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HOUSE BILL NO. 6133
A bill to amend 1939 PA 280, entitled
"The social welfare act,"
by amending sections 105d, 109, 111i, and 111j (MCL 400.105d,
400.109, 400.111i, and 400.111j), section 105d as amended by 2023
PA 98, section 109 as amended by 2025 PA 45, section 111i as added
by 2000 PA 187, and section 111j as added by 1988 PA 445, and by
adding sections 111o, 111p, and 111q.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 105d. (1) The department shall seek approval from the 1
United States Department of Health and Human Services to do, 2
June 25, 2026, Introduced by Reps. Aragona, Johnsen, DeBoyer and Harris and referred to
Committee on Insurance.
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without jeopardizing federal match dollars or otherwise incurring 1
federal financial penalties, and upon on approval shall do, all of 2
the following: 3
(a) Enroll individuals eligible under section 4
1396a(a)(10)(A)(i)(VIII) of title XIX who meet the citizenship 5
provisions of 42 CFR 435.406 and who are otherwise eligible for the 6
medical assistance program under this act into a contracted health 7
plan. 8
(b) Give enrollees described in subdivision (a) a choice in 9
choosing among contracted health plans. 10
(c) Ensure that all enrollees described in subdivision (a) 11
have access to a primary care practitioner who is licensed, 12
registered, or otherwise authorized to engage in the primary care 13
practitioner's health care profession in this state and to 14
preventive services. The department shall require that all new 15
enrollees be assigned and have scheduled an initial appointment 16
with their primary care practitioner within 60 days of initial 17
enrollment. The department shall monitor and track contracted 18
health plans for compliance in this area with this subdivision and 19
consider that compliance in any health plan incentive programs. The 20
department shall ensure that the contracted health plans have 21
procedures to ensure that the privacy of the enrollees' personal 22
information is protected in accordance with the health insurance 23
portability and accountability act of 1996, Public Law 104-191. 24
(d) Establish cost sharing requirements for enrollees 25
described in subsection (1)(a) subdivision (a) as approved by the 26
United States Department of Health and Human Services. 27
(e) Implement a plan to encourage use of high-value services, 28
while discouraging low-value services such as nonurgent emergency 29
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department use. 1
(f) Develop incentives for enrollees and providers who assist 2
the department in detecting fraud and abuse in the medical 3
assistance program. The department shall provide an annual report 4
that includes the type of fraud detected, the amount saved, and the 5
outcome of the investigation to the legislature. 6
(g) Allow for services provided by telemedicine from a 7
practitioner who is licensed, registered, or otherwise authorized 8
under section 16171 of the public health code, 1978 PA 368, MCL 9
333.16171, to engage in the practitioner's health care profession 10
in the state where the patient is located. 11
(2) For services rendered to an uninsured individual, a 12
hospital that participates in the medical assistance program under 13
this act shall accept 115% of Medicare rates as payments in full 14
from an uninsured individual with an annual income level up to 250% 15
of the federal poverty guidelines. 16
(3) The department shall develop and implement a plan to 17
enroll all existing fee-for-service enrollees into contracted 18
health plans if allowable by law, if the medical assistance program 19
is the primary payer and if that enrollment is cost-effective. This 20
includes all newly eligible enrollees as described in subsection 21
(1)(a). The department shall include contracted health plans as the 22
mandatory delivery system in its waiver request. The department 23
shall identify all remaining populations eligible for managed care, 24
develop plans for their integration into managed care, and provide 25
recommendations for a performance bonus incentive plan mechanism 26
for long-term care managed care providers that are consistent with 27
other managed care performance bonus incentive plans. The 28
department shall make recommendations for a performance bonus 29
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incentive plan for long-term care managed care providers of up to 1
3% of their Medicaid capitation payments, consistent with other 2
managed care performance bonus incentive plans. These payments 3
shall must comply with federal requirements and shall be based on 4
measures that identify the appropriate use of long-term care 5
services and that focus on consumer satisfaction, consumer choice, 6
and other appropriate quality measures applicable to community-7
based and nursing home services. Beginning on the effective date of 8
the amendatory act that added section 111o, the department shall 9
disenroll an individual in a skilled nursing facility who is 10
enrolled under the Michigan coordinated health plan after 45 days 11
of care in the skilled nursing facility. The department shall 12
automatically enroll the individual disenrolled under this 13
subsection into a fee-for-service plan under the medical assistance 14
program. 15
(4) The department shall implement a pharmaceutical benefit to 16
encourage the use of high-value, low-cost prescriptions, such as 17
generic prescriptions when such an alternative exists for a branded 18
product and 90-day prescription supplies, as recommended by the 19
enrollee's prescribing provider and as is consistent with section 20
109h and sections 9701 to 9709 of the public health code, 1978 PA 21
368, MCL 333.9701 to 333.9709. 22
(5) The department in collaboration with the contracted health 23
