Michigan Laws 500.2212b – Policy issued under MCL 550.3405 and to health maintenance organization contract; applicability; termination of affiliation or participation between primary care physician and insurer; notice to insur
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Terms Used In Michigan Laws 500.2212b
- Contract: A legal written agreement that becomes binding when signed.
- Fraud: Intentional deception resulting in injury to another.
- Health maintenance organization: means that term as defined in section 3501. See Michigan Laws 500.106
- Insurer: means an individual, corporation, association, partnership, reciprocal exchange, inter-insurer, Lloyds organization, fraternal benefit society, or other legal entity, engaged or attempting to engage in the business of making insurance or surety contracts. See Michigan Laws 500.106
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
(1) This section applies to a policy issued under section 3405 and to a health maintenance organization contract.
(2) If affiliation or participation between a primary care physician and an insurer terminates, the physician may provide written notice of this termination within 15 days after the physician becomes aware of the termination to each insured who has chosen the physician as his or her primary care physician. If an insured is in an ongoing course of treatment with any other physician that is affiliated or participating with the insurer and the affiliation or participation between the physician and the insurer terminates, the physician may provide written notice of this termination to the insured within 15 days after the physician becomes aware of the termination. The notices under this subsection may also describe the procedure for continuing care under subsections (3) and (4).
(3) If affiliation or participation between an insured’s current physician and an insurer terminates, the insurer shall permit the insured to continue an ongoing course of treatment with that physician as follows:
(a) For 90 days after the date of notice to the insured by the physician of the physician’s termination with the insurer.
(b) If the insured is in her second or third trimester of pregnancy at the time of the physician’s termination, through postpartum care directly related to the pregnancy.
(c) If the insured is determined to have an advanced illness before a physician’s termination or knowledge of the termination and the physician was treating the advanced illness before the date of termination or knowledge of the termination, for the remainder of the insured’s life for care directly related to the treatment of the advanced illness.
(4) Subsection (3) applies only if the physician agrees to all of the following:
(a) To continue to accept as payment in full reimbursement from the insurer at the rates applicable before the termination.
(b) To adhere to the insurer’s standards for maintaining quality health care and to provide to the insurer necessary medical information related to the care.
(c) To otherwise adhere to the insurer’s policies and procedures, including, but not limited to, those concerning utilization review, referrals, preauthorizations, and treatment plans.
(5) An insurer shall provide written notice to each affiliated or participating physician that if affiliation or participation between the physician and the insurer terminates, the physician may do both of the following:
(a) Notify the insurer’s insureds under the care of the physician of the termination if the physician does so within 15 days after the physician becomes aware of the termination.
(b) Include in the notice under subdivision (a) a description of the procedures for continuing care under subsections (3) and (4).
(6) This section does not create an obligation for an insurer to provide to an insured coverage beyond the maximum coverage limits permitted by the insurer’s policy or certificate with the insured. This section does not create an obligation for an insurer to expand who may be a primary care physician under a policy or certificate.
(7) As used in this section:
(a) “Advanced illness” means that term as defined in section 5653 of the public health code, 1978 PA 368, MCL 333.5653.
(b) “Physician” means an allopathic physician, osteopathic physician, or podiatric physician.
(c) “Terminates” or “termination” includes the nonrenewal, expiration, or ending for any reason of a participation agreement or affiliated provider contract between a physician and an insurer, but does not include a termination by the insurer for failure to meet applicable quality standards or for fraud.