reglab/statecodes huggingface dataset:
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3508 - Quality Assessment Program; Quality Improvement Program.

500.3508 Quality assessment program; quality improvement program.
Sec. 3508.
(1) A health maintenance organization shall develop and maintain a quality assessment program that includes, at a minimum, systematic collection, analysis, and reporting of relevant data in accordance with statutory and regulatory requirements.
(2) A health maintenance organization shall establish and maintain a quality improvement program to design, measure, assess, and improve the processes and outcomes of health care as identified in the program. A health maintenance organization shall place the quality improvement program under the direction of its medical director and include all of the following in the program:
(a) A written statement of the program's objectives, lines of authority and accountability, evaluation tools, including data collection responsibilities, and performance improvement activities.
(b) An annual effectiveness review of the program.
(c) A written quality improvement plan that, at a minimum, describes how the health maintenance organization analyzes both the processes and outcomes of care, identifies the targeted diagnoses and treatments to be reviewed each year, uses a range of appropriate methods to analyze quality, compares program findings with past performance and internal goals and external standards, measures the performance of affiliated providers, and conducts peer review activities.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3509 - Certificate of Authority; Application; Form; Limitation; Change of Service Area.

500.3509 Certificate of authority; application; form; limitation; change of service area.
Sec. 3509.
(1) An application to the director for a certificate of authority must be on a form prescribed and provided by the director.
(2) A certificate of authority issued to a health maintenance organization under this act is limited to the service area described in the application on which the certificate of authority was issued. Approved parts of a health maintenance organization's service area are not required to be contiguous.
(3) A health maintenance organization seeking to change the approved service area shall submit an application to change service area to the director and shall not change the service area until approval is received. The director shall specify the information required to be in the application under this subsection.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3511 - Governing Body; Election of Enrollee Board Members; Requirements; Meetings.

500.3511 Governing body; election of enrollee board members; requirements; meetings.
Sec. 3511.
(1) A health maintenance organization's governing body must include no less than 1 individual who represents the health maintenance organization's membership.
(2) A health maintenance organization that is under a contract with this state to provide medical services authorized under subchapter XIX or XXI of the social security act, 42 USC 1396 to 1396w-5 and 1397aa to 1397mm, shall comply with either of the following requirements:
(a) A minimum of 1/3 of its governing body must be representatives of its membership consisting of enrollees of the organization who are not compensated officers, employees, or other individuals responsible for the conduct of, or financially interested in, the organization's affairs.
(b) The health maintenance organization must establish a consumer advisory council that reports to the governing body. The consumer advisory council must include at least 1 enrollee, 1 family member or legal guardian of an enrollee, and 1 consumer advocate.
(3) A health maintenance organization's governing body shall meet at least quarterly unless specifically exempted from this requirement by the director.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3513 - Health Maintenance Organization Operations; Regulation by Director; Incorporation as Legal Entity.

500.3513 Health maintenance organization operations; regulation by director; incorporation as legal entity.
Sec. 3513.
(1) The director shall regulate health delivery aspects of health maintenance organization operations to ensure that health maintenance organizations are capable of providing care and services promptly, appropriately, and in a manner that ensures continuity and acceptable quality of health care. The director shall encourage health maintenance organizations to use a wide variety of health-related disciplines and facilities and to develop services that contribute to the prevention of disease and disability and the restoration of health.
(2) The director shall ensure that health maintenance organizations operate in the interest of enrollees consistent with overall health care cost containment while delivering acceptable quality of care and services that are available and accessible to enrollees with appropriate administrative costs and health care provider incentives. A health maintenance organization shall do all of the following:
(a) Provide, as promptly as appropriate, health services in a manner that ensures continuity and imparts quality health care under conditions the director considers to be in the public interest.
(b) Provide health services within its service area that are available and accessible to enrollees 24 hours a day and 7 days a week for the treatment of emergency episodes of illness or injury.
(c) Provide that reasonable provisions exist for an enrollee to obtain emergency health services both within and outside of its service area.
(3) A health maintenance organization must be incorporated as a distinct legal entity under the business corporation act, 1972 PA 284, MCL 450.1101 to 450.2098, the nonprofit corporation act, 1982 PA 162, MCL 450.2101 to 450.3192, or the Michigan limited liability company act, 1993 PA 23, MCL 450.4101 to 450.5200.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3515 - Additional Health Services; Deductibles; Copayments; "Preventive Health Care Services" Defined; Partial Payment From Government or Private Person.