plans shall create financial incentives for enrollees who 24
demonstrate improved health outcomes, practice healthy behaviors, 25
or complete screenings or procedures that improve health outcomes. 26
(6) The performance bonus incentive pool for contracted health 27
plans shall must include targets established for at least 3 and no 28
more than 5 objectives established by the department in 29
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collaboration with the contracted health plans. Targets should 1
focus on key current health priorities, improve health equity, 2
utilize established measurements to set a baseline for performance 3
improvement, and be determined at least 6 months before the 4
measurement period to support planning and execution necessary for 5
achievement of desired outcomes. 6
(7) The department shall ensure that all capitated payments 7
made to contracted health plans are actuarially sound. This 8
subsection applies whether or not either or both of the waivers 9
requested under this section are approved, the patient protection 10
and affordable care act is repealed, or the state terminates or 11
opts out of the program established under this section. 12
(8) The department shall withhold, at a minimum, 0.75% of 13
payments to contracted health plans, except for specialty prepaid 14
health plans, for the purpose of expanding the existing performance 15
bonus incentive pool. Distribution of funds from the performance 16
bonus incentive pool is contingent on the contracted health plan's 17
completion of the required performance or compliance metrics. 18
(9) The department may measure contracted health plan or 19
specialty prepaid health plan performance metrics, as applicable, 20
on application of standards of care as that relates to appropriate 21
treatment of substance use disorders and efforts to reduce 22
substance use disorders. 23
(10) The department shall make available at least 3 years of 24
state medical assistance program data, without charge, to any 25
vendor considered qualified by the department who indicates 26
interest in submitting proposals to contracted health plans in 27
order to implement cost savings and population health improvement 28
opportunities through the use of innovative information and data 29
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management technologies. Any program or proposal to the contracted 1
health plans must be consistent with the state's goals of improving 2
health, increasing the quality, reliability, availability, and 3
continuity of care, and reducing the cost of care of the eligible 4
population of enrollees described in subsection (1)(a). The use of 5
the data described in this subsection for the purpose of assessing 6
the potential opportunity and subsequent development and submission 7
of formal proposals to contracted health plans is not a cost or 8
contractual obligation to the department or the state. 9
(11) For the purposes of submitting reports and other 10
information or data required under this section only, "legislature" 11
means the senate majority leader, the speaker of the house of 12
representatives, the chairs of the senate and house of 13
representatives appropriations committees, the chairs of the senate 14
and house of representatives appropriations subcommittees on the 15
department budget, and the chairs of the senate and house of 16
representatives standing committees on health policy. 17
(12) As used in this section: 18
(a) "Patient protection and affordable care act" means the 19
patient protection and affordable care act, Public Law 111-148, as 20
amended by the federal health care and education reconciliation act 21
of 2010, Public Law 111-152. 22
(b) "Telemedicine" means that term as defined in section 3476 23
of the insurance code of 1956, 1956 PA 218, MCL 500.3476. 24
Sec. 109. (1) An eligible individual may receive the following 25
medical services under this act: 26
(a) Hospital services that an eligible individual may receive 27
consist of medical, surgical, or obstetrical care, together with 28
necessary drugs, X-rays, physical therapy, prosthesis, 29
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transportation, and nursing care incident to the medical, surgical, 1
or obstetrical care. The period of inpatient hospital service must 2
be the minimum period necessary in this type of facility for the 3
proper care and treatment of the individual. Necessary 4
hospitalization to provide dental care must be provided if 5
certified by the attending dentist with the approval of the 6
department. An individual who is receiving medical treatment as an 7
inpatient because of a diagnosis of mental disease may receive 8
service under this section, notwithstanding the mental health code, 9
1974 PA 258, MCL 330.1001 to 330.2106. The department must pay for 10
hospital services according to the state plan for medical 11
assistance adopted under section 10 and approved by the United 12
States Department of Health and Human Services. 13
(b) Physician Physician's services authorized by the 14
department. The services may be furnished in the physician's 15
office, the eligible individual's home, a medical institution, or 16
elsewhere in case of emergency. A physician must be paid a 17
reasonable charge for the service rendered. The department must 18
determine reasonable charges. Reasonable charges must not be more 19
than those paid in this state for services rendered under title 20
XVIII. 21
(c) Nursing home services in a state licensed nursing home, a 22
medical care facility, or other facility or identifiable unit of 23
that facility, certified by the appropriate authority as meeting 24
established standards for a nursing home under the laws and rules 25
of this state and the United States Department of Health and Human 26
Services, to the extent found necessary by the attending physician, 27
dentist, or certified Christian Science practitioner. An eligible 28
