Michigan Laws 124.85 – Public employer with 50 or more employees; claims utilization and cost information; compilation; “relevant period” defined; disclosure; availability; protected health information not included
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Terms Used In Michigan Laws 124.85
- Carrier: means a health, dental, or vision insurance company authorized to do business in this state under, and a health maintenance organization or multiple employer welfare arrangement operating under, the insurance code of 1956, 1956 PA 218, MCL 500. See Michigan Laws 124.73
- Commissioner: means the director of the department of insurance and financial services. See Michigan Laws 124.73
- Contract: A legal written agreement that becomes binding when signed.
- Covered individual: means an individual covered by a contract under section 15(3)(a)(iv). See Michigan Laws 124.73
- Medical benefit plan: means a plan, established and maintained by a carrier or 1 or more public employers, that provides for the payment of medical, optical, or dental benefits, including, but not limited to, hospital and physician services, prescription drugs, and related benefits, to public employees. See Michigan Laws 124.73
- month: means a calendar month; the word "year" a calendar year; and the word "year" alone shall be equivalent to the words "year of our Lord". See Michigan Laws 8.3j
- Public employer: means a city, village, township, county, or other political subdivision of this state; any intergovernmental, metropolitan, or local department, agency, or authority, or other local political subdivision; a school district, a public school academy, or an intermediate school district, as those terms are defined in the revised school code, 1976 PA 451, MCL 380. See Michigan Laws 124.73
- Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide.
- Specialty prescription drug: means a prescription drug used to treat a rare, complex, or chronic medical condition that meets any of the following requirements:
(i) Requires special administration including, but not limited to, inhalation or infusion. See Michigan Laws 124.73state: when applied to the different parts of the United States, shall be construed to extend to and include the District of Columbia and the several territories belonging to the United States; and the words "United States" shall be construed to include the district and territories. See Michigan Laws 8.3o
(1) Notwithstanding subsection (2), a public employer that has 50 or more employees in medical benefit plans shall be provided with claims utilization and cost information as provided in subsection (3).
(2) Two or more public employers that are in an arrangement and together have 50 or more employees in medical benefit plans or have signed a letter of intent to enter together 50 or more public employees into medical benefit plans, shall each be provided with claims utilization and cost information as provided in subsection (3) that is aggregated for all the public employees together of those public employers, and, except as otherwise permitted under subsection (1), shall not be separated out for any of those public employers.
(3) All medical benefit plans in this state shall compile, and shall make available in an electronic, spreadsheet-compatible format complete and accurate claims utilization and cost information for the medical benefit plan in the aggregate and for each public employer entitled to that information under subsection (1) or (2) and each subgroup of public employees of such a public employer if the subgroup has 50 or more public employees covered by the medical benefit plan, as follows:
(a) A census of all covered employees, including all of the following:
(i) Year of birth.
(ii) Gender.
(iii) Zip code.
(iv) The contract coverage type for the employee, such as single, 2-person, or family, and number of individuals covered by contract.
(b) Incurred and paid claims data for the employee group covered by the medical benefit plan, including at least all of the following:
(i) For a plan that provides medical benefits, information concerning enrollment and hospital and medical claims under the plan, presented in a manner that clearly shows all of the following:
(A) For each month, the total number of covered employees and the number of covered employees in each contract coverage type included in the census under subdivision (a)(iv).
(B) For each month, the total number of covered individuals and the number of covered individuals in each contract coverage type included in the census under subdivision (a)(iv).
(C) Number and total expenditures for inpatient claims for each month.
(D) Number and total expenditures for outpatient claims for each month.
(E) Number and total expenditures for all other medical claims for equipment, devices, and services, including services rendered in the private office of a physician or other health professional, for each month.
(ii) For a plan that provides prescription drug benefits, information concerning enrollment and prescription drugs claims under the plan, presented in a manner that clearly shows all of the following:
(A) For each month, the total number of covered employees and the number of covered employees in each contract coverage type included in the census under subdivision (a)(iv).
(B) For each month, the total number of covered individuals and the number of covered individuals in each contract coverage type included in the census under subdivision (a)(iv).