500.3515 Additional health services; deductibles; copayments; "preventive health care services" defined; partial payment from government or private person.
Sec. 3515.
(1) A health maintenance organization may provide additional health services or any other related health care service or treatment not required under this act.
(2) A health maintenance organization may have health maintenance contracts with deductibles. A health maintenance organization may have health maintenance contracts that include copayments, stated as dollar amounts for the cost of covered services, and coinsurance, stated as percentages for the cost of covered services. This subsection does not limit the director's authority to regulate and establish fair, sound, and reasonable copayment and coinsurance limits including out of pocket maximums.
(3) A health maintenance organization shall not require that contributions be made to a deductible for preventive health care services. As used in this subsection, "preventive health care services" means services designated to maintain an individual in optimum health and to prevent unnecessary injury, illness, or disability.
(4) A health maintenance organization may accept from governmental agencies and from private persons payments covering any part of the cost of health maintenance contracts.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2002, Act 304, Imd. Eff. May 10, 2002 ;-- Am. 2002, Act 621, Imd. Eff. Dec. 23, 2002 ;-- Am. 2005, Act 306, Imd. Eff. Dec. 21, 2005 ;-- Am. 2016, Act 97, Eff. Aug. 1, 2016 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3517 - Healthy Lifestyle Programs; Emergency or Out-of-Area Service; Payment of Expenses or Fees.

500.3517 Healthy lifestyle programs; emergency or out-of-area service; payment of expenses or fees.
Sec. 3517.
(1) A health maintenance contract shall not provide for payment of cash or other material benefit to an enrollee other than as permitted under the law of this state or as approved by the director under section 2236.
(2) Subsection (1) does not prohibit a health maintenance organization from promoting optimum health by offering to all currently enrolled subscribers or to all currently covered enrollees 1 or more healthy lifestyle programs. As used in this subsection, "healthy lifestyle program" means a program recognized by a health maintenance organization that enhances health, educates enrollees on health-related matters, or reduces risk of disease, including, but not limited to, promoting nutrition and physical exercise and compliance with disease management programs and preventive service guidelines that are supported by evidence-based medical practice. A healthy lifestyle program may include other requirements in addition to those that enhance health, educate enrollees on health-related matters, or reduce risk of disease if the healthy lifestyle program, taken as a whole, meets the intent of this subsection. Subsection (1) does not prohibit a health maintenance organization from offering a currently enrolled subscriber or currently covered enrollee goods, vouchers, or equipment that supports achieving optimal health goals. An offering of goods, vouchers, or equipment under this subsection is not a violation of subsection (1) and is not valuable consideration, a material benefit, a gift, a rebate, or an inducement under this act.
(3) For an emergency episode of illness or injury that requires immediate treatment before it can be secured through the health maintenance organization, or for an out-of-area service specifically authorized by the health maintenance organization, an enrollee may use a provider in or outside of this state not normally engaged by the health maintenance organization to render service to its enrollees. The health maintenance organization shall pay reasonable expenses or fees to the provider or enrollee as appropriate in an individual case. These transactions are not acts of insurance and, except as provided in this chapter and section 3406k, are not otherwise subject to this act.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2005, Act 306, Imd. Eff. Dec. 21, 2005 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3519 - Contract and Contract Rates; Fairness; Rate Differential; Basic Health Services to Large Employers Required.

500.3519 Contract and contract rates; fairness; rate differential; basic health services to large employers required.
Sec. 3519.
(1) A health maintenance organization contract and the contract's rates, including any deductibles, copayments, and coinsurances, between the organization and its subscribers must be fair, sound, and reasonable in relation to the services provided, and the procedures for offering and terminating contracts must not be unfairly discriminatory.
(2) A health maintenance organization contract and the contract's rates must not discriminate on the basis of race, color, creed, national origin, residence within the approved service area of the health maintenance organization, lawful occupation, sex, handicap, or marital status, except that marital status may be used to classify individuals or risks for the purpose of insuring family units. The director may approve a rate differential based on sex, age, residence, disability, marital status, or lawful occupation, if the differential is supported by sound actuarial principles, a reasonable classification system, and is related to the actual and credible loss statistics or reasonably anticipated experience for new coverages. A healthy lifestyle program as defined in section 3517(2) is not subject to the director's approval under this subsection and is not required to be supported by sound actuarial principles, a reasonable classification system, or be related to actual and credible loss statistics or reasonably anticipated experience for new coverages.
(3) A health maintenance organization contract shall offer basic health services to large employers in at least 1 health maintenance contract.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2002, Act 304, Imd. Eff. May 10, 2002 ;-- Am. 2002, Act 621, Imd. Eff. Dec. 23, 2002 ;-- Am. 2005, Act 306, Imd. Eff. Dec. 21, 2005 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3521 - Prepayment Rates; Filing and Approval of Methodology; Schedule.