individual may receive nursing home services in an extended care 29
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services program established under section 22210 of the public 1
health code, 1978 PA 368, MCL 333.22210, to the extent found 2
necessary by the attending physician when the combined length of 3
stay in the acute care bed and short-term nursing care bed exceeds 4
the average length of stay for Medicaid hospital diagnostic related 5
group reimbursement. The department shall not make a final payment 6
under title XIX for benefits available under title XVIII without 7
documentation that title XVIII claims have been filed and denied. 8
The department must pay for nursing home services according to the 9
state plan for medical assistance adopted according to section 10 10
and approved by the United States Department of Health and Human 11
Services. A county must reimburse a county maintenance of effort 12
rate determined on an annual basis for each patient day of Medicaid 13
nursing home services provided to eligible individuals in long-term 14
care facilities owned by the county and licensed to provide nursing 15
home services. For purposes of determining rates and costs 16
described in this subdivision, all of the following apply: 17
(i) For county-owned facilities with per patient day updated 18
variable costs exceeding the variable cost limit for the county 19
facility, county maintenance of effort rate means 45% of the 20
difference between per patient day updated variable cost and the 21
concomitant nursing home-class variable cost limit, the quantity 22
offset by the difference between per patient day updated variable 23
cost and the concomitant variable cost limit for the county 24
facility. The county rate must not be less than zero. 25
(ii) For county-owned facilities with per patient day updated 26
variable costs not exceeding the variable cost limit for the county 27
facility, county maintenance of effort rate means 45% of the 28
difference between per patient day updated variable cost and the 29
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concomitant nursing home class variable cost limit. 1
(iii) For county-owned facilities with per patient day updated 2
variable costs not exceeding the concomitant nursing home class 3
variable cost limit, the county maintenance of effort rate must 4
equal zero. 5
(iv) For the purposes of this section: "per patient day updated 6
variable costs and the variable cost limit for the county facility" 7
must be determined according to the state plan for medical 8
assistance; for freestanding county facilities the "nursing home 9
class variable cost limit" must be determined according to the 10
state plan for medical assistance and for hospital attached county 11
facilities the "nursing class variable cost limit" must be 12
determined according to the state plan for medical assistance plus 13
$5.00 per patient day; and "freestanding" and "hospital attached" 14
must be determined according to the federal regulations. 15
(v) If the county maintenance of effort rate computed under 16
this section exceeds the county maintenance of effort rate in 17
effect as of September 30, 1984, the rate in effect as of September 18
30, 1984 must remain in effect until a time that the rate computed 19
under this section is less than the September 30, 1984 rate. This 20
limitation remains in effect until December 31, 2030 or until a new 21
reimbursement system determined by the department replaces the 22
current system, whichever is sooner. For each subsequent county 23
fiscal year, the maintenance of effort rate may not increase by 24
more than $1.00 per patient day each year. 25
(vi) For county-owned facilities, reimbursement for plant costs 26
must continue to be based on interest expense and depreciation 27
allowance unless otherwise provided by law. 28
(d) Pharmaceutical services from a licensed pharmacist of the 29
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individual's choice as prescribed by a licensed physician or 1
dentist and approved by the department. In an emergency, but not 2
routinely, the individual may receive pharmaceutical services 3
rendered personally by a licensed physician or dentist on the same 4
basis as approved for pharmacists. 5
(e) Other medical and health services as authorized by the 6
department. 7
(f) Psychiatric care provided according to the guidelines 8
established by the department to the extent of appropriations made 9
available by the legislature for the fiscal year. 10
(g) Screening, laboratory services, diagnostic services, early 11
intervention services, and treatment for chronic kidney disease 12
under guidelines established by the department. A clinical 13
laboratory performing a creatinine test on an eligible individual 14
under this subdivision must include in the lab report the 15
glomerular filtration rate (eGFR) of the individual and must report 16
it as a percentage of kidney function remaining. 17
(h) Medically necessary acute medical detoxification for 18
opioid use disorder, medically necessary inpatient care at an 19
approved facility, or care in an appropriately licensed substance 20
use disorder residential treatment facility. 21
(i) Mental health screenings during the postpartum period as 22
described in section 9137 of the public health code, 1978 PA 368, 23
MCL 333.9137. 24
(2) The director must provide notice to the public, according 25
to applicable federal regulations, and must obtain the approval of 26
the committees on appropriations of the house of representatives 27
and senate of the state legislature, of a proposed change in the 28
statewide method or level of reimbursement for a service, if the 29
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proposed change is expected to increase or decrease payments for 1
that service by 1% or more during the 12 months after the effective 2
date of the change. 3
