HB-4714, As Passed House, June 13, 2013

SUBSTITUTE FOR

HOUSE BILL NO. 4714

A bill to amend 1939 PA 280, entitled

"The social welfare act,"

by amending sections 105, 105a, 106, 107, 108, and 109c (MCL

400.105, 400.105a, 400.106, 400.107, 400.108, and 400.109c),

section 105 as amended by 1980 PA 321, section 105a as added by

1988 PA 438, sections 106 and 107 as amended by 2006 PA 144, and

section 109c as amended by 1994 PA 302, and by adding sections 105c

and 105d.

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

Sec. 105. (1) The ~~state~~ department of community health shall

establish a program for medical assistance for the medically

indigent under title XIX. The director of the ~~state~~ department of

community health shall administer the program established by the

~~state~~ department of community health and shall be responsible for

determining eligibility under this act. Except as otherwise

provided in this act, the director may delegate the authority to

perform a function necessary or appropriate for the proper

administration of the program.

(2) As used in this section and sections 106 to 112, "peer

review advisory committee" means an entity comprising professionals

and experts who are selected by the director and nominated by an

organization or association or organizations or associations

representing a class of providers.

(3) As used in sections 106 to 112, "professionally accepted

standards" means those standards developed by peer review advisory

committees and professionals and experts with whom the director is

required to consult.

(4) As used in this section and sections 106 to 112,

"provider" means an individual, sole proprietorship, partnership,

association, corporation, institution, agency, or other legal

entity, who has entered into an agreement of enrollment specified

by the director ~~pursuant to~~ under section ~~111b(1)(c).~~111b(4).

Sec. 105a. (1) The department of community health shall

develop written information that sets forth the eligibility

requirements for participation in the program of medical assistance

administered under this act. The written information shall be

updated not less than every 2 years.

(2) The department of community health shall provide copies of

the written information described in subsection (1) to all of the

following persons, agencies, and health facilities:

(a) A person applying to the department of community health

for participation in the program of medical assistance administered

under this act who is considering institutionalization for the

person or person's family member in a nursing home or home for the

aged.

(b) Each nursing home in the state.

(d) Each adult foster care facility in the state.

(e) Each area agency on aging.

(f) The office of services to the aging.

(g) Local health departments.

(h) Community mental health boards.

(i) Medicaid and medicare certified home health agencies.

(j) County medical care facilities.

(k) Appropriate department of ~~social services~~ community health

personnel.

(l) Any other person, agency, or health facility determined to

be appropriate by the department of community health.

Sec. 105c. The department of community health shall provide a

process by which individuals may apply for or renew medical

assistance eligibility through in-person assistance, by telephone,

or on a website from which the department of community health shall

enroll individuals who are eligible for the medical assistance

program or the MIChild program without regard to the program for

which the individual applied. This section does not apply if either

of the following occurs:

(a) If the department of community health is unable to obtain

House Bill No. 4714 (H-3) as amended June 13, 2013

a federal waiver as provided in section 105d.

[(B) IF FEDERAL GOVERNMENT MATCHING FUNDS FOR THE PROGRAM

DESCRIBED IN SECTION 105D ARE REDUCED BELOW 100% AND ANNUAL STATE

SAVINGS AND OTHER SAVINGS ASSOCIATED WITH THE IMPLEMENTATION OF THAT

PROGRAM ARE NOT SUFFICIENT TO COVER THE REDUCED FEDERAL MATCH. THE

DEPARTMENT OF COMMUNITY HEALTH SHALL DETERMINE HOW ANNUAL STATE SAVINGS

AND OTHER SAVINGS WILL BE CALCULATED BY JUNE 1, 2014.]

Sec. 105d. (1) The department of community health shall seek a

waiver from the United States department of health and human

services to do, and upon approval of the waiver 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 that provides for an account into which money from any source,

including, but not limited to, the enrollee, the enrollee's

employer, and private or public entities on the enrollee's behalf,

can be deposited to pay for incurred health expenses.

(b) Give enrollees described in subdivision (a) a choice in

choosing a contracted health plan.

have access to a primary care physician and to preventive services.

