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HB 6133

Human services: medical services; regulations regarding managed care plans; provide for.

2025-2026 Regular Session Introduced by Joe Aragona and 3 co-sponsors

Michigan would shift Medicaid to contracted managed care with enrollment, cost-sharing, value-based incentives, and stronger oversight, including standardized claims and data repor

bill electronically reproduced 06/25/2026
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Bill Summary · HB 6133

Summary of HB 6133 (Michigan, 2025-2026)

Purpose and intent

  • This bill amends the Social Welfare Act (1939 PA 280) to restructure how Medicaid is delivered and paid for in Michigan, shifting toward managed care arrangements (contracted health plans) with enhanced oversight, provider access, and payment rules.
  • It seeks federal approval to implement contract-based managed care for certain Medicaid populations, lays out enrollment, access, cost-sharing, incentives, and performance measures, and strengthens the claims processing and prior authorization framework.

Key provisions and changes

  • Managed care enrollment and choice (Sec. 105d):

    • Requires the Department to seek federal approval to enroll eligible individuals (as defined by specific Medicaid criteria and citizenship rules) into contracted health plans.
    • Enrollees would have a choice among contracted health plans.
    • Mandates access to a primary care practitioner and requires an initial appointment within 60 days of enrollment.
    • Plans must protect enrollee privacy under HIPAA.
    • Establishes cost-sharing requirements for enrolled individuals.
    • Aims to encourage high-value services and reduce low-value or nonurgent emergency use.
    • Creates incentives for enrollees and providers to detect fraud and abuse; annual report on fraud impact and investigations.

  • Telemedicine (Sec. 105d(1)(k))

    • Allows telemedicine with out-of-state licensed practitioners when patient is located in Michigan.

  • Uninsured hospital payments (Sec. 105d(2))

    • Hospitals participating in Medicaid would accept 115% of Medicare rates as payment in full for uninsured individuals with income up to 250% of the Federal Poverty Level.

  • Enrollment of fee-for-service to managed care (Sec. 105d(3))

    • Requires enrollment of existing fee-for-service enrollees into contracted health plans if cost-effective and allowable by law.
    • Designates contracted health plans as the mandatory delivery system in waiver requests.
    • Identifies populations eligible for managed care and explores performance bonuses for long-term care providers (provisioning up to 3% of Medicaid capitation, with compliance to federal rules).

  • Pharmaceutical and value-based care (Sec. 105d(4)-(6))

    • Implements a high-value, low-cost pharmaceutical benefit (emphasizing generics and 90-day prescriptions, aligned with related public health code sections).
    • Creates financial incentives for enrollees and providers tied to health outcomes, healthy behaviors, and screenings.
    • Establishes a performance bonus incentive pool with 3-5 measurable objectives aligned to health priorities and equity; requires at least 6 months lead time before measuring period.

  • Capitation and performance oversight (Sec. 105d(7)-(9))

    • Requires actuarially sound capitation payments to contracted plans.
    • Dedicates a minimum 0.75% of plan payments to the performance bonus pool; funds contingent on meeting metrics.
    • Allows measurement of performance on substance use disorder treatment and reduction efforts.

  • Data, reporting, and analytics (Sec. 105d(10)-(12))

    • Requires state data sharing with qualified vendors for cost savings and population health improvement proposals (state data remains available at no cost to qualified bidders).
    • Defines data usage in the context of evaluating managed care performance.