500.3521 Prepayment rates; filing and approval of methodology; schedule.
Sec. 3521.
(1) The methodology used to determine prepayment rates by category rates charged by the health maintenance organization and any changes to either the methodology or the rates shall be filed with and approved by the commissioner before becoming effective.
(2) A health maintenance organization shall submit supporting data used in the development of a prepayment rate or rating methodology and all other data sufficient to establish the financial soundness of the prepayment plan or rating methodology.
(3) The commissioner may annually require a schedule of rates for all subscriber contracts and riders. All submissions shall note changes of rates previously filed or approved.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3523 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3523 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to provisions included in health maintenance contract.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3527 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3527 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to performance of obligations under health maintenance contract.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3528 - Health Maintenance Organization; Credentialing Verification; Accreditation by Nationally Recognized Accredited Body.

500.3528 Health maintenance organization; credentialing verification; accreditation by nationally recognized accredited body.
Sec. 3528.
(1) A health maintenance organization shall establish written policies and procedures for credentialing verification of all health professionals with whom the health maintenance organization contracts. A health maintenance organization shall apply these standards consistently. This act does not require a health maintenance organization to select a provider as an affiliated provider solely because the provider meets the health maintenance organization's credentialing verification standards. This act does not prevent a health maintenance organization from using separate or additional criteria in selecting the health professionals with whom it contracts.
(2) A health maintenance organization is considered to meet the requirements of this section if the health maintenance organization is accredited by a nationally recognized accredited body approved by the director. As used in this subsection, "nationally recognized accredited body" includes the National Committee for Quality Assurance.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2002, Act 621, Imd. Eff. Dec. 23, 2002 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3530 - Availability of Covered Services; Assurance; Establishment and Maintenance of Proximity.

500.3530 Availability of covered services; assurance; establishment and maintenance of proximity.
Sec. 3530.
(1) A health maintenance organization shall maintain contracts with those numbers and those types of affiliated providers that are sufficient to assure that covered services are available to its enrollees without unreasonable delay. The commissioner shall determine what is sufficient as provided in this section and as may be established by reference to reasonable criteria used by the health maintenance organization, including, but not limited to, provider-covered person ratios by specialty, primary care provider-covered person ratios, geographic accessibility, waiting times for appointments with participating providers, hours of operation, and the volume of technological and specialty services available to serve the needs of enrollees requiring technologically advanced or specialty care.
(2) If a health maintenance organization has an insufficient number or type of participating providers to provide a covered benefit, the health maintenance organization shall ensure that the enrollee obtains the covered benefit at no greater cost to the enrollee than if the benefit were obtained from participating providers, or shall make other arrangements acceptable to the commissioner.
(3) A health maintenance organization shall establish and maintain adequate arrangements to ensure reasonable proximity of participating providers to the business or personal residence of enrollees. In determining whether a health maintenance organization has complied with this provision, the commissioner shall give due consideration to the relative availability of health care providers in the service area.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3533 - Prudent Purchaser Contracts; Reimbursement for Unauthorized Services or Services by Nonaffiliated Providers.

500.3533 Prudent purchaser contracts; reimbursement for unauthorized services or services by nonaffiliated providers.
Sec. 3533.
Subject to section 3405, a health maintenance organization may offer prudent purchaser contracts to groups or individuals and in conjunction with those contracts a health maintenance organization may pay or may reimburse enrollees, or may contract with another person to pay or reimburse enrollees, for unauthorized services or for services by nonaffiliated providers in accordance with the terms of the contract and subject to copayments, coinsurances, deductibles, or other financial penalties designed to encourage enrollees to obtain services from affiliated providers.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2005, Act 306, Imd. Eff. Dec. 21, 2005 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3535 - Solicitation or Advertising.

