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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

FRANK J. KELLEY, ATTORNEY GENERAL


Opinion No. 6410

December 22, 1986

NON-PROFIT HEALTH CARE CORPORATION REFORM ACT:

Right of subscriber to select health care provider

Reimbursement by health care corporation to health care provider selected by subscriber

A subscriber has a right to receive health care services specified in a health care certificate issued by Blue Cross and Blue Shield of Michigan either from an ophthalmologist or an optometrist licensed under the Public Health Code to provide the services.

Blue Cross and Blue Shield of Michigan may not deny reimbursement to the licensed health care provider for services rendered to the subscriber based solely upon the subscriber's choice of the class of provider.

Honorable Matthew McNeeley

State Representative

The Capitol

Lansing, Michigan

You have requested my opinion whether Blue Cross and Blue Shield of Michigan (BCBSM) may deny payment for certain eye care services when performed by optometrists rather than by ophthalmologists. Your question is:

"Assuming that a particular eye care service is covered under a Blue Cross/Blue Shield certificate or policy, and assuming the optometrist is duly licensed to perform the said eye care service, does Sec. 502(3) of 1980 PA 350 prohibit Blue Cross/Blue Shield from denying reimbursement to an optometrist who provides the said eye care service while accepting claims from medical doctors (opthalmologists) who provide the same eye care service?"

Under the Non-Profit Health Care Corporation Reform Act, MCL 550.1101 et seq; MSA 24.660(101) et seq, both licensed optometrists and ophthalmologists are "health care providers" capable of contracting with BCBSM to provide services to BCBSM subscribers. MCL 550.1105(4); MSA 24.660(105)(4), MCL 333.17411; MSA 14.15(17411), and MCL 333.17011; MSA 14.15(17011). "Health care services" are defined as those provided, ordered or prescribed by a health care provider. MCL 550.1105(5); MSA 24.660(105)(5). "Health care benefit" means the right under a certificate to have payment made by BCBSM for a specified health care service. MCL 550.1105(1); MSA 24.660(105)(1).

While BCBSM may limit the health care benefits it will furnish and may divide those benefits it does furnish into classes or kinds, MCL 550.1401(2); MSA 24.660(401)(2), there is nothing in the Non-Profit Health Care Corporation Reform Act which authorizes BCBSM to deny authorized services to its subscribers based upon their choice of the class of provider as long as the health care provider is licensed under the Public Health Code and legally qualified to provide the service. On the contrary, MCL 550.1502(3); MSA 24.660(502)(3), expressly provides for the free choice of providers by subscribers:

"[E]ach member of the health care corporation shall at all times have a choice of professional health care providers."

It is my opinion, therefore, that a subscriber has a right to receive health care services specified in a health care certificate issued by Blue Cross and Blue Shield of Michigan either from an ophthalmologist or an optometrist licensed under the Public Health Code to provide the services.

It is my further opinion that Blue Cross and Blue Shield of Michigan may not deny reimbursement to the licensed health care provider for services rendered to the subscriber based solely upon the subscriber's choice of the class of provider.

Frank J. Kelley

Attorney General


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