(3) At the time of enrollment, a Medicaid managed care 4
organization shall make the following information available to an 5
enrolled individual: 6
(a) Identity, location, qualifications, and availability of 7
participating providers. 8
(b) Enrollee rights and responsibilities. 9
(c) Grievance and appeal procedures. 10
(d) Covered items and services. 11
(4) (3) As used in this act: 12
(a) "Medicaid managed care organization" means a Medicaid 13
contracted health plan. 14
(b) (a) "Title XVIII" means title XVIII of the social security 15
act, 42 USC 1395 to 1395lll.1395mmm. 16
(c) (b) "Title XIX" means title XIX of the social security 17
act, 42 USC 1396 to 1396w-7.1396w-9. 18
(d) (c) "Title XX" means title XX of the social security act, 19
42 USC 1397 to 1397n-13. 20
Sec. 111i. (1) The commissioner director of office the 21
department of insurance and financial and insurance services shall 22
establish a timely claims processing and payment procedure to be 23
used by health professionals and facilities in billing for, and 24
qualified health plans in processing and paying claims for, 25
medicaid Medicaid services rendered. The commissioner director of 26
the department of insurance and financial services shall consult 27
with the department, of community health, health professionals and 28
facilities, and qualified health plans in establishing this the 29
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timely payment procedure established under this subsection. 1
(2) The timely claims processing and payment procedure 2
established by the commissioner director of the department of 3
insurance and financial services under subsection (1) shall must 4
provide for all of the following: 5
(a) That a "clean claim", for the purposes of this section, 6
means a claim that does, at a minimum, all of the following: 7
(i) Identifies the health professional or health facility that 8
provided treatment or service, including a matching identifying 9
number. 10
(ii) Identifies the patient and plan. 11
(iii) Lists the date and place of service. 12
(iv) Is for covered services. 13
(v) Is certified pursuant to under section 111b(17) and has 14
the identifying information required under section 111b(21). 15
(vi) If necessary, substantiates the medical necessity and 16
appropriateness of the care or service provided. 17
(vii) If prior authorization is required for certain patient 18
care or services, includes any applicable authorization number, as 19
appropriate. 20
(viii) Includes additional documentation based upon on services 21
rendered as reasonably required by the payer. 22
(b) A universal system of coding to be used on all medicaid 23
Medicaid claims submitted to qualified health plans. 24
(c) That a claim must be transmitted electronically or as 25
otherwise specified by the commissioner and a qualified health plan 26
must be able to receive a claim transmitted electronically. 27
(d) That a health professional and facility must bill a 28
qualified health plan within 1 year after the date of service or 29
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date of discharge from the health facility. 1
(e) That after a health professional or facility has submitted 2
a claim to a qualified health plan, the health professional or 3
facility shall not resubmit the same claim to the qualified health 4
plan unless the time frame in subdivision (f) has passed or as 5
provided in subdivision (h). 6
(f) Except as otherwise provided in this subdivision, that a 7
clean claim must be paid within 45 days after receipt of the claim 8
by the qualified health plan. For a pharmaceutical clean claim, the 9
clean claim must be paid within the industry standard time frame 10
for paying the claim as of the effective date of this subdivision 11
June 20, 2000, or within 45 days after receipt of the claim by the 12
qualified health plan, whichever is sooner. A clean claim that is 13
not paid within this time frame shall must bear simple interest at 14
a rate of 12% per annum. 15
(g) That a qualified health plan must state in writing to the 16
health professional or facility any defect in the claim within 30 17
days after receipt of the claim. 18
(h) That a health professional and a health facility have 30 19
days after receipt of a notice that a claim or a portion of a claim 20
is defective within which to correct the defect. The qualified 21
health plan shall pay the claim within 30 days after the defect is 22
corrected. 23
(i) That a qualified health plan must notify the health 24
professional or facility and the commissioner of the defect if a 25
claim or a portion of a claim is returned from a health 26
professional or facility under subdivision (h) and remains 27
defective for the original reason or a new reason. 28
(j) An external review procedure for adverse determinations of 29
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payment as provided in subsections (4) and (5). The costs for the 1
external review procedure shall must be assessed as determined by 2
the commissioner.director of the department of insurance and 3
financial services. 4
(k) Penalties to be applied to health professionals, health 5
facilities, and qualified health plans for failing to adhere to the 6
timely claims processing and payment procedure established under 7
this section. 8
(l) A system for notifying the licensing entity for health 9
maintenance organizations, qualified health plans, and other health 10
care insurers if a penalty is incurred under subdivision (k). 11
(3) If a qualified health plan determines that 1 or more 12
covered services listed on a claim are payable, the qualified 13
health plan shall pay for those services and shall not deny the 14
entire claim because 1 or more other covered services listed on the 15
claim are defective or because 1 or more other services listed on 16
the claim are not covered services. 17
(4) The commissioner director of the department of insurance 18