(d) Require enrollees described in subdivision (a) with annual

incomes between 100% to 133% of the federal poverty guidelines to

contribute not more than 5% of income for cost-sharing

requirements. Contributions required in this subdivision do not

apply for the first 6 months an individual described in subdivision

(a) is enrolled. Required contributions to an account used to pay

for incurred health expenses can be reduced to 0% if healthy

behaviors are met. Co-pays cannot be reduced to less than 2% of

income. Contributions may be reduced by the contracted health plan

based on the enrollee's attaining specific goals to improve or

maintain healthy behaviors that include, but are not limited to,

completing a department of community health-approved annual health

risk assessment to identify unhealthy characteristics, including

alcohol and tobacco use, obesity, and immunization status. If the

enrollee described in subdivision (a) becomes ineligible for

medical assistance under the program described in this section, any

contribution made on his or her behalf into the account described

in subdivision (a) shall be returned to that enrollee in the form

of a voucher to purchase private insurance.

(e) During the enrollment process, inform enrollees described

in subdivision (a) about advance directives and require the

enrollees to complete a department of community health-approved

advance directive on a form that includes an option to decline.

(f) Develop incentives for enrollees who assist the department

of community health in detecting fraud and abuse in the medical

assistance program.

(g) Allow for services provided through telemedicine.

(2) Any hospital that participates in the medical assistance

program under this act shall discount charges to uninsured

individuals who have an annual income level under 133% of the

federal poverty guidelines to 115% of rates paid by medicare.

House Bill No. 4714 (H-3) as amended June 13, 2013

(3) Not more than 7 calendar days after receiving a waiver

from the United States department of health and human services to

implement the provisions of this section, the department of

community health shall submit a written copy of the approved waiver

provisions to the senate majority leader, the speaker of the house

of representatives, and the senate and house standing committees on

matters of health for review.

[(4) The department of community health shall develop and implement

a plan to enroll all fee-for-service enrollees into contracted health

plans if allowable by law and if the medical assistance program is the

primary payer. This includes all newly eligible enrollees as described

in subsection (1)(a). The department of community health is directed to include contracted health plans as the mandatory delivery system in its waiver request. The department of community health also shall pursue any and all necessary waivers to enroll persons eligible for both medicaid and medicare into managed care beginning july 1, 2014. By september 30, 2015, the department of community health shall identify all remaining populations eligible for managed care and develop plans for their integration into managed care.]

(5) By September 30, 2016, the department of community health

shall implement a pharmaceutical benefit that utilizes co-pays at

appropriate levels allowable by the centers for medicare and

medicaid services to encourage the use of high-value, low-cost

prescriptions, such as generic prescriptions and 90-day

prescription supplies, as recommended by the enrollee's physician.

(6) The department of community health shall work with

providers, contracted health plans, and other departments as

necessary to create processes that reduce the amount of uncollected

co-pays and deductibles for the program described in this section

and reduce the administrative cost of collecting those co-pays and

deductibles.

(7) The program described in this section shall include

information regarding the impact on the health status of the

covered population of enrollees described in subsection (1)(a)

including a targeted assessment related to employability and shall

promote employment-related services and job training available to

lower the medical assistance program caseloads by assisting able-

bodied adult medical assistance recipients who are unemployed into

the workforce. "Able-bodied adult medical assistance recipients"

means adults aged 21 to under 65 who are not included in the

provisions of 42 CFR 440.315.

(8) The program described in this section is created to extend

health coverage to this state's low-income citizens and to provide

health insurance cost relief to individuals and to the business

community by reducing the cost shift of uncompensated care. To that

end, the department of community health shall examine the financial

reports of hospitals and evaluate the impact that providing medical

coverage to the expanded population of enrollees described in

subsection (1)(a) has had on uncompensated care. By December 31,

2014, the department of community health shall make an initial

baseline report to the legislature regarding uncompensated care and

each December 31 after that shall make a report regarding the

evidence of the reduction in uncompensated care compared to the

initial baseline report. Based on the evidence of the reduction in

uncompensated care borne by the hospitals in this state, beginning

April 1, 2015, the department of community health shall

proportionately reduce the disproportionate share payments to

hospitals for the purpose of producing general fund savings. The

department of community health shall recognize any savings from

this reduction by September 30, 2016. All the reports required

under this subsection shall be made available to the legislature

and shall be made available and easily accessible on the department

of community health's and the legislature's websites.