500.3535 Solicitation or advertising.
Sec. 3535.
Solicitation of enrollees or advertising of the services, charges, or other nonprofessional aspects of the health maintenance organization's operation under this section is not in violation of laws relating to solicitation or advertising by health professionals. A health maintenance organization shall not, in its solicitation or advertising allowed under this section, include advertising that makes a qualitative judgment as to a health professional who provides services for the health maintenance organization. A health maintenance organization shall not, in its solicitation or advertising allowed under this section, offer a material benefit or other thing of value as an inducement to prospective subscribers other than the services of the health maintenance organization.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3537 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3537 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to open enrollment period for health maintenance organizations.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3539 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3539 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to exclusions and limitations contained in nongroup contract and renewal requirements.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3541 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3541 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to health professional advocating on behalf of enrollee.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3542 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3542 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to prohibition against use of financial inducement or payment to health professional.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3543 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3543 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to owning or investing in third party administrator.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3544 - Noninsured Benefit Plan; Processing and Payment of Claims.

500.3544 Noninsured benefit plan; processing and payment of claims.
Sec. 3544.
(1) A health maintenance organization may process and pay claims on behalf of a noninsured benefit plan only after the health maintenance organization has received adequate money from the noninsured benefit plan sponsor to fully cover the claim payments.
(2) As used in this section, "noninsured benefit plan" means that term as defined in section 5208.
History:
Add. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3545 - Acquisition of Obligations From Another Managed Care Entity.

500.3545 Acquisition of obligations from another managed care entity.
Sec. 3545.
With the director's prior approval, a health maintenance organization may acquire obligations from another managed care entity. The director shall not grant prior approval unless the director determines that the transaction will not jeopardize the health maintenance organization's financial security.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3547 - Health Care Service Operations; Visitation or Examination by Director; Consultation With Enrollees; Authority; Access to Information Relating to Delivery of Services; Submission of Information Regarding Proposed Contract.

500.3547 Health care service operations; visitation or examination by director; consultation with enrollees; authority; access to information relating to delivery of services; submission of information regarding proposed contract.
Sec. 3547.
(1) The director at any time may visit or examine the health care service operations of a health maintenance organization and consult with enrollees to the extent necessary to carry out the intent of this act.
(2) The director has the authority granted under chapter 2 with regard to a health maintenance organization under this chapter.
(3) A health maintenance organization shall give the director access to all information of the health maintenance organization relating to the delivery of health services, including, but not limited to books, papers, computer databases, and documents, in a manner that preserves the confidentiality of the health records of individual enrollees.
(4) At the request of the director, a health maintenance organization shall submit information regarding a proposed contract between the health maintenance organization and an affiliated provider that the director considers necessary to ensure that the contract is in compliance with this act.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3548 - Maintenance of Books, Records, Files, and Financial Records; Funds and Assets.

500.3548 Maintenance of books, records, files, and financial records; funds and assets.
Sec. 3548.
(1) A health maintenance organization shall keep all of its books, records, and files at or under the control of its principal place of doing business in this state, and shall keep a record of all of its securities, notes, mortgages, or other evidences of indebtedness, representing investment of funds at its principal place of doing business in this state in the same manner as provided for in section 5256.
(2) A health maintenance organization shall maintain financial records for its health maintenance activities separate from the financial records of any other operation or activity.
(3) A health maintenance organization shall hold and maintain legal title to all assets, including cash and investments. A health maintenance organization shall not commingle funds or assets in pooling or cash management type arrangements with affiliates or other persons. A health maintenance organization shall hold all of its assets separate from all other activities of other members in a holding company system.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3549 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3549 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to notice to appropriate board by health maintenance organization as to disciplinary action.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3551 - Health Maintenance Organization; Net Worth.

500.3551 Health maintenance organization; net worth.
Sec. 3551.
(1) A health maintenance organization shall determine its minimum net worth using accounting procedures approved by the director. The accounting procedures must ensure that a health maintenance organization is financially and actuarially sound.
(2) To obtain or maintain a certificate of authority in this state, a health maintenance organization shall possess and maintain unimpaired net worth in an amount determined adequate by the director to continue to comply with section 403 but not in an amount less than the following, as applicable:
(a) For a health maintenance organization that contracts with or employs providers in numbers sufficient to provide 90% of the health maintenance organization's benefit payout, minimum net worth is the greatest of the following:
(i) $1,500,000.00.
(ii) Four percent of the health maintenance organization's subscription revenue.
(iii) Three months' uncovered expenditures.
(b) For a health maintenance organization that does not contract with or employ providers in numbers sufficient to provide 90% of the health maintenance organization's benefit payout, minimum net worth is the greatest of the following:
(i) $3,000,000.00.
(ii) Ten percent of the health maintenance organization's subscription revenue.
(iii) Three months' uncovered expenditures.
(3) The director shall take into account the risk-based capital requirements as developed by the National Association of Insurance Commissioners in order to determine adequate compliance with section 403 under this section.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3553 - Certificate of Authority; Deposit Requirements.