and financial services shall establish an external review procedure 19
as provided in this subsection and subsection (5). A health 20
professional or facility may request an external review by the 21
commissioner director of the department of insurance and financial 22
services of a qualified health plan's adverse determination if the 23
health professional or facility makes the request not later than 30 24
days after receipt of a the notice required under subsection 25
(2)(i). Within 10 days after a request for an external review, the 26
commissioner director of the department of insurance and financial 27
services shall complete a preliminary review to determine whether 28
the external review may proceed or request more information from 29
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the health professional, facility, or the qualified health plan. 1
The health professional, facility, or the qualified health plan 2
shall supply the commissioner director of the department of 3
insurance and financial services with the requested information not 4
later than 10 business days after receipt of the request for 5
information from the commissioner. director of the department of 6
insurance and financial services. Not later than 5 business days 7
after receipt of any information requested by the commissioner, 8
director of the department of insurance and financial services, the 9
commissioner director of the department of insurance and financial 10
services shall complete a preliminary review to determine whether 11
the external review may proceed. If the commissioner director of 12
the department of insurance and financial services determines the 13
external review may not proceed, the commissioner director of the 14
department of insurance and financial services shall notify in 15
writing the health professional or facility of the specific reasons 16
for the determination and may permit the health professional or 17
facility to reapply for a preliminary review by the commissioner. 18
If the commissioner determines the external review may proceed, the 19
commissioner shall notify in writing the health professional or 20
facility and the qualified health plan and shall require the 21
qualified health plan to provide, not later than 7 business days 22
after receipt of the notice, any information used by the qualified 23
health plan in making the adverse determination. Failure by a 24
health professional, or facility, or qualified health plan to 25
provide the commissioner director of the department of insurance 26
and financial services with requested information permits the 27
commissioner director of the department of insurance and financial 28
services to terminate a review and issue a decision reversing or 29
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affirming an adverse determination. 1
(5) If the commissioner director of the department of 2
insurance and financial services determines that an external review 3
may proceed, the commissioner director of the department of 4
insurance and financial services shall immediately assign an 5
independent review organization to conduct the external review. 6
Only an independent review organization meeting qualifications 7
established by the commissioner shall director of the department of 8
insurance and financial services may be assigned to conduct an 9
external review. The independent review organization may request 10
the health professional or facility and the qualified health plan 11
to provide information and shall review all pertinent information 12
submitted by the health professional or facility and the qualified 13
health plan along with the terms of coverage under the medicaid 14
Medicaid plan. The independent review organization shall make a 15
written recommendation that includes the rationale and supporting 16
documentation and any recommendation for an assessment of interest 17
to the commissioner supporting documentation not later than 30 days 18
after being assigned as the review organization. The commissioner 19
director of the department of insurance and financial services 20
shall notify in writing the health professional or facility and the 21
qualified health plan of his or her the decision of the director 22
of the department of insurance and financial services reversing or 23
affirming the qualified health plan's adverse determination and 24
shall include the principal reasons for the decision not later than 25
15 days after receipt of the assigned independent review 26
organization's recommendation. If an adverse determination is 27
reversed, the qualified health plan shall immediately pay the claim 28
and any interest assessed by the commissioner. director of the 29
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department of insurance and financial services. 1
(6) Beginning not later than October 1, 2000 and continuing 2
thereafter, the department of community health shall not enter into 3
or renew a contract with a qualified health plan unless the 4
qualified health plan agrees to follow the timely claims processing 5
and payment procedure established under this section and requires 6
health professionals and facilities under contract with the 7
qualified health plan to follow the timely claims processing and 8
payment procedure established under this section. The department of 9
community health shall not enter into or renew a contract with a 10
qualified health plan unless the commissioner director of the 11
department of insurance and financial services determines that the 12
qualified health plan satisfies all of the following: 13
(a) Is a health maintenance organization licensed or issued a 14
certificate of authority in this state. 15
(b) Uses standardized claims as outlined in the provider 16
contract and accepts claims submitted electronically in a generally 17
accepted format. 18
(c) Demonstrates the ability to provide all required or 19