(9) The department of insurance and financial services shall

examine the financial reports of health insurers and evaluate the

impact that providing medical coverage to the expanded population

of enrollees described in subsection (1)(a) has had on rates. The

department of insurance and financial services shall consider the

evaluation described in this subsection in the annual approval of

rates. By December 31, 2014, the department of insurance and

financial services shall make an initial baseline report to the

legislature regarding rates and each December 31 after that shall

make a report regarding the evidence of the reduction in rates

compared to the initial baseline report. All the reports required

under this subsection shall be made available to the legislature

and shall be made available and easily accessible on the department

of community health's and the legislature's websites.

(10) The department of community health shall explore and

develop a range of innovations and initiatives to improve the

effectiveness and performance of the medical assistance program and

to lower overall health care costs in this state. The department of

community health shall report the results of the efforts described

in this subsection to the chairs of the house and senate

appropriation subcommittees on department of community health

matters and to the house and senate fiscal agencies by September

30, 2015. The report required under this subsection shall also be

made available and easily accessible on the department of community

health's and the legislature's websites. The department of

community health shall pursue a broad range of innovations and

initiatives as time and resources allow. However, these innovations

and initiatives shall include, at a minimum, all of the following:

(a) The value and cost-effectiveness of optional medicaid

benefits as described in federal statute.

(b) The identification of private sector, primarily small

business, benefit differences compared to the medical assistance

program services and justification for the differences.

measure the medical assistance program's return on investment for

taxpayers.

(d) Review and evaluation of the effectiveness of current

incentives for contracted health plans, providers, and

beneficiaries with recommendations for expanding and refining

incentives to accelerate improvement in health outcomes, healthy

behaviors, and cost-effectiveness.

(e) Review and evaluation of the current design principles

that serve as the foundation for the state's medical assistance

program.

(11) By January 1, 2014, the department of community health

and the contracted health plans in collaboration with providers

shall create financial incentives for all of the following:

(a) Contracted health plans that meet specified population

improvement goals.

(b) Providers who meet specified quality and cost targets.

maintain healthy behaviors as identified in a health risk

assessment as identified by their primary care practitioner.

(12) The department of community health shall ensure that all

capitated payments made to contracted health plans are actuarially

sound.

(13) The department of community health shall maintain

administrative costs at a level of not more than 1% of the

department of community health's portion of the state medical

assistance program. These administrative costs shall be capped at

the total administrative costs for the fiscal year ending September

30, 2016, except for inflation and project-related costs required

to achieve medical assistance savings.

(14) The department of community health shall require

contracted health plans to have procedures and compliance metrics

for contribution payments to ensure that contribution requirements

are being met.

(15) The department of community health shall measure

contracted health plan performance on application of standards of

care as that relates to appropriate treatment of substance abuse.

(16) If a waiver requested under this section is not approved

by the United States department of health and human services by

December 31, 2015, medical coverage for individuals described in

subsection (1)(a) shall no longer be provided. If the waiver is not

approved by December 31, 2015, then by January 31, 2016, the

department of community health shall notify enrollees that the

program described in subsection (1) shall be terminated on April

30, 2016. Individuals who are eligible under 42 CFR 440.315 are not

subject to the provisions of the waiver. The waiver must allow

individuals who have had medical assistance coverage for 48

cumulative months beginning on the date of their enrollment under

subsection (1)(a) and who are between 100% to 133% of the federal

poverty guidelines to choose to do either of the following:

(a) Purchase private insurance coverage through an exchange

operated in this state and be considered eligible for federal

subsidies by the federal government.

(b) Remain in the medical assistance program but increase

cost-sharing requirements up to 7% of income. Required

contributions to an account used to pay for incurred health

expenses can be reduced to 0%. Co-pays cannot be reduced to less

than 3% of income.

(17) The department of community health shall make available

at least 3 years of state medical assistance program data, without

charge, to any vendor considered qualified by the department of

community health 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 of community health or the state.

(18) In order to continue with the reform and expansion

program described in this section beyond December 31, 2015, the

department of community health must receive full waiver approval

before December 31, 2015. If the department of community health has

not received full waiver approval by December 31, 2013, the

department of community health shall request written documentation

from the United States department of health and human services by

December 31, 2013 that if the waivers described in this section are

rejected causing the medical assistance program to revert back to

the eligibility requirements in effect on the effective date of the

amendatory act that added this section, there will be no financial

federal funding penalty.