(C) Amount charged and amount paid for prescription drugs claims for each month.
(D) Total amount charged and amount paid for brand prescription drugs claims for each month.
(E) Total amount charged and amount paid for generic prescription drugs claims for each month.
(F) Total amount charged and amount paid for specialty prescription drug claims for each month.
(G) The 50 prescription drugs for which claims were most frequently paid.
(H) The 50 prescription drugs for which expenditures were the largest.
(iii) For a plan that provides medical or prescription drug benefits, in addition to the information required under subparagraphs (i) and (ii), as applicable, information concerning covered individuals with total medical or prescription drug claims, or both, exceeding $25,000.00 for any 12-month period for which claims utilization and cost information are provided, presented in a manner that clearly shows all of the following separately for each covered individual:
(A) Total medical expenditures for the individual.
(B) Total prescription drug expenditures for the individual.
(C) Whether the covered individual is currently covered by the medical benefit plan.
(D) The covered individual’s diagnoses.
(iv) For a plan that provides dental benefits, information concerning dental claims and total expenditures for these claims under the plan, presented in a manner that clearly shows at least all of the following:
(A) Number of claims submitted and total charged.
(B) Number of and total expenditures for claims paid.
(C) Total expenditures for claims submitted to network providers.
(v) For a plan that provides optical benefits, information concerning optical claims and total expenditures for these claims under the plan, presented in a manner that clearly shows at least all of the following:
(A) Number of claims submitted and total charged.
(B) Number of and total expenditures for claims paid.
(C) Total expenditures for claims submitted to network providers.
(c) Fees and administrative expenses for the most recent experience year, reported separately for medical, prescription drug, dental, and optical plans, and presented in a manner that clearly shows at least all of the following:
(i) The dollar amounts paid for specific and aggregate stop-loss insurance.
(ii) The dollar amount of administrative expenses incurred or paid, reported separately for medical, pharmacy, dental, and vision.
(iii) The total dollar amount of retentions and other expenses.
(iv) The dollar amount for all service fees paid.
(v) The dollar amount of any fees or commissions paid to agents, consultants, third party administrators, or brokers by the medical benefit plan or by any public employer or carrier participating in or providing services to the medical benefit plan, reported separately for medical, prescription drug, stop-loss, dental, and vision.
(vi) Other information as may be required by the commissioner.
(d) For medical, prescription drug, dental, and optical plans, a benefit summary for the current year’s plan and, if benefits have changed during any of the 2 most recent 12-month periods for which claims utilization and cost information are provided, a brief benefit summary for each of those periods for which the benefits were different.
(4) Except as otherwise provided in subsection (3) and subject to subsection (5), claims utilization and cost information required to be compiled under this section must be compiled as follows:
(a) On an annual basis.
(b) At the request of a public employer. A public employer may not request claims utilization and cost information more than 4 times per calendar year. Claims utilization and cost information compiled upon the request of a public employer must be compiled within 30 days after the request.
(5) Claims utilization and cost information compiled under this section must cover a relevant period. For purposes of this subsection, the term “relevant period” means the 24-month period ending no more than 60 days before the compilation of the information for the medical benefit plan under consideration. However, if the medical benefit plan has been in effect for a period of less than 24 months, the relevant period shall be that shorter period.
(6) A public employer or combination of public employers shall disclose the claims utilization and cost information required to be provided under subsections (1) and (2) to any carrier or administrator it solicits to provide benefits or administrative services for its medical benefit plan, and to the employee representative of employees covered under the medical benefit plan, and upon request to any carrier or administrator who requests the opportunity to submit a proposal to provide benefits or administrative services for the medical benefit plan at the time of the request for bids. The public employer shall make the claims utilization and cost information required under this section available within a reasonable period of time.
(7) The claims utilization and cost information required under this section shall include only de-identified health information as permitted under the health insurance portability and accountability act of 1996, Public Law 104-191, or regulations promulgated under that act, 45 C.F.R. § part parts 160 and 164, and shall not include any protected health information as defined in the health insurance portability and accountability act of 1996, Public Law 104-191, or regulations promulgated under that act, 45 C.F.R. § part parts 160 and 164.