covered medicaid Medicaid services including covered specialty care 20
to the estimated number of enrollees on a regional basis. 21
(d) Meets the criteria for delivering the comprehensive 22
package of services under the department of community health's 23
department's comprehensive health plan. 24
(7) The commissioner director of the department of insurance 25
and financial services shall report to the senate and house of 26
representatives appropriations subcommittees on community health by 27
October 1, 2001 on the timely claims processing and payment 28
procedure established under this section. 29
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(8) It is not a fraudulent act for a health professional or 1
facility to submit a claim under this section that includes 1 or 2
more rendered services that are determined not to constitute 3
covered services. 4
(9) Beginning January 1, 2027, a Medicaid managed care 5
organization shall ensure that 99% of clean claims from providers 6
are adjudicated within 14 calendar days after receipt of the 7
claims, and 100% are adjudicated within 30 calendar days after 8
receipt of the claims, for covered services rendered to covered 9
individuals in skilled nursing facilities who are enrolled with the 10
Medicaid managed care organization at the time the service was 11
delivered. A clean claim that is not paid within 14 calendar days 12
must bear a simple interest payment of 12% per annum. 13
(10) A managed care plan shall initiate administrative action 14
and recover improper payments or overpayments related to claims 15
paid by the managed care plan within 6 months after the date the 16
claim was paid or after the date of any applicable reconciliation, 17
whichever is later. Except for overpayments identified under a 18
credible allegation of fraud, the managed care plan shall confer 19
with the applicable state agency before pursuing overpayment 20
recoveries for claims where more than 6 months have passed since 21
the claims were paid or adjudicated. The managed care plan shall 22
not subject these claims to repayment or offset against future 23
claim reimbursements without prior consent from the applicable 24
state agency. Any claim improperly recovered or offset will be 25
subject to penalties of up to $1,000.00 per claim. 26
(11) (9) As used in this section: 27
(a) "Medicaid" means the program of medical assistance program 28
established under section 105. 29
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(b) "Medicaid managed care organization" means a Medicaid 1
contracted health plan. 2
(c) (b) "Qualified health plan" means, at a minimum, an 3
organization that meets the criteria for delivering the 4
comprehensive package of services under the department of community 5
health's department's comprehensive health plan. 6
Sec. 111j. (1) If Except as otherwise provided in section 7
111o, if the director requires prior authorization for any medical 8
services or equipment, a request by a provider for prior 9
authorization shall must be approved or rejected within 15 working 10
days after the request is received by the director. If additional 11
information is needed in support of the prior authorization 12
request, the director shall request additional information either 13
verbally or in writing not later than 15 working days after 14
receiving the prior authorization request. Upon On receiving the 15
additional information from the provider, the director shall 16
approve or deny the completed prior authorization request not later 17
than 10 working days after receiving the additional information. 18
The time period limitations specified in this subsection shall does 19
not apply to prior authorization requests for transplantation and 20
other extraordinary services. 21
(2) Claims for routine, ordinary medical services or equipment 22
shall must not be subject to prior authorization, and claims for 23
medical supplies shall must not be subject to prior authorization. 24
(3) The director, by rule, shall do both of the following: 25
(a) Prescribe, by category, what information is required from 26
a provider to support a request for prior authorization. 27
(b) Prescribe which medical services or equipment are subject 28
to prior authorization and list, by category, those medical 29
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services or equipment. 1
(4) The director shall establish a reimbursement system for 2
medical services or equipment receiving prior authorization based 3
upon on reasonable cost up to a maximum reimbursement screen of 4
acquiring the medical service or equipment, and shall develop an 5
automated payment system, including at least fee screens and 6
necessary edits. The state department shall make vendor payments 7
through the automated payment system. 8
(5) The director shall waive the requirement for prior 9
authorization if both of the following conditions exist: 10
(a) Processing a request for prior authorization will cause an 11
inpatient hospital stay to be prolonged. 12
(b) The cost of the medical services or equipment is less than 13
the estimated cost of the additional inpatient hospital stay. 14
(6) The director, not later than 180 days after the effective 15
date of this section, March 30, 1989, shall maintain and implement 16
automated records of all approved prior authorization requests 17
according to each medical services recipient involved. 18
(7) This section does not authorize the provision of any 19
medical services, supplies, or equipment that are not otherwise 20
designated to be covered services, supplies, or equipment under 21
this act. 22
(8) As used in this section: , "prior authorization" means a 23
requirement imposed by the director, by which any claim for a 24
particular covered medical service or equipment is payable only if 25
the director's approval for the provision of that service or 26
equipment is given before the service or equipment is furnished. 27
