 30 days...
• Section 500.3539 Nongroup Contract; Exclusion Or Limitation; Preexisting Condition; Renewal Or Continuation Of Nongroup Contract Or Group Contract; Guaranteed Renewal; Healthy Lifestyle Program; "Group" Defined.
  (1) For an individual covered under a nongroup contract or under a contract not covered under subsection (2), a health maintenance organization may exclude...
• Section 500.3541 Advocation By Health Professional.
  A health maintenance organization shall not prohibit or discourage a health professional from advocating on behalf of an enrollee for appropriate medical treatment options...
• Section 500.3542 Inducement To Health Professional Prohibited; Exception.
  (1) A health maintenance organization shall not use any financial incentive or make any payment to a health professional that acts directly or indirectly...
• Section 500.3543 Third Party Administrator.
  (1) With the commissioner's approval, a health maintenance organization may own or invest in a third party administrator. The commissioner shall grant approval upon...
• Section 500.3545 Acquisition Of Obligations From Another Managed Care Entity.
  With the commissioner's prior approval, a health maintenance organization may acquire obligations from another managed care entity. The commissioner shall not grant prior approval...
• Section 500.3547 Health Care Service Operations; Visitation Or Examination By Commissioner; Consultation With Enrollees; Additional Authority.
  (1) The commissioner at any time may visit or examine the health care service operations of a health maintenance organization and consult with enrollees...
• Section 500.3548 Maintenance Of Books, Records, And Files; Funds And Assets.
  (1) A health maintenance organization shall keep all of its books, records, and files at or under the control of its principal place of...
• Section 500.3549 Disciplinary Action; Notice To Board.
  A health maintenance organization shall notify the appropriate board as to any disciplinary action taken by the health maintenance organization for any of the...
• Section 500.3551 Health Maintenance Organization; Net Worth.
  (1) A health maintenance organization's minimum net worth shall be determined using accounting procedures approved by the commissioner that ensure that a health maintenance...
• Section 500.3553 Minimum Deposit Requirements.
  (1) Minimum deposit requirements for a health maintenance organization shall be determined as provided under this section and using accounting procedures approved by the...
• Section 500.3555 Financial Plan.
  A health maintenance organization shall maintain a financial plan evaluating, at a minimum, cash flow needs and adequacy of working capital. The plan shall...
• Section 500.3557 Notice Of Changes In Operations.
  A health maintenance organization shall file notice with the commissioner of any substantive changes in operations no later than 30 days after the substantive...
• Section 500.3559 Reinsurance Contract Or Plan; Purpose; Filing; Approval; Coverage.
  (1) Subject to subsection (2), a health maintenance organization shall obtain a reinsurance contract or establish a plan of self-insurance as may be necessary...
• Section 500.3561 Insolvency; Continuation Of Benefits.
  A health maintenance organization shall have a plan for handling insolvency that allows for continuation of benefits for the duration of the contract period...
• Section 500.3563 Insolvency; Allocation Of Group Coverage To Health Maintenance Organizations And Insurers Participating In Enrollment Process; Allocation Of Group Coverage To Health Maintenance Organizations Or Insurers Within Service Area; Nongroup Coverage; Reassignment Of Enrollees Of Insolvent Organization Contracting With State Funded Health Care Program.
  (1) If a health maintenance organization becomes insolvent, upon the commissioner's order all other health maintenance organizations and health insurers that participated in the...
• Section 500.3565 Cancellation Of Contract By Nongroup Subscriber.
  (1) A nongroup subscriber, in addition to other rights available to revoke an offer, may cancel a health maintenance contract within 72 hours after...
• Section 500.3567 Cancellation Of Contract With Nongroup Enrollee By Health Maintenance Organization.
  (1) A health maintenance contract shall clearly delineate all conditions under which the health maintenance organization may cancel coverage for an enrollee. (2) A...
• Section 500.3569 Assumption Of Financial Risk; “requiring An Affiliated Provider To Assume Financial Risk” Defined.
  (1) Except as provided in section 3515(2), a health maintenance organization shall assume full financial risk on a prospective basis for the provision of...
• Section 500.3571 State And Federal Health Programs.
  A health maintenance organization is not precluded from meeting the requirements of, receiving money from, and enrolling beneficiaries or recipients of state and federal...
• Section 500.3573 Operation Of Health Care Delivery System Not Meeting Requirements Of Act; Permitted Conduct; Limitations.
  A person proposing to operate a system of health care delivery and financing that is to be offered to individuals, whether or not as...
• Section 500.3580 Consumer Guide To Health Maintenance Organizations; Publication; Contents; Data; Writing, Presentation, Promotion, And Distribution Of Guide; Access Through Internet.
  (1) The commissioner shall prepare and beginning January 1, 2001 and annually thereafter publish a consumer guide to health maintenance organizations as provided in...

Last modified: October 10, 2016