Issued and entered December 19, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On October 18, 2002, Petitioner XXXXXXXXXXXX filed a request for external review with the Commissioner of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act, MCL 550.1901 to MCL 550.1929. After a review of the material submitted, the Commissioner accepted the request.
There is no medical issue; therefore, review by an Independent Review Organization (IRO) is not required. The issue involved is contractual in nature. The Commissioner reviews contractual issues under MCL 550.1911(7). On October 31, 2002, the Office of Financial and Insurance Services (OFIS) received from Care Choices HMO (Care Choices) the information it used to make its final adverse determination in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner was a Care Choices member in March and April 2001. Her Care Choices coverage was subject to the Care Choices HMO Subscriber Certificate. She received obstetrician/gynecologist (OB/GYN) services on XXXXXXXX, and XXXXXXXX from an out-of-network physician. Care Choices denied Petitioner coverage for those services, because they were not obtained within the Care Choices network of participating providers. Petitioner initiated Care Choices’s internal grievance process, and Care Choices reached a final adverse determination in her case on XXXXXXXXXXX. Petitioner is seeking reimbursement for the cost of those services.

III
ISSUE

Did Care Choices properly deny Petitioner coverage for OB/GYN services from an out-of-network provider?

IV
ANALYSIS

Petitioner’s Argument

Petitioner argues her coverage allowed her to refer herself to the OB/GYN who provided the services at issue in this case. She claims a Care Choices customer service operator told her that she could refer herself to any OB/GYN. She also relied on the Care Choices web site in choosing her OB/GYN for the XXXXXXXX, and the XXXXXX, appointments. In a statement she submitted to Care Choices on XXX XXXXXX, Petitioner quoted the web site (http://www.carechoices.com/members/svcselectobgyn.shtml) as saying members are allowed to direct themselves to a Care Choices OB/GYN for annual well-woman and routine obstetrical or gynecological services. She states she made the appointments for the services at issue with a Care Choices network doctor, but received the services from a different physician without knowing he was not a participating provider. Therefore, Care Choices’s final adverse determination in this case should be reversed.

Respondent’s Argument

Care Choices argues the services at issue in this case do not meet the requirements for coverage in the Care Choices HMO Subscriber Certificate. In its final adverse determination letter to Petitioner, Care Choices stated:

On XXXXXXXXXXXX the Member Reconsideration Committee upheld the original adverse determination for the following reasons:

· Per Subscriber Certificate Section 5.2 Covered Services; services covered by Care Choices must be…Provided by an HMO participating provider except in emergencies

· Section 7.9 Member has the responsibility to work as a partner with HMO and to use participating providers.

Therefore, Care Choices HMO will not be responsible for services received out of the network, as they are benefit exclusion under the medical plan that your employer purchased.

Commissioner’s Review

The Commissioner carefully reviewed the arguments and documents presented by the parties. The focus of this analysis is whether the out-of-network OB/GYN services Petitioner received were covered 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, 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.

Therefore, the Commissioner finds the out-of-network services Petitioner received were clearly not eligible for coverage.

Furthermore, the Care Choices web site language Petitioner cited does not allow members to direct themselves to any OB/GYN they chose. It states only that members who select their own OB/GYN may do so within the Care Choices network. Petitioner’s acknowledgement of that language establishes she had notice that out-of-network OB/GYN services were not a covered benefit for her, above and beyond the notice provided by her Subscriber Certificate. An examination of Petitioner’s bill for the services at issue shows she was an established patient of the attending physician in this case. As such, her argument that she did not know he was out-of-network is unpersuasive. Also, an examination of Care Choices’s Provider Affiliation List shows that neither the attending physician nor the doctor she made her appointments with were network providers at that time the services were rendered. Therefore, the Commissioner finds Petitioner could not have reasonably expected Care Choices to cover the out-of-network OB/GYN services she received. Accordingly, the Commissioner finds Care Choices’s final adverse determination in this matter is valid.

V
ORDER

It is ORDERED that Care Choices’s August 20, 2002, final adverse determination in this case is upheld. Care Choices is not required to cover the out-of-network OB/GYN services Petitioner received on XXXXXXXXXX, and XXXXXXXX.

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.