May 9, 2013, Introduced by Reps. Lori and Pscholka and referred to the Committee on Michigan Competitiveness.
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.
(c) Each hospital 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 shall provide a process by which
individuals may apply for or renew medical assistance eligibility
through a website from which the department shall enroll
individuals in the appropriate health care program without regard
to the specific program for which the individual applies. This
section does not apply if either of the following occurs:
(a) If the department of community health is unable to obtain
a waiver from the United States department of health and human
services to implement the provisions of section 105d or 106(1)(c).
(b) If at any time the federal government does not provide
funding at a level of 100% for implementation and administration of
section 106(1)(c).
Sec. 105d. (1) The department of community health shall seek a
waiver from the United States department of health and human
services to do all of the following:
(a) Enroll nondisabled adults with an annual income level
below 133% of the federal poverty guidelines who meet the
citizenship provisions of 42 CFR 435.406(a)(1) 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 can be deposited to pay for incurred health expenses,
except that nondisabled adults have the option to decline
enrollment into the medical assistance program under this act and
select private health insurance either on or off the American
health benefit exchange established or operating in this state.
(b) Give nondisabled adults described in subdivision (a) a
choice in choosing a contracted health plan.
(c) Ensure that all nondisabled adults described in
subdivision (a) have access to a primary care physician and to
preventive services.
(d) Develop incentives for healthy behavior and for progress
made toward healthy behavior on the part of nondisabled adults
described in subdivision (a).
(e) Develop incentives for eligible enrollees who assist the
department of community health in detecting fraud and abuse in the
medical assistance program.
(f) Allow for services provided through telemedicine.
(g) Allow nondisabled adults to receive medical assistance
under this act for not more than 48 months. The 48-month count
begins on the date that the provisions of section 106(1)(c) are
implemented and shall not include any months before that date.
Nondisabled adults who have received medical assistance under
section 106(1)(c) for 48 months and are no longer eligible as
described in this subdivision may select private health insurance
either on or off the American health benefit exchange established
or operating in this state.
(2) Any hospital that participates in the medical assistance
program under this act shall not charge uninsured individuals who
have an annual income level under 100% of the federal poverty
guidelines more than 115% of rates charged to medicare.
(3) Nondisabled adults enrolled in the medical assistance
program under subsection (1)(a) shall make contributions of not
more than 5% of their annual income into the accounts described in
subsection (1)(a) based on the department of community health's
determination of the nondisabled adult's ability to pay.
Contributions may include, but are not limited to, deductibles,
copayments, premiums, or other applicable charges as determined by
the department of community health.
(4) 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 legislature for review.
(5) By not later than March 1, 2015 and annually by every
March 1 after that, the department of community health shall
provide a report to the legislature that includes, but is not
limited to, information regarding the impact on the health status
of the covered population including a targeted assessment related
to employability, the cost effectiveness of the medical assistance
program, and an evaluation of the financial impact on the state's
health care and health insurance systems.
(6) As used in this section:
(a) "Nondisabled adult" means an individual aged 21 to under
65 who is not eligible through a disability category existing on
the effective date of the amendatory act that added this subsection
for the purposes of medical assistance eligibility.
(b) "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
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.
(c) Except as otherwise provided in section 106a, the
nondisabled adult has an annual income level below 133% of the
federal poverty guidelines. As used in this subdivision,
"nondisabled adult" means an individual 21 years of age to under 65
years of age who is not eligible through a disability category
existing on the effective date of the amendatory act that added
this subsection for the purposes of medical assistance eligibility.
This subdivision does not apply if either of the following occurs:
(i) If the department of community health is unable to obtain a
waiver from the United States department of health and human
services to implement the provisions of this subdivision or section
105d.
(ii) If at any time the federal government does not provide
funding at a level of 100% for implementation and administration of
this subdivision.
(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.
(c) (b)
"Medical institution"
means a state licensed or
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
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 waiver from the United States department of health and human
services to implement the provisions of section 105d or 106(1)(c).
(b) If at any time the federal government does not provide
funding at a level of 100% for implementation and administration of
section 106(1)(c).
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.
(c) Homemaker 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.
(c) The number of persons and the annual expenditure for
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.
(c)
Not later than 3 years after the effective date of this
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.