Applicability of MCL 500.3157(2) to Home Health Aide and Skilled Nursing Care _________________________________________________

- 1 - STATE OF MICHIGAN DEPARTMENT OF INSURANCE AND FINANCIAL SERVICES Bulletin 2026-15-INS In the matter of: Applicability of MCL 500.3157(2) to Home Health Aide and Skilled Nursing Care _________________________________________________/ Issued and entered this 24th day of April 2026 by Anita G. Fox Director On October 20, 2025, the Michigan Court of Appeals issued a published decision in West Michigan Home Care Services, Inc v Meemic Insurance Company, ___ Mich App ___; ___ NW2d ___ (2025) (Docket No. 369151) (“West Michigan”), holding that because Medicare pays for home health aide and skilled nursing care, the cap in MCL 500.3157(2) applies to those services. The Court, however, did not indicate how the precise Medicare payable amounts are to be determined in any particular case for the purposes of performing a payment or reimbursement calculation under MCL 500.3157(2). The Department’s Utilization Review (“UR”) Section will review and process provider appeals consistent with the West Michigan ruling, i.e., that Medicare has an “amount payable” for home health aide and skilled nursing care (“services at issue”). However, for the Department to issue an UR order addressing the appropriateness of payments made for the services at issue in any particular case, the Petitioner’s documentation supporting its appeal must include: (1) the documented Medicare reimbursement rate that applies to the services at issue; or (2) information required by the Centers for Medicare & Medicaid Services’ (“CMS”) Home Health PPS Web Pricer to determine the rate. A provider that supports its appeal with information required by the CMS Home Health PPS Web Pricer must submit all of the following: a) The provider’s CMS Certification Number (“CCN”); b) The date the patient was admitted to the home health agency; c) The “From-Through” dates related to the dates of service at issue; d) The Beneficiary Core-Based Statistical Area (“CBSA”) for the beneficiary’s residence; e) The two-digit State and three-digit County Federal Information Processing Standards (“FIPS”) codes; and f) The patient-specific Health Insurance Prospective Payment System (“HIPPS”) code. Under Mich Admin Code, R 500.65(4), the Department is required to base its UR decisions upon the written materials submitted by the parties, and the failure of any party to supply any information in a timely manner shall result in a decision based upon information available to the Director at the time of the decision. Providers that believe they are due additional reimbursement for claims subject to West Michigan should first contact the insurer to request reprocessing of those claims. Providers are encouraged to work with insurers as they determine the appropriate reimbursement rates under Medicare in any given case. If a dispute related to a claim cannot be resolved directly with the insurer, the provider may contact the Department for assistance at - 2 - DIFSComplaints@michigan.gov. Providers and insurers are reminded to refer to Bulletin 2025-11-INS, issued April 25, 2025, which provides additional payment and billing guidance for no-fault automobile insurers and health care providers. The Department will provide updated guidance as necessary. Any questions regarding this Bulletin should be directed to: Department of Insurance and Financial Services Office of Appeals and Market Regulation 530 West Allegan Street, 7th Floor Lansing, Michigan 48933 Toll-Free: (877) 999-6442 /s/ _________________________________________ Anita G. Fox Director