Issued and entered January 21, 2003 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On July 23, 2002, XXXXXXXXXXXX (Petitioner) filed a request for external review with the Commissioner of the Office of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act (PRIRA) MCL 550.1901 et seq. After an assessment of the material submitted, the Commissioner accepted the request.

A determination on medical issues was required. The Commissioner assigned the case to the MAXIMUS Center for Health Dispute Resolution (CHDR), an independent review organization (IRO). The Commissioner directed the IRO to provide the opinion and recommendation of a medical expert. The IRO completed its review on August 13, 2002, and sent it to the Office of Financial and Insurance Services (OFIS).

II
FACTUAL BACKGROUND

Petitioner is a Care Choices HMO (Care Choices) member. She receives her coverage through her former employer, located in Michigan, so the service area for the Care Choices plan she subscribes to is in Michigan. However, Petitioner now resides in XXXXXXX. She seeks coverage for health care she obtained in XXXXXXX, outside of Care Choices’s service area and from doctors not in Care Choices’s network of service providers.

On December 6, 2001, Petitioner telephoned her primary care physician (PCP) in Michigan and requested a referral for out-of-network urgent care. She alleges she reported symptoms including a jaundiced complexion, chest pains, shortness of breath and difficulty breathing, abdominal pain, nausea and vomiting, muscle weakness, disorientation, visual disturbances, extreme fatigue, and a decreased appetite. Her PCP’s records only document the report of a jaundiced complexion and visual disturbances. Petitioner’s PCP did not grant her a referral based on the conclusion that her symptoms did not require urgent care.

Petitioner saw an out-of-network doctor that same day without a referral from her PCP. She later saw an out-of-network specialist on several occasions to evaluate and treat her condition. Care Choices denied Petitioner coverage for all out-of-network health services she received from December 6, 2001 to March 5, 2002, based on its findings that she did not obtain referrals from her PCP and the services were not emergency care. Petitioner exhausted Care Choices’s internal grievance procedures, and Care Choices reached a final adverse determination on May 14, 2002.

III
ISSUE

Did Care Choices properly deny Petitioner coverage for health care she received outside of her contracted service area and outside of Care Choices’s network of service providers?

IV
ANALYSIS

Petitioner’s Position

Petitioner argues Care Choices should cover her out-of-area, out-of-network health care, because it was medically necessary care. She claims her PCP acted negligently by refusing to give her referrals for the services at issue in this case. She asserts her PCP did not consider all of her symptoms, especially the most urgent ones that indicated she required urgent care. Petitioner contends she made every effort to comply with the terms of her coverage before she received treatment, but she was unable to do so because her PCP did not provide her with an appropriate standard of care. She argues it was her PCP’s fault, and not her own, that she did not satisfy all of Care Choices’s conditions for coverage. Petitioner believes that but for her PCP’s negligent conduct, Care Choices would have covered the services at issue in this case. Petitioner therefore claims that the Commissioner should reverse Care Choices’s final adverse determination.

Care Choices’ Position

In its May 14, 2002, final adverse determination letter to Petitioner, Care Choices claims:

• Care Choices HMO will not cover costs associated with…non-authorized, non-approved services obtained…from non-participating, out of plan providers.
  
  …[Petitioner] knew or should have known that:
  
• [Petitioner is] permanently living outside of Care Choices HMO’s service area and that [she] knew or should have known that Care Choices HMO only covers emergency services while living out of our services area.
• As a Care Choices HMO member [Petitioner] require[s] a referral for non-emergent services and that all referrals to non-participating providers require a referral from [one’s] primary care physician and the prior approval of Care Choices HMO’s medical director and that [Petitioner] did not have referrals or prior approval for any of these services [at issue in this case.]
• [Petitioner’s] condition…was not emergent in nature.
• Services were available in-plan.
• Care Choices HMO would not cover these services.

* * *

As a Care Choices HMO member it is [Petitioner’s] responsibility to (Member Handbook, pages 25-26):

• Use Care Choices HMO participating physicians and health care facilities
• Follow all Care Choices HMO procedures
• Pay for services that are not covered by Care Choices HMO if [Petitioner] seek[s] or receive[s] these services
• Request that Care Choices HMO review and approve all service that must be certified or approved in advance
• Pay for covered services when [Petitioner] choose[s] to obtain services and do[es] not follow Care Choices HMO rules that require that [she] request and receive approval in advance

Therefore, Care Choices claims that the Commissioner should uphold the final adverse determination in this case.

IRO’S Recommendation

A physician, board certified in internal medicine and board eligible in endocrinology, reviewed the medical issues in this case. The IRO reviewer found that the symptoms Petitioner indicated during her first visit to a physician in XXXXXXX could have been the result of adrenal insufficiency. The IRO reviewer indicated that the symptoms contained in Petitioner’s endocrinologist notes of February 4, 2002 were consistent with adrenal insufficiency and hypothyroidism. The IRO reviewer indicated that while Petitioner was becoming more symptomatic, there was little information in her medical records to suggest that she had a medical emergency when she received out-of-network services in XXXXXXX. The IRO noted that a month passed before Petitioner was given any treatment for her adrenal insufficiency. The IRO reviewer indicated that if there had been a concern about Petitioner’s condition she would have been given full replacement therapy while waiting the MRI. The IRO also noted there was no mention in Petitioner’s medical records of symptoms of chest pain or shortness of breath, which might have required emergency care. The IRO reviewer noted her symptoms dated back to at least September 2001, and she did not receive adequate treatment for her condition until February 2002, indicating she did not need immediate medical attention. Therefore, the IRO determined the medical services Petitioner received from December 2001 to March 2002 were not emergent in nature.

Commissioner’s Review

The Commissioner carefully reviewed the arguments and documents submitted by the parties, as well as the findings of the IRO. The focus of this analysis is whether the health care Petitioner received outside of her contracted service area and outside of Care Choices’s network of service providers was a covered benefit under her Care Choices HMO Subscriber Certificate. Health maintenance organizations (HMOs), like Care Choices, operate within a network of medical providers who sign contracts with the HMO and charge the HMO a specially negotiated rate for various services and expenses. As a result, a fundamental premise of an HMO is to centralize health care delivery within the network of providers. If an HMO member uses an out-of-network provider, then payment for the services are greatly restricted or perhaps excluded.

In the case at hand, Petitioner’s Care Choices HMO Subscriber Certificate specifically conditions HMO coverage upon members receiving services within a network of participating providers. Section 5.2 of the Certificate states:

5.2 Covered Services-General
Requirements for Covered Services
Services covered by HMO must be:
(5) Provided by a HMO Participating Provider, except in emergencies.

This requirement in the Certificate is clear and provides for only one exception. Care Choices members may use a non-participating provider only in a medical emergency.

Petitioner obtained the services at issue in this case outside of the Care Choices network of providers, so they are only eligible for coverage if they were emergency care. The findings of the IRO reviewer show that those services were not emergency care. Accordingly, the Commissioner finds that Care Choices final adverse determination in this matter is valid.

V
ORDER

The Commissioner therefore upholds the Care Choices May 14, 2002, final adverse determination in this case. Care Choices is not required to cover Petitioner’s medical care from non-participating providers from December 2001 to March 2002.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.