500.3553 Certificate of authority; deposit requirements.
Sec. 3553.
(1) To obtain or maintain a certificate of authority in this state, a health maintenance organization shall possess and maintain a deposit in an amount determined adequate by the director to continue to comply with section 403 but not less than $100,000.00 plus 5% of annual subscription revenue up to a $1,000,000.00 maximum deposit.
(2) A health maintenance organization shall make the deposit required under subsection (1) with the state treasurer or with a federal or state chartered financial institution under a trust indenture acceptable to the director for the sole benefit of the subscribers and enrollees in case of insolvency.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3555 - Financial Plan.

500.3555 Financial plan.
Sec. 3555.
A health maintenance organization shall maintain a financial plan evaluating, at a minimum, cash flow needs and adequacy of working capital. The plan under this subsection must do all of the following:
(a) Demonstrate compliance with all health maintenance organization financial requirements provided for in this act.
(b) Provide for adequate working capital, which must not be negative at any time. The director may establish a minimum working capital requirement for a health maintenance organization to ensure the prompt payment of liabilities.
(c) Identify the means of achieving and maintaining a positive cash flow, including provisions for retirement of existing or proposed indebtedness.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3557 - Notice of Changes in Operations.

500.3557 Notice of changes in operations.
Sec. 3557.
A health maintenance organization shall file notice with the director of any substantive changes in operations within 30 days after the substantive change in operations occurs. A substantive change in operations includes, but is not limited to, any of the following:
(a) A change in the health maintenance organization's officers or directors. In addition to the notification, the health maintenance organization shall file a disclosure statement on a form prescribed by the director for each newly appointed or elected officer or director.
(b) A change in the location of corporate offices.
(c) A change in the organization's articles of incorporation or bylaws. A health maintenance organization shall include a copy of the revised articles of incorporation or bylaws with the notice.
(d) A change in contractual arrangements under which the health maintenance organization is managed.
(e) Any other significant change in operations.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3559 - Reinsurance Contract or Plan of Self-Insurance; Purpose; Filing; Approval; Coverage.

500.3559 Reinsurance contract or plan of self-insurance; purpose; filing; approval; coverage.
Sec. 3559.
(1) Subject to subsection (2), a health maintenance organization shall obtain a reinsurance contract or establish a plan of self-insurance as necessary to ensure solvency or to protect subscribers in the event of insolvency. A reinsurance contract must be with an insurer that is authorized or eligible to transact insurance in this state.
(2) A health maintenance organization shall file a reinsurance contract or plan under subsection (1) for approval with the director within 30 days after the finalization of the contract or plan. A reinsurance contract or plan must clearly state all services to be received by the health maintenance organization. A reinsurance contract or plan is considered approved 30 days after it is filed with the director unless disapproved in writing by the director before the expiration of the 30 days.
(3) A health maintenance organization shall maintain insurance coverage to protect the health maintenance organization that includes, at a minimum, fire, theft, fidelity, general liability, errors and omissions, director's and officer's liability coverage, and malpractice insurance. A health maintenance organization shall obtain the director's prior approval before self-insuring for these coverages.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Compiler's Notes:
Enacting section 3 of Act 276 of 2016 provides:"Enacting section 3. On the effective date of this amendatory act, an insurer may submit to the director of the department of insurance and financial services for approval any modification to policies and certificates that were approved before or on the effective date of this amendatory act, to conform with amendments made to the insurance code of 1956, 1956 PA 218, MCL 500.100 to 500.8302, by this amendatory act. This enacting section does not apply to rates and rating methodologies."
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3561 - Insolvency; Continuation of Benefits.