(19) As used in this section, "telemedicine" means that term

as defined in section 3476 of the insurance code of 1956, 1956 PA

218, MCL 500.3476.

Sec. 106. (1) A medically indigent individual is defined as:

(a) An individual receiving family independence program

benefits or an individual receiving supplemental security income

under title XVI or state supplementation under title XVI subject to

limitations imposed by the director according to title XIX.

(b) Except as provided in section 106a, an individual who

meets all of the following conditions:

(i) The individual has applied in the manner the ~~family~~

~~independence agency~~ department of community health prescribes.

(ii) The individual's need for the type of medical assistance

available under this act for which the individual applied has been

professionally established and payment for it is not available

through the legal obligation of a public or private contractor to

pay or provide for the care without regard to the income or

resources of the patient. The state department is and the

department of community health are subrogated to any right of

recovery that a patient may have for the cost of hospitalization,

pharmaceutical services, physician services, nursing services, and

other medical services not to exceed the amount of funds expended

by the state department or the department of community health for

the care and treatment of the patient. The patient or other person

acting in the patient's behalf shall execute and deliver an

assignment of claim or other authorizations as necessary to secure

the right of recovery to the department or the department of

community health. A payment may be withheld under this act for

medical assistance for an injury or disability for which the

individual is entitled to medical care or reimbursement for the

cost of medical care under sections 3101 to 3179 of the insurance

code of 1956, 1956 PA 218, MCL 500.3101 to 500.3179, or under

another policy of insurance providing medical or hospital benefits,

or both, for the individual unless the individual's entitlement to

that medical care or reimbursement is at issue. If a payment is

made, the state department or the department of community health,

to enforce its subrogation right, may do either of the following:

(a) intervene or join in an action or proceeding brought by the

injured, diseased, or disabled individual, the individual's

guardian, personal representative, estate, dependents, or

survivors, against the third person who may be liable for the

injury, disease, or disability, or against contractors, public or

private, who may be liable to pay or provide medical care and

services rendered to an injured, diseased, or disabled individual;

(b) institute and prosecute a legal proceeding against a third

person who may be liable for the injury, disease, or disability, or

against contractors, public or private, who may be liable to pay or

provide medical care and services rendered to an injured, diseased,

or disabled individual, in state or federal court, either alone or

in conjunction with the injured, diseased, or disabled individual,

the individual's guardian, personal representative, estate,

dependents, or survivors. The state department may institute the

proceedings in its own name or in the name of the injured,

diseased, or disabled individual, the individual's guardian,

personal representative, estate, dependents, or survivors. As

provided in section 6023 of the revised judicature act of 1961,

1961 PA 236, MCL 600.6023, the state department or the department

of community health, in enforcing its subrogation right, shall not

satisfy a judgment against the third person's property that is

exempt from levy and sale. The injured, diseased, or disabled

individual may proceed in his or her own name, collecting the costs

without the necessity of joining the state department, the

department of community health, or the state as a named party. The

injured, diseased, or disabled individual shall notify the state

department or the department of community health of the action or

proceeding entered into upon commencement of the action or

proceeding. An action taken by the state, or the state department,

or the department of community health in connection with the right

of recovery afforded by this section does not deny the injured,

diseased, or disabled individual any part of the recovery beyond

the costs expended on the individual's behalf by the state

department or the department of community health. The costs of

legal action initiated by the state shall be paid by the state. A

payment shall not be made under this act for medical assistance for

an injury, disease, or disability for which the individual is

entitled to medical care or the cost of medical care under the

worker's disability compensation act of 1969, 1969 PA 317, MCL

418.101 to 418.941; except that payment may be made if an

appropriate application for medical care or the cost of the medical

care has been made under the worker's disability compensation act

of 1969, 1969 PA 317, MCL 418.101 to 418.941, entitlement has not

been finally determined, and an arrangement satisfactory to the

state department or the department of community health has been

made for reimbursement if the claim under the worker's disability

compensation act of 1969, 1969 PA 317, MCL 418.101 to 418.941, is

finally sustained.

(iii) The individual has an annual income that is below, or

subject to limitations imposed by the director and because of

medical expenses falls below, the protected basic maintenance

level. The protected basic maintenance level for 1-person and 2-

person families shall be at least 100% of the payment standards

generally used to determine eligibility in the family independence

program. For families of 3 or more persons, the protected basic

maintenance level shall be at least 100% of the payment standard

generally used to determine eligibility in the family independence

program. These levels shall recognize regional variations and shall

not exceed 133-1/3% of the payment standard generally used to

determine eligibility in the family independence program.