(a) (9) As used in this section, "by category" "By category" 28
means using a categorization system containing at least each of the 29
21
OOH H05835'25_HB6133_INTR_1 g4sqrn
following categories: 1
(i) (a) Communication aids. 2
(ii) (b) Hearing aids. 3
(iii) (c) Incontinence supplies. 4
(iv) (d) Orthotic devices. 5
(v) (e) Ostomy supplies. 6
(vi) (f) Prosthetic devices. 7
(vii) (g) Respiratory equipment. 8
(viii) (h) Seating systems. 9
(ix) (i) Visual aids. 10
(x) (j) Wheelchairs and mobility aids. 11
(b) "Prior authorization" means a requirement imposed by the 12
director, by which any claim for a particular covered medical 13
service or equipment is payable only if the director's approval for 14
the provision of that service or equipment is given before the 15
service or equipment is furnished. 16
Sec. 111o. (1) A Medicaid managed care organization shall 17
provide a standard prior authorization decision for a nursing 18
facility within 7 calendar days of submission and an expedited 19
prior authorization decision within 72 hours of submission. 20
(2) A Medicaid managed care organization shall provide 21
specific information about prior authorization denials, regardless 22
of how the prior authorization request is submitted. 23
(3) A prior authorization request that is not authorized 24
within the time frames specified in subsections (1) and (2) must be 25
considered approved. 26
(4) Beginning not later than January 1, 2027, each Medicaid 27
managed care organization shall submit to the department quarterly 28
data on all of the following, disaggregated by provider type, for 29
22
OOH H05835'25_HB6133_INTR_1 g4sqrn
skilled nursing facilities: 1
(a) Prior authorization activity, including information 2
regarding all of the following: 3
(i) Total number of prior authorization requests received. 4
(ii) Number of requests approved. 5
(iii) Number of requests denied. 6
(iv) Number of denied requests that were appealed. 7
(v) Outcome of appealed decisions, including the number 8
reversed in whole or in part. 9
(b) Concurrent review activity, including information 10
regarding all of the following: 11
(i) Total number of concurrent review requests received. 12
(ii) Frequency of concurrent review requests by service type 13
and provider type. 14
(iii) Number of concurrent review requests approved in full. 15
(iv) Number of concurrent review requests denied in whole or in 16
part. 17
(v) Number of denied requests that were appealed by the 18
enrollee or provider. 19
(vi) Outcome of appealed decisions, including the number of 20
denials reversed in full, in part, or upheld. 21
(c) Postservice payment activity, including information 22
regarding all of the following: 23
(i) Number of claims denied after services were rendered. 24
(ii) Number of denials under subparagraph (i) that involved 25
services previously authorized or approved. 26
(iii) Number and outcome of provider or enrollee appeals related 27
to postservice denials. 28
23
OOH H05835'25_HB6133_INTR_1 g4sqrn
(d) Timeliness and delay metrics, including information 1
regarding all of the following: 2
(i) Average and median time to decision for initial prior 3
authorization requests. 4
(ii) Number and percentage of delayed authorizations that 5
exceeded the Centers for Medicare and Medicaid Services timeliness 6
standards. All metrics under this subparagraph must be reported 7
separately for each provider type in a manner enabling comparative 8
analysis across provider categories. 9
(5) The department shall make the data submitted under 10
subsection (4) available to the public on its website in a format 11
that comports with all of the following: 12
(a) Enables beneficiaries and providers to compare plans by 13
prior authorization and denial metrics. 14
(b) Disaggregates data by provider type, service category, and 15
geographic region where feasible. 16
(c) Protects personally identifiable information and 17
proprietary trade secrets. 18
(d) Is searchable, downloadable, and updated at least 19
quarterly. 20
(6) The department shall develop and publish a consumer-facing 21
summary for each Medicaid managed care organization that includes 22
all of the following information: 23
(a) Overall denial rate for prior authorization requests. 24
(b) Percentage of denials overturned on appeal. 25
(c) Percentage of postservice payment denials. 26
(d) Timeliness of decisions. 27
(e) Any relevant compliance actions or corrective action plans 28
imposed on the plan by the Centers for Medicare and Medicaid 29
24
OOH H05835'25_HB6133_INTR_1 g4sqrn
Services relating to utilization management practices. 1
(f) Clear indicators showing how the plan performs across 2
different provider types. 3
(7) As used in this section: 4
(a) "Appeal" includes all levels of reconsideration or review 5
initiated by the beneficiary or provider, including external review 6
entities. 7
(b) "Concurrent review" means a utilization management process 8
conducted by a Medicaid managed care organization or any of its 9
delegated entities during the course of an enrollee's ongoing 10
receipt of healthcare services, for the purpose of determining the 11
continued medical necessity, appropriateness, or level of care of 12
such services in real time or near real time. 13
(c) "Medicaid managed care organization" means a Medicaid 14
contracted health plan. 15
(d) "Payment denial" means a refusal to pay, in whole or in 16
part, for services rendered by a provider, regardless of prior 17
authorization status. 18
(e) "Prior authorization" means any requirement imposed by a 19
managed care plan for approval of coverage before a service or item 20
is furnished to a beneficiary. 21
(f) "Provider type" means the category of provider furnishing 22
services, as defined by the Centers for Medicare and Medicaid 23
Services, including hospitals, skilled nursing facilities, home 24
health agencies, hospice providers, physicians, and other entities. 25
