550.1833. Definitions.
Sec. 3.
As used in this act:
(a) "Autism coverage reimbursement program" or "program" means the autism coverage reimbursement program created under section 5.
(b) "Autism diagnostic observation schedule", "autism spectrum disorders", "diagnosis of autism spectrum disorders", and "treatment of autism spectrum disorders" mean those terms as defined under section 416e of the nonprofit health care corporation reform act, 1980 PA 350, MCL 550.1416e, and section 3406s of the insurance code of 1956, 1956 PA 218, MCL 500.3406s.
(c) "Carrier" means any of the following:
(i) An insurer or health maintenance organization regulated under the insurance code of 1956, 1956 PA 218, MCL 500.100 to 500.8302.
(ii) A health care corporation regulated under the nonprofit health care corporation reform act, 1980 PA 350, MCL 550.1101 to 550.1704.
(iii) A specialty prepaid health plan.
(iv) A group health plan sponsor including, but not limited to, 1 or more of the following:
(A) An employer if a group health plan is established or maintained by a single employer.
(B) An employee organization if a plan is established or maintained by an employee organization.
(C) If a plan is established or maintained by 2 or more employers or jointly by 1 or more employers and 1 or more employee organizations, the association, committee, joint board of trustees, or other similar group of representatives of the parties that establish or maintain the plan.
(d) "Department" means the department of licensing and regulatory affairs.
(e) "Excess loss" or "stop loss" means coverage that provides insurance protection against the accumulation of total claims exceeding a stated level for a group as a whole or protection against a high-dollar claim on any 1 individual.
(f) "Federal act" means the federal patient protection and affordable care act, Public Law 111-148, as amended by the federal health care and education reconciliation act of 2010, Public Law 111-152, and any regulations promulgated under those acts.
(g) "Federal employee health benefit program" means the program of health benefits plans, as defined in 5 USC 8901, available to federal employees under 5 USC 8901 to 8914.
(h) "Fund" means the autism coverage fund created in section 7.
(i) "Group health plan" means an employee welfare benefit plan as defined in section 3(1) of subtitle A of title I of the employee retirement income security act of 1974, Public Law 93-406, 29 USC 1002, to the extent that the plan provides medical care, including items and services paid for as medical care to employees or their dependents as defined under the terms of the plan directly or through insurance, reimbursement, or otherwise.
(j) "Medicaid" means the program of medical assistance established under title XIX of the social security act, 42 USC 1396 to 1396w-5.
(k) "Medicare" means the federal medicare program established under title XVIII of the social security act, 42 USC 1395 to 1395kkk-1.
(l) "Medicare advantage plan" means a plan of coverage for health benefits under part C of title XVIII of the social security act, 42 USC 1395w-21 to 1395w-28.
(m) "Medicare part D" means a plan of coverage for prescription drug benefits under part D of title XVIII of the social security act, 42 USC 1395w-101 to 1395w-154.
(n) "Paid claims" means actual payments, net of recoveries, made for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders whether made to a provider or reimbursed to an individual by a carrier, third party administrator, or excess loss or stop loss carrier. Paid claims do not include any of the following:
(i) Claims paid for services rendered to a nonresident of this state.
(ii) Claims paid for services rendered to a person covered under a health benefit plan for federal employees.
(iii) Claims paid for services rendered outside of this state to a person who is a resident of this state.
(iv) Claims paid under a federal employee health benefit program, medicare, medicare advantage plan, medicare part D, tricare, by the United States veterans administration, and for high-risk pools established pursuant to the federal act.
(v) Costs paid by an individual for cost-sharing requirements, including deductibles, coinsurance, or copays.
(vi) Claims paid by, or on behalf of, this state.
(vii) Claims paid that are covered by medicaid.
(viii) Claims paid for which the carrier or third party administrator has already been reimbursed or compensated, in whole or in part, through any increase in premiums or rates or from any other source.
(ix) Beginning January 1, 2014, claims paid for services that are included in the essential health benefits as required pursuant to the federal act.
(o) "Specialty prepaid health plan" means that term as described in section 109f of the social welfare act, 1939 PA 280, MCL 400.109f.
(p) "Third party administrator" means an entity that processes claims under a service contract and that may also provide 1 or more other administrative services under a service contract.
2012, Act 101, Imd. Eff. Apr. 18, 2012
[Compiler] For transfer of autism coverage reimbursement program from department of licensing and regulatory affairs to department of insurance and financial services, see E.R.O. No. 2013-1, compiled at MCL 550.991.