(iv) The individual, if a family independence program related

individual and living alone, has liquid or marketable assets of not

more than $2,000.00 in value, or, if a 2-person family, the family

has liquid or marketable assets of not more than $3,000.00 in

value. The ~~state~~ department of community health shall establish

comparable liquid or marketable asset amounts for larger family

groups. Excluded in making the determination of the value of liquid

or marketable assets are the values of: the homestead; clothing;

household effects; $1,000.00 of cash surrender value of life

insurance, except that if the health of the insured makes

continuance of the insurance desirable, the entire cash surrender

value of life insurance is excluded from consideration, up to the

maximum provided or allowed by federal regulations and in

accordance with ~~state~~ department of community health rules; the

fair market value of tangible personal property used in earning

income; an amount paid as judgment or settlement for damages

suffered as a result of exposure to agent orange, as defined in

section 5701 of the public health code, 1978 PA 368, MCL 333.5701;

and a space or plot purchased for the purposes of burial for the

person. For individuals related to the title XVI program, the

appropriate resource levels and property exemptions specified in

title XVI shall be used.

(v) The individual is not an inmate of a public institution

except as a patient in a medical institution.

(vi) The individual meets the eligibility standards for

House Bill No. 4714 (H-3) as amended June 13, 2013

supplemental security income under title XVI or for state

supplementation under the act, subject to limitations imposed by

the director of the department of community health according to

title XIX; or meets the eligibility standards for family

independence program benefits; or meets the eligibility standards

for optional eligibility groups under title XIX, subject to

limitations imposed by the director of the department of community

health according to title XIX.

1396a(a)(10)(A)(i)(VIII) of title XIX. This subdivision does not

apply if either of the following occurs:

(i) If the department of community health is unable to obtain a

federal waiver as provided in section 105d.

[(ii) IF FEDERAL GOVERNMENT MATCHING FUNDS FOR THE PROGRAM

DESCRIBED IN SECTION 105D ARE REDUCED BELOW 100% AND ANNUAL STATE

SAVINGS AND OTHER SAVINGS ASSOCIATED WITH THE IMPLEMENTATION OF THAT

PROGRAM ARE NOT SUFFICIENT TO COVER THE REDUCED FEDERAL MATCH. THE

DEPARTMENT OF COMMUNITY HEALTH SHALL DETERMINE HOW ANNUAL STATE SAVINGS

AND OTHER SAVINGS WILL BE CALCULATED BY JUNE 1, 2014.]

(2) As used in this act:

(a) ~~"Medicaid contracted~~ "Contracted health plan" means a

managed care organization with whom the state department or the

department of community health contracts to provide or arrange for

the delivery of comprehensive health care services as authorized

under this act.

(b) "Federal poverty guidelines" means the poverty guidelines

published annually in the federal register by the United States

department of health and human services under its authority to

revise the poverty line under section 673(2) of subtitle B of title

VI of the omnibus budget reconciliation act of 1981, 42 USC 9902.

approved hospital, nursing home, medical care facility, psychiatric

hospital, or other facility or identifiable unit of a listed

institution certified as meeting established standards for a

nursing home or hospital in accordance with the laws of this state.

(d) ~~(c)~~ "Title XVI" means title XVI of the social security

act, 42 USC 1381 to ~~1382j and 1383 to~~ 1383f.

(3) An individual receiving medical assistance under this act

or his or her legal counsel shall notify the state department or

the department of community health when filing an action in which

the state department or the department of community health may have

a right to recover expenses paid under this act. If the individual

is enrolled in a ~~medicaid~~ contracted health plan, the individual or

his or her legal counsel shall provide notice to the ~~medicaid~~

contracted health plan in addition to providing notice to the state

department.

(4) If a legal action in which the state department, the

department of community health, a ~~medicaid~~ contracted health plan,

or ~~both has~~ all 3 have a right to recover expenses paid under this

act is filed and settled after November 29, 2004 without notice to

the state department, the department of community health, or the

~~medicaid~~ contracted health plan, the state department, the

department of community health, or the ~~medicaid~~ contracted health

plan may file a legal action against the individual or his or her

legal counsel, or both, to recover expenses paid under this act.

