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A Letter from Governor John Engler
Dear Michigan Health Care Consumer:
The number of Michigan citizens who are enrolled in managed care plans for their health insurance coverage continues to grow. Today, nearly one of every four Michigan citizens gets their coverage from HMO's. Managed care is an effective way to assure affordable care and contain costs. However, limitations placed on patients and providers are raising significant concerns about health care quality and consumer protection.
To protect health care consumers in the era of managed care, Michigan has adopted a comprehensive Patient Bill of Rights. Knowing your rights and how to exercise them is the first step toward being a better consumer in today's health care market. Your rights, guaranteed under these new laws, are fully explained in the following brochure. Please take the time to read about them now.
I wish you and your family the best of health.
Sincerely,
John Engler
Michigan's Patient Bill of Rights
| The Michigan Patient Bill of Rights guarantees you these new rights:
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Your health care insurance rights have changed for the better. Just when people are concerned about big changes in health care, the legislature and Governor Engler have guaranteed new patient rights. The Michigan Patient Bill of Rights took effect on October 1, 1997.
These rights are guaranteed if you have a health coverage provider through:
This new law does not apply if you get your health coverage through a private self-insured employer and you enroll in an option that is not covered by state rules. Federal law applies in those situations. If you need more information about your rights call the Michigan Insurance Bureau at (517) 373-0240.
Now you can get the information you need about your health care coverage.
When you enroll in your plan, you will get written information about:
In addition, if you are in a health plan where you choose from a list of approved health professionals, you can ask for more information about:
Complaints are faster & easier. Guaranteed.
If you have a life-threatening illness, complaints are handled even faster.
You can get an answer to your complaint within 72 hours in this kind of emergency. If you appeal that answer to the health plan, you will get a final answer within 30 working days. Or, you can appeal the first answer to the state.
You get health care coverage sooner for problems you already had when you applied.
Coverage of health problems you already had depends on whether your coverage is with a group of by yourself. It also depends on what kind of coverage you have. The chart on the following page shows the differences. The new federal insurance law may also give you more assurances of coverage for pre-existing conditions, renewals, and other issues.
More Guarantees.
In addition to the Patient Bill of Rights, the legislature and Governor Engler have passed other new laws to protect the consumer. These laws provide better payment for emergency room care. They also protect the doctor's right to tell you about your options.
No one can put a gag on your doctor.
Doctors can fully advocate for their patients. This is guaranteed by these new laws. Doctors are free to talk with you about all health care options. Insurance companies cannot put gag clauses into physician contracts.
If you need to go to the emergency room, your insurance will pay for it.
The new Michigan law guarantees that if you have HMO coverage you get emergency room care that is medically necessary. You can get care until your medical condition is stable. You don't need to worry that insurance won't pay. You don't need prior approval.
| Type of Health Care Coverage Provider | Who is affected | If the medical care was recommended for a condition within the following period of time prior to enrollment... | You will not be covered for that condition for the following period of time after enrollment |
| Blue Cross & Blue Shield of Michigan (BCBSM) | Individuals not covered under a group policy | 6 months | 6 months* |
| Group policies | No waiting period | No waiting period | |
| HMO's | Individuals not covered under a group policy | 6 months | 6 months* |
| Group policies | No waiting period | No waiting period | |
| Insurance Companies | Individuals and Groups of 2-50 | 6 months | 12months* |
| Groups of over 50 | 6 months | 6 months | |
*There is no waiting period if you converted to individual coverage from group coverage with the same coverage provider.
Emergency health services - medical services that become necessary when an individual experiences the sudden onset of a severe medical condition which shows itself through severe symptoms or signs, including severe pain. If immediate medical attention is not received, this condition could seriously threaten a patient's health, impair bodily functions or damage organs. If the patient is a pregnant women, the absence of such services could lead to serious consequences.
Enrollment - the process by which a health plan signs up groups and individuals for membership or the total number of people who participate in a health plan.
Gag clause - a clause sometimes included in health plan contracts that prevents or discourages doctors from telling their patients about different treatments available to them. Sometimes a gag clause also keeps doctors from disclosing financial arrangements between the health plan and the doctor. In Michigan including such a clause is prohibited because it would create a conflict of interest for the physician and undermine patient trust.
Health Maintenance Organization (HMO) - an entity that provides, offers or arranges for coverage of health services needed by plan members for a fixed, prepaid amount of money.
Health Plan - a health maintenance organization, preferred provider organization, insured plan, self-funded plan, or other entity that covers health care services.
Pre-existing Condition - a condition for which medical advice, diagnosis, care, or treatment was recommended or received before a patient joined a health plan.
Preferred Provider Organization (PPO) - an entity generally consisting of hospitals and doctors. PPO provides health care services usually at discounted rates in return for faster claims payment and a somewhat predictable market share. Patients can choose between using PPO or non-PPO providers. Generally, it is less expensive for patients to use PPO providers.