Sec. 111p. (1) A Medicaid managed care organization shall 26
ensure that nursing facilities and long-term supports and services 27
providers are paid no less than the current Medicaid fee-for-28
service rate. 29
25
OOH H05835'25_HB6133_INTR_1 g4sqrn
(2) Quality assurance supplement payments must be paid 1
monthly. 2
Sec. 111q. (1) A Medicaid managed care organization must 3
always be ready and willing to enter into health care provider 4
service contracts with a qualified health care provider of the 5
category or categories that are necessary to provide the health 6
care services covered by the Medicaid managed care organization if 7
the health care provider meets all of the following requirements: 8
(a) Is licensed in this state. 9
(b) Desires to become a participant health care provider of 10
the Medicaid managed care organization. 11
(c) Meets the requirements of the Medicaid managed care 12
organization. 13
(d) Practices within the general area served by the Medicaid 14
managed care organization. 15
(2) This section does not preclude a Medicaid managed care 16
organization from refusing to contract with a health care provider 17
who is unqualified or does not meet the terms and conditions of the 18
Medicaid managed care organization's participating provider 19
contract, or from terminating or refusing to renew the contract of 20
a health care provider who is unqualified or does not comply with, 21
or refuses to comply with, the terms and conditions of the 22
participating health care provider contract, including, but not 23
limited to, practice standards and quality requirements. The 24
contract must provide for written notice to the participating 25
health care provider detailing any breach of contract for which the 26
Medicaid managed care organization proposes that the contract be 27
terminated or not renewed and provide for a reasonable period of 28
time for the participating health care provider to cure the breach 29
26
OOH H05835'25_HB6133_INTR_1 g4sqrn
before termination or nonrenewal. If the breach has not been cured 1
within that time, the contract may be terminated or not renewed. 2
Notwithstanding this subsection, if the breach of contract for 3
which the Medicaid managed care organization proposes that the 4
contract be terminated or not renewed is a willful breach, fraud, 5
or a breach that poses an immediate danger to public health or 6
safety, the contract may be terminated or not renewed immediately. 7
(3) A Medicaid managed care organization must establish a 8
grievance procedure for health care providers that provides for 9
arbitration or other grievance procedures that provide for 10
reasonable due process protections for the resolution of grievances 11
and the protection of the rights of the parties. 12
(4) A Medicaid managed care organization may not require, as 13
an element of any health care provider contract, that the health 14
care provider agree to do any of the following: 15
(a) Deny an eligible individual access to services not covered 16
by the Medicaid managed care plan if the eligible individual is 17
informed that the eligible individual will be responsible to pay 18
for the noncovered services and the member nonetheless desires to 19
obtain the services. 20
(b) Refrain from treating an eligible individual, at the 21
eligible individual's request and expense, if the health care 22
provider has been, but is no longer, a contracting health care 23
provider under the Medicaid managed care plan and the health care 24
provider has notified the eligible individual that the health care 25
provider is no longer a contracting health care provider under the 26
Medicaid managed care plan. 27
(c) Renegotiate adjustment by the Medicaid managed care 28
organization of the heath care provider's contractual reimbursement 29
27
OOH H05835'25_HB6133_INTR_1 g4sqrn
rate to equal the lowest reimbursement rate the health care 1
provider has agreed to charge any other payor. 2
(d) Adjust or enter into negotiations to adjust the health 3
care provider's charges to the Medicaid managed care organization 4
if the health care provider agrees to charge another payor lower 5
rates. 6
(e) Disclose the health care provider's contractual 7
reimbursement rates from other payors. 8
(5) A Medicaid managed care organization shall not refuse to 9
contract with or compensate for covered services an otherwise 10
eligible health care provider or nonparticipating health care 11
provider solely because the provider has in good faith communicated 12
with 1 or more current, former, or prospective patients regarding 13
the provisions, terms, or requirements of the Medicaid managed care 14
organization's products as they relate to the needs of the 15
provider's patients. 16
(6) As part of a health care provider contract, a Medicaid 17
managed care organization may require a health care provider to 18
indemnify and hold harmless the Medicaid managed care organization 19
under certain circumstances if the Medicaid managed care 20
organization also agrees to indemnify and hold harmless the health 21
care provider under comparable circumstances. 22
(7) On request and within a reasonable time, a Medicaid 23
managed care organization shall make available to any party to a 24
health care provider contract any documents referred to or adopted 25
by reference in the contract except for information that is 26
proprietary, a trade secret, or a confidential personnel record. 27
(8) A Medicaid managed care organization shall permit a 28
contracting heath care provider who is practicing in conformity 29
28
Final Page
OOH H05835'25_HB6133_INTR_1 g4sqrn
with community standards to advocate for the health care provider's 1
patient without being subject to termination or penalty for the 2
sole reason of the advocacy. 3
(9) Subsections (1) and (2) apply to heath care provider 4
participation contracts entered into beginning January 1, 2027. 5