  • ** Medicaid managed care organization (MCO) safeguards and operations (Sec. 111i, 111j, 111o, 111p, 111q):**

    • Establishes a timely claims processing and payment system with standardized clean claims, electronic transmission, and universal coding for Medicaid claims.
    • Sets timeframes: clean claims paid within 45 days (except certain pharma claims with industry-standard timing); interest of 12% per year on late clean claims.
    • Requires prompt defect notices and opportunities to cure defects; external review processes for disputed payments.
    • Requires quarterly reporting by MCOs on prior authorization activity, concurrent review, postservice denials, and timeliness metrics for skilled nursing facility patients (starting 2027).
    • Public reporting of data and a consumer-facing summary for each MCO, including denial rates, appeal outcomes, timeliness, and utilization management compliance.
    • Mandates ready access to contracting with qualified health care providers and protections against retaliation or coercion for providers who advocate for patients; outlines provider contract norms, grievance processes, and prohibitions on anti-competitive provisions.
    • Specifies contract terms for provider participation starting January 1, 2027.

  • Prior Authorization (Sec. 111j and 111o):

    • Establishes strict timelines for prior authorization decisions (standard and expedited) and criteria for when requests are deemed approved if not decided timely.
    • Defines a comprehensive, category-based approach to what requires prior authorization and the information standard that must accompany requests.
    • Creates an automated reimbursement system for prior-authorized services and outlines waivers when pre-authorization would prolong inpatient stays at lower cost.

  • Payment and rates (Sec. 111o, 111p):

    • Requires MCOs to ensure nursing facilities and long-term supports/providers are paid no less than the current fee-for-service rate.
    • Sets quality assurance and monthly payment for certain supplements.

  • Provider contracts and network requirements (Sec. 111q):

    • Requires MCOs to be ready to contract with qualified providers who meet licensure and contract requirements and practice in the service area.
    • Allows non-contraction with unqualified providers but requires clear breach notices and cure periods.
    • Prohibits unduly punitive terms against providers who advocate for patients and limits certain unilateral rate adjustments.
    • Requires transparency and access to contract documents and allows provider advocacy without penalty.

Who would be affected

  • Medicaid-eligible individuals (enrollees) who would gain managed care enrollment, access to a primary care doctor, and new cost-sharing and value-based incentives.
  • Medicaid managed care organizations (MCOs) and contracted health plans operating in Michigan.
  • Health care providers, including physicians, hospitals, skilled nursing facilities, long-term care providers, and other clinicians who bill Medicaid or participate in MCO networks.
  • Uninsured individuals receiving care from hospitals participating in Medicaid (hospital payment terms set at 115% of Medicare rates up to 250% FPL).
  • State agencies: Department of Health and Human Services (referred to as the Department and the Department of Insurance and Financial Services) responsible for implementation, claims processing, prior authorization, and data reporting.

Procedural and timeline aspects

  • Enactment and implementation depend on federal approvals and subsequent state actions, including waiver applications.
  • Certain provisions specify effective dates:
    • Provider contract-related provisions for new terms begin January 1, 2027.
    • Data reporting and public data availability begin on or after 2027 for certain prior authorization and utilization metrics.
    • The prior authorization framework requires systematic automation and standardization as part of ongoing implementation.
  • A requirement to disenroll skilled nursing facility enrollees from Michigan Coordinated Health Plan after 45 days, with automatic reenrollment into fee-for-service under the MA program (effective upon the act’s amended sections taking effect).
  • The act mandates annual reporting to Legislature on fraud detection, cost savings, and performance metrics, and requires a public-facing dashboard and consumer summaries.
  • The bill adds new sections 111o, 111p, and 111q to the existing statutory framework to support the expanded managed care, prior authorization, and provider contract requirements.

Potential impact considerations

  • Increased emphasis on value-based care, fraud detection, and consumer protections within Medicaid managed care.
  • Expanded use of telemedicine and private sector data analytics to improve population health and control costs.
  • Stronger claims processing timelines and external review mechanisms could affect payer operations and provider cash flows.
  • Financial incentive structures (capitation bonuses, quality metrics) aim to align provider performance with health outcomes and patient satisfaction.
  • Administrative requirements for reporting and transparency may enhance accountability but increase regulatory burden on MCOs and providers.

Note: This summary reflects the bill text as introduced and focuses on substantive provisions, affected parties, and timelines.

Compiled from official sources — confirm details with the bill’s official record.

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