The following opinion is presented on-line for informational use only and does not replace the official version. (Mich Dept of Attorney General Web Site - www.ag.state.mi.us)


STATE OF MICHIGAN

JENNIFER M. GRANHOLM, ATTORNEY GENERAL

HEALTH MAINTENANCE ORGANIZATIONS:

HOSPITALS:

PHYSICIANS AND SURGEONS:

PUBLIC HEALTH:

Reimbursement for emergency health services provided to Medicaid patients

Under the Public Health Code and the Medicaid managed care program, where the requirements of these statutes are otherwise satisfied, a health maintenance organization must reimburse physicians for emergency health services provided to Medicaid patients, including instances when the physician has not obtained prior authorization from the patient's health maintenance organization.


Opinion No. 7036

October 18, 1999


Honorable Michael D. Bishop
State Representative
The Capitol
Lansing, Michigan


You have asked whether health maintenance organizations may deny reimbursement for emergency health services provided to Medicaid patients on grounds that the providing physician failed to obtain prior authorization from the health maintenance organization.

Congress, through adoption of section 4701(a) of the Balanced Budget Act of 1997, Pub. L. 105-33, gave to the states the option of utilizing managed care organizations as a method of providing Medicaid funded health care services. The State of Michigan chose this option and entered into contracts with managed care organizations establishing qualified health plans. These plans utilize health maintenance organizations (HMOs), which are required to provide care to Michigan Medicaid recipients pursuant to 42 USC 1396u-2. Subsection (b)(2) of this statute, which requires the provision of emergency services without prior authorization, states:

(A) In general

Each contract with a medicaid managed care organization under section 1396b(m) of this title and each contract with a primary care case manager under section 1396d(t)(3) of this title shall require the organization or manager --

(i) to provide coverage for emergency services (as defined in subparagraph (B) without regard to prior authorization or the emergency care provider's contractual relationship with the organization or manager . . . .

(Emphasis added.)

Subsection (b)(2) of the federal statute defines "emergency services" as follows:

(B) "Emergency services" defined

In subparagraph (A)(i), the term "emergency services" means, with respect to an individual enrolled with an organization, covered inpatient and outpatient services that --

(i) are furnished by a provider that is qualified to furnish such services under this subchapter, and

(ii) are needed to evaluate or stabilize an emergency medical condition (as defined in subparagraph (C)).

(C) "Emergency medical condition defined"

In subparagraph (B)(ii), the term "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in --

(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,

(ii) serious impairment to bodily functions, or

(iii) serious dysfunction of any bodily organ or part.

Moreover, HMOs doing business in Michigan are governed by the Public Health Code (Code), 1978 PA 368, MCL 333.1101 et seq; MSA 14.15(1101) et seq, which is "AN ACT to protect and promote the public health; . . . to regulate health maintenance organizations and certain third party administrators and insurers."

Section 21005(2) of the Code defines "health maintenance organization" as a health facility or agency that:

(a) Delivers health maintenance services which are medically indicated to enrollees under the terms of its health maintenance contract, directly or through contracts with affiliated providers, in exchange for a fixed prepaid sum or per capita prepayment, without regard to the frequency, extent, or kind of health services.

(b) Is responsible for the availability, accessibility, and quality of the health maintenance services provided.

Section 21004 of the Code defines "emergency health services" as follows:

(1) "Emergency health services" means medically necessary services provided to an enrollee for the sudden onset of a medical condition that manifests itself by signs and symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health or to a pregnancy in the case of a pregnant woman, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. A health maintenance organization shall not deny payment for emergency health services up to the point of stabilization provided to an enrollee under this subsection because of either of the following:

(a) The final diagnosis.

(b) Prior authorization was not given by the health maintenance organization before emergency health services were provided.

(2) "Enrollee" means an individual who is entitled to receive health maintenance services under a health maintenance contract.

(3) "Stabilization" means the point at which no material deterioration of a condition is likely, within reasonable medical probability, to result from or occur during transfer of the patient.

(Emphasis added.)

Similarly, section 21077(2) of the Code requires that:

In case of an emergency episode of illness or injury which requires immediate treatment before it can be secured through the health maintenance organization, or for an out-of-area service specifically authorized by the health maintenance organization, an enrollee may utilize a provider within or without this state not normally engaged by the health maintenance organization to render service to its enrollees. The organization shall pay reasonable expenses or fees to the provider or enrollee as appropriate in an individual case.1

(Emphasis added.)

Thus, both the Congress and the Michigan Legislature have adopted similar legislative provisions requiring HMOs to provide for emergency health services without the necessity of prior authorization. To determine the Legislature's intent in adopting statutes, one must look to their plain meaning. In Dussia v Monroe County Employee Retirement System, 386 Mich 244, 249, 191 NW2d 307 (1971), the court stated: "'It is a cardinal rule that the Legislature must be held to intend the meaning which it has plainly expressed, and in such cases there is no room for construction, or attempted interpretation to vary such meaning.'"

Federal Medicaid and Michigan HMO statutory provisions, by their plain language, require that HMOs include emergency medical services within their coverage. That coverage must include medical services for a condition of acute or sudden onset until the condition is stabilized. To qualify for coverage, the insured's condition must be characterized by signs and symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could result in: (1) serious jeopardy to the individual's health; (2) serious jeopardy to a pregnancy; (3) serious impairment to a bodily function; or (4) serious dysfunction of any organ or body part. HMOs must make payment for emergency medical services without regard to prior authorization. Indeed, section 21027(1)(a) of the Code provides that the Michigan Department of Community Health, with the concurrence of the Michigan Insurance Bureau, may sanction an HMO for noncompliance with the Code.

It is my opinion, therefore, that under the Public Health Code and the Medicaid managed care program, where the requirements of these statutes are otherwise satisfied, a health maintenance organization must reimburse physicians for emergency health services provided to Medicaid patients, including instances when the physician has not obtained prior authorization from the patient's health maintenance organization.




JENNIFER M. GRANHOLM
Attorney General


1 Michigan's Legislature has adopted essentially identical provisions with regard to emergency health services in section 418 of the Nonprofit Health Care Corporation Reform Act, 1980 PA 350, MCL 550.1101 et seq; MSA 24.660(101) et seq, which provides, inter alia, for the regulation and supervision of nonprofit health care corporations by the commissioner of insurance, and in section 3406k of the Insurance Code of 1956, 1956 PA 218, MCL 500.100 et seq; MSA 24.1100 et seq, which revises and consolidates the laws relating to the insurance and surety business.

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