The attorney general shall recover any cost or attorney fees

associated with a recovery under this subsection.

(5) The state department or the department of community health

has first priority against the proceeds of the net recovery from

the settlement or judgment in an action settled in which notice has

been provided under subsection (3). A ~~medicaid~~ contracted health

plan has priority immediately after the state department or the

department of community health in an action settled in which notice

has been provided under subsection (3). The state department, the

department of community health, and a ~~medicaid~~ contracted health

plan shall recover the full cost of expenses paid under this act

unless the state department, the department of community health, or

the ~~medicaid~~ contracted health plan agrees to accept an amount less

than the full amount. If the individual would recover less against

the proceeds of the net recovery than the expenses paid under this

act, the state department, the department of community health, or

~~medicaid~~ contracted health plan, and the individual shall share

equally in the proceeds of the net recovery. As used in this

subsection, "net recovery" means the total settlement or judgment

less the costs and fees incurred by or on behalf of the individual

who obtains the settlement or judgment.

Sec. 107. (1) In establishing financial eligibility for the

medically indigent, ~~as defined in section 106,~~ income shall be

disregarded in accordance with standards established for the

related categorical assistance program. For medical assistance

only, income shall include the amount of contribution that an

estranged spouse or parent for a minor child is making to the

House Bill No. 4714 (H-3) as amended June 13, 2013

applicant according to the standards of the ~~state~~ department of

community health, or according to a court determination, if there

is a court determination. Nothing in this section eliminates the

responsibility of support established in section 76 for cash

assistance received under this act.

(2) The department of community health shall apply a modified

adjusted gross income methodology in determining if an individual's

annual income level is below 133% of the federal poverty

guidelines. This subsection does not apply if either of the

following occurs:

(a) If the department of community health is unable to obtain

a federal waiver as provided in section 105d.

[(B) IF FEDERAL GOVERNMENT MATCHING FUNDS FOR THE PROGRAM DESCRIBED

IN SECTION 105D ARE REDUCED BELOW 100% AND ANNUAL STATE SAVINGS AND

OTHER SAVINGS ASSOCIATED WITH THE IMPLEMENTATION OF THAT PROGRAM ARE NOT

SUFFICIENT TO COVER THE REDUCED FEDERAL MATCH. THE DEPARTMENT OF

COMMUNITY HEALTH SHALL DETERMINE HOW ANNUAL STATE SAVINGS AND OTHER

SAVINGS WILL BE CALCULATED BY JUNE 1, 2014.]

Sec. 108. A medically indigent person as defined under

~~subdivision (1) of~~ section ~~106,~~ 106(1) is entitled to all the

services enumerated in ~~subsections (a), (b), (c), (d), (e) and (f)~~

of section 109. A medically indigent person as defined under

~~subdivision (2) of~~ section ~~106~~ 106(2) is entitled to medical

services enumerated in ~~subsections (a), (c) and (e) of section 109.~~

section 109(a), (c), and (e). He ~~shall also be~~ or she is entitled

to the services enumerated in ~~subsections (b),~~ section 109(b), (d),

and (f) ~~of section 109~~ to the extent of appropriations made

available by the legislature for the fiscal year. Medical services

shall be rendered upon certification by the attending licensed

physician and dental services shall be rendered upon certification

of the attending licensed dentist that a service is required for

the treatment of an individual. The services of a medical

institution shall be rendered only after referral by a licensed

physician or dentist and certification by him or her that the

services of the medical institution are required for the medical or

dental treatment of the individual, except that referral is not

necessary in case of an emergency. Periodic recertification that

medical treatment ~~which~~ that extends over a period of time is

required in accordance with regulations of the ~~state~~ department

~~shall be~~ of community health is a condition of continuing

eligibility to receive medical assistance. To comply with federal

statutes governing medicaid, the ~~state~~ department of community

health shall provide ~~such~~ early and periodic screening, diagnostic

and treatment services to eligible children as it ~~deems~~ considers

necessary.

Sec. 109c. (1) The ~~state~~ department of community health shall

include, as part of its program of medical services under this act,

home- or community-based services to eligible persons whom the

~~state~~ department of community health determines would otherwise

require nursing home services or similar institutional care

services under section 109. The home- or community-based services

shall be offered to qualified eligible persons who are receiving

inpatient hospital or nursing home services as an alternative to

those forms of care.