500.3561 Insolvency; continuation of benefits.
Sec. 3561.
A health maintenance organization shall have a plan for handling insolvency that allows for continuation of benefits for the duration of the health maintenance contract period for which premiums have been paid and continuation of benefits to any enrollee who is confined on the date of insolvency in an inpatient facility until his or her discharge from the facility. Continuation of benefits in the event of insolvency is satisfied if the health maintenance organization has at least 1 of the following, as approved by the director:
(a) A financial guarantee contract insured by a surety bond issued by an independent insurer with a secure rating from a rating agency that meets the requirements of section 436a(1)(p).
(b) A reinsurance contract issued by an authorized or eligible insurer to cover the expenses to be paid for continued benefits after an insolvency.
(c) A contract between the health maintenance organization and its affiliated providers that provides for the continuation of provider services in the event of the health maintenance organization's insolvency. A health maintenance organization shall include in a contract under this subdivision a mechanism for appropriate sharing by the health maintenance organization of the continuation of provider services as approved by the director and shall not include a provision that continuation of provider services is solely the responsibility of the affiliated providers.
(d) An irrevocable letter of credit.
(e) An insolvency reserve account established with a federal or state chartered financial institution under a trust indenture acceptable to the director for the sole benefit of subscribers and enrollees, equal to 3 months' premium income.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3565 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3565 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to cancellation of contract with nongroup member enrollee by nongroup subscriber.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3567 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3567 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to cancellation of contract with nongroup member enrollee by health maintenance organization.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3569 - Assumption of Financial Risk.

500.3569 Assumption of financial risk.
Sec. 3569.
(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 health services under a health maintenance organization contract. A health maintenance organization may do any of the following:
(a) Require an affiliated provider to assume financial risk under the terms of its contract.
(b) Obtain insurance.
(c) Make other arrangements for the cost of providing to an enrollee health services the aggregate value of which is more than $5,000.00 in a year for that enrollee.
(2) If the health maintenance organization requires an affiliated provider to assume financial risk under the terms of its contract, the contract must require both of the following:
(a) The health maintenance organization to pay the affiliated provider, including a subcontracted provider, directly or through a licensed third party administrator for health services provided to its enrollees.
(b) The health maintenance organization to keep all pooled funds and withhold amounts and account for them on its financial books and records and reconcile them at year end pursuant to the contract.
(3) For purposes of this section, a health maintenance organization requires an affiliated provider to assume financial risk if it shares with the affiliated provider, in return for consideration, a portion of the chance of loss, including expenses incurred, related to the delivery of health services to enrollees. The type of transactions under which a health maintenance organization may require an affiliated provider to assume financial risk under this section include, but are not limited to, full or partial capitation agreements, withholds, risk corridors, and indemnity agreements.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3571 - State or Federal Health Programs.

500.3571 State or federal health programs.
Sec. 3571.
A health maintenance organization that participates in a state or federal health program shall meet the solvency and financial requirements of this act, unless the health maintenance organization is in receivership or under supervision. Notwithstanding any provision of this act to the contrary, a health maintenance organization that participates in a state or federal health program is not required to offer benefits or services that exceed the requirements of the applicable program. This section does not apply to state employee or federal employee health programs.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2005, Act 306, Imd. Eff. Dec. 21, 2005 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3573 - Operation of Health Care Delivery System Not Meeting Requirements of Act; Permitted Conduct; Limitations.

500.3573 Operation of health care delivery system not meeting requirements of act; permitted conduct; limitations.
Sec. 3573.
(1) A person that proposes to operate a system of health care delivery and financing to be offered to individuals, whether or not as members of groups, in exchange for a fixed payment and to be organized so that providers and the organization are in some part at risk for the cost of services in a manner similar to a health maintenance organization, but that fails to meet the requirements of this act for a health maintenance organization, may operate the system of health care delivery and financing if the director finds that the proposed operation will benefit persons who will be served by it. The director shall authorize and regulate the operation of the system in the same manner as a health maintenance organization under this act, including the filing of periodic reports, except to the extent that the director finds that the regulation is inappropriate to the system of health care delivery and financing.
(2) A person operating a system of health care delivery and financing under this section shall not advertise or solicit or in any way identify itself in a manner implying to the public that it is a health maintenance organization authorized under this act.
History:
Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2016, Act 276, Imd. Eff. July 1, 2016
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-35 - Chapter 35 Health Maintenance Organizations (500.3501...500.3580) › Section 500.3580 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3580 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to consumer guide to health maintenance organization.
Popular Name:
Act 218
Popular Name:
HMO
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-36 - Chapter 36 Group and Blanket Disability Insurance (500.3600...500.3650) › Section 500.3600 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3600 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to scope of chapter.
Popular Name:
Act 218
2023 Michigan Compiled Laws › Chapter 500 - Insurance Code of 1956 › Act 218 of 1956 - The Insurance Code of 1956 (500.100 - 500.8302) › 218-1956-36 - Chapter 36 Group and Blanket Disability Insurance (500.3600...500.3650) › Section 500.3601 - Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.

500.3601 Repealed. 2016, Act 276, Imd. Eff. July 1, 2016.
Compiler's Notes:
The repealed section pertained to "group disability insurance" definition.
Popular Name:
Act 218