Updates to Michigan’s External Review and Internal Grievance Process
On July 1, 2016, Michigan chaptered HB 4933 – 4935 which makes several important changes to the state’s internal grievance and external review processes. The bills have been assigned Public Act No. 276 with immediate effect. The bill will become law on July 13, 2016.
H.B. 4933 makes changes to Michigan’s Patient’s Right to Independent Review Act.
H.B. 4935 makes changes to the Insurance Code.
The following, taken from the Michigan Legislature’s website, are the changes to Michigan’s Patient’s Right to Independent Review Act:
- Provide that a person who requested an expedited external review due to a life- or health-threatening medical condition would be considered to have exhausted the health carrier’s internal grievance process;
- Require a health carrier to notify a covered person that the carrier could waive its internal grievance process and the requirement for a covered person to exhaust that process before filing a request for an external review or an expedited external review; and that a covered person would be considered to have exhausted the internal grievance process if the carrier failed to comply with the requirements of that process, unless the failure were minor and did not prejudice or harm the covered person;
- Require notices required under the Act to conform to Federal regulations.
- After December 31, 2016, extend the time period in which a covered person may file a request for an external review from 60 days to 120 days following an adverse or final adverse determination.
- Require the Director of the Department of Insurance and Financial Services (DIFS), within five days after receiving an external review request involving an experimental or investigational health service or treatment, to conduct a preliminary review to determine if the request met criteria prescribed in the bill.
- Require a covered person who submitted an incomplete request for external review to provide the information or materials needed to complete the request within 30 days after receiving notice from the DIFS Director.
- Require the reviewing entity, in making its recommendation regarding an external or expedited external review involving experimental or investigational service or treatment, to consider whether the service or treatment was approved by the U.S. Food and Drug Administration (FDA) and whether it was appropriate based on medical or scientific evidence or evidence-based standards.
- Require an independent review organization to be accredited by a nationally recognized accrediting organization in order to be approved to conduct external reviews under the Act.
- Include a nonprofit dental care corporation in the definition of “health carrier”.
The following are the changes made to the Insurance Code. Note that this is not a comprehensive list of the changes made by the bill, but rather are the changes that pertain to the subject matter covered by RegQuest.
- Include a health maintenance organization (HMO) in the Code’s general definition of “insurer”
- Revise the deadline by which an insurer must make a final determination in response to an insured’s or enrollee’s submission of an internal formal grievance.
Now, a final determination must be made in writing by the insurer not later than 30 calendar days after a formal preservice grievance is submitted or 60 calendar days after a formal postservice grievance is submitted in writing by the insured or enrollee. Previously, an insurer had 35 calendar days.
A preservice grievance is defined as a grievance relating to services for which the insurer conditions receipt of the services, in whole or in part, on approval of the services in advance of receiving the service.
A postservice grievance is defined as a grievance relating to services that have already been received by the insured or enrollee.
The bill also changes the definition of “adverse determination” to include any of the following:
- A determination by an insurer or its designee utilization review organization that a request for a benefit, on application of any utilization review technique, does not meet the insurer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced or terminated or payment is not provided or made, in whole or in part, for the benefit;
- The denial, reduction, termination, or failure to provide or make payment, in whole or in part, for a benefit based on a determination by an insurer or its designee utilization review organization of a covered person’s eligibility for coverage from the insurer;
- A prospective review or retrospective review determination that denies, reduces, or terminates or fails to provide or make payment, in whole or in part, for a benefit;
- A rescission of coverage determination;
- Failure to respond in a timely manner to a request for a determination.
Additionally, a written notice required to be given under the amended sections of code must now be provided in a culturally and linguistically appropriate manner, as required under 45 CFR 147.136(B)(2)(II)(E).
Please be sure to review the bills and consult with the Department of Insurance with any additional questions.
The views expressed in this post do not necessarily reflect the official policy, position, or opinions of RegQuest. This update is provided for informational purposes. Please consult with an attorney regarding any legal matters discussed herein and/or a clinical expert regarding any health-related matters.