(2) The home- or community-based services shall include

safeguards adequate to protect the health and welfare of

participating eligible persons, and shall be provided according to

a written plan of care for each person. The services available

under the home- or community-based services program shall include,

at a minimum, all of the following:

(a) Home delivered meals.

(b) Chore services.

(d) Respite care.

(e) Personal care.

(f) Adult day care.

(g) Private duty nursing.

(h) Mental health counseling.

(i) Caregiver training.

(j) Emergency response systems.

(k) Home modification.

(l) Transportation.

(m) Medical equipment and supply services.

(3) This section shall be implemented so that the average per

capita expenditure for home- or community-based services for

eligible persons receiving those services does not exceed the

estimated average per capita expenditure that would have been made

for those persons had they been receiving nursing home services,

inpatient hospital or similar institutional care services instead.

(4) The ~~state~~ department of community health shall seek a

waiver necessary to implement this program from the federal

department of health and human services, as provided in section

1915 of title XIX, 42 ~~U.S.C.~~ USC 1396n. The department of community

health shall request any modifications of the waiver that are

necessary in order to expand the program in accordance with

subsection (9).

(5) The ~~state~~ department of community health shall establish

policy for identifying the rules for persons receiving inpatient

hospital or nursing home services who may qualify for home- or

community-based services. The rules shall contain, at a minimum, a

listing of diagnoses and patient conditions to which the option of

home- or community-based services may apply, and a procedure to

determine if the person qualifies for home- or community-based

services.

(6) The ~~state~~ department of community health shall provide to

the legislature and the governor an annual report showing the

detail of its home- and community-based case finding and placement

activities. At a minimum, the report shall contain each of the

following:

(a) The number of persons provided home- or community-based

services who would otherwise require inpatient hospital services.

This shall include a description of medical conditions, services

provided, and projected cost savings for these persons.

(b) The number of persons provided home- or community-based

services who would otherwise require nursing home services. This

shall include a description of medical conditions, services

provided, and projected cost savings for these persons.

personal care services.

(d) The number of hearings requested concerning home- or

community-based services and the outcome of each hearing which has

been adjudicated during the year.

(7) The written plan of care required under subsection (2) for

an eligible person shall not be changed unless the change is

prospective only, and the ~~state~~ department of community health does

both of the following:

(a) Not later than 30 days before making the change, except in

the case of emergency, consults with the eligible person or, in the

case of a child, with the child's parent or guardian.

(b) Consults with each medical service provider involved in

the change. This consultation shall be documented in writing.

(8) An eligible person who is receiving home- or community-

based services under this section, and who is dissatisfied with a

change in his or her plan of care or a denial of any home- or

community-based service, may demand a hearing as provided in

section 9, and subsequently may appeal the hearing decision to

circuit court as provided in section 37.

(9) The ~~state~~ department of community health shall expand the

home- and community-based services program by increasing the number

of counties in which it is available, in conformance with this

subsection. The program may be limited in total cost and in the

number of recipients per county who may receive services at 1 time.

Subject to obtaining the waiver and any modifications of the waiver

sought under subsection (4), the program shall be expanded as

follows:

(a) Not later than ~~1 year after the effective date of this~~

~~subsection,~~ July 14, 1995, home- and community-based services shall

be available to eligible applicants in those counties that, when

combined, contain at least 1/4 of the population of this state.

(b) Not later than ~~2 years after the effective date of this~~

~~subsection,~~ July 14, 1996, home- and community-based services shall

be available to eligible applicants in those counties that, when

combined, contain at least 1/2 of the population of this state.

~~subsection,~~ July 14, 1997, home- and community-based services shall

be available to eligible applicants in those counties that, when

combined, contain at least 3/4 of the population of this state.

(d) Not later than ~~4 years after the effective date of this~~

~~subsection,~~ July 14, 1998, home- and community-based services shall

be available to eligible applicants on a statewide basis.

(10) The ~~state~~ department of community health shall work with

the office of services to the aging in implementing the home- and

community-based services program, including the provision of

preadmission screening, case management, and recipient access to

services.

Enacting section 1. This amendatory act does not do either of

the following:

(a) Authorize the establishment or operation of a state-

created American health benefit exchange in this state related to

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) Convey any additional statutory, administrative, rule-