Bulletin No. 2001-03-INS

Ambulance Service Benefits

Issued and entered March 19, 2001 by Frank M. Fitzgerald, Commissioner of Financial and Insurance Services 
 

INFORMATIONAL AND INTERPRETIVE STATEMENT

It has come to the attention of the Office of Financial and Insurance Services that health carriers have different interpretations of what services must be included under the definition of emergency health services found in the Insurance Code and the Nonprofit Healthcare Corporation Reform Act.  MCL 333.20902(4); MSA 14.15(20902) of the Public Health Code defines ambulance as, "a motor vehicle or rotary aircraft that is primarily used or designated as available to provide transportation and basic life support, limited advanced life support, or advanced life support."  "Emergency medical services" includes ground and air ambulances, as well as any other form of ambulance service needed.  These services must be included as part of a health carrier's plan if the benefit package provides coverage for any emergency health service.

However, health carriers may institute reasonable standards to define the circumstances under which service charges will be covered as they relate to the medical emergency.  For example, health plans may require the service be medically necessary, the service must be for transporting the patient to the nearest hospital capable of treating the patient, and  the service must be provided by a licensed ambulance service.  Air ambulance services must be preauthorized by a physician.   These definitions provide examples of ways health plans may place reasonable standards in place and are not meant to be a definitive listing of standards to be used.

Health Maintenance Organizations (HMO)

MCL 500.3517(3); MSA 24.13519(3) requires that all HMO member contracts include, at a minimum, "basic health services."

MCL 500.3501(b); MSA 24.13501(b) defines "basic health services" to include "emergency health services." 

MCL 500.3503(1); MSA 24.13503(1) extends the provisions of Chapter 34 to HMOs, unless specifically excluded.  Section 3406k is not specifically excluded. 

MCL 500.3406k; MSA 24.13406(11) defines emergency health services as "...medically necessary services provided to an insured 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.  An insurer shall not deny payment for emergency health services up to the point of stabilization provided to an insured under this subsection because of:

(a) The final diagnosis. 
(b) Prior authorization was not given by the insurer before emergency health services were provided."

The Commissioner has determined emergency health services must include, but are not limited to, the use of emergency vehicles and emergency air transport to ensure the ability to stabilize the patient.

Commercial Insurers

If commercial insurers include emergency medical health services in its benefit package, it must comply with MCL 500.3406k.  If emergency medical health services are included, they must cover charges for ground and air ambulance subject to certain reasonable standards they may develop, as provided in the examples above.

Non Profit Healthcare Corporation (BCBSM)

MCL 550.1418; MSA 24.660(418) states "A health care corporation certificate that provides coverage for emergency health services shall provide coverage for medically necessary services provided to a member 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 care corporation shall not deny payment for emergency health services up to the point of stabilization provided to a member under this subsection because of either of the following:

(a) the final diagnosis 
(b) prior authorization was not given by the health care corporation before emergency health services were provided."

If a patient requires ambulance service then emergency health services pursuant to current statutory provisions must be defined to provide ambulance service that includes, but is not limited to, emergency ground vehicles and emergency air transport.  The nonprofit healthcare corporation may produce certain reasonable standards, as well.

HMOs must offer medical emergency services pursuant to MCL 500.3406k.  Once commercial insurers choose to provide emergency medical services in their contract, they also must follow the provisions of MCL 500.3406k.  Nonprofit healthcare corporations must offer emergency services as defined in MCL 550.1418.  Emergency medical services must include ambulance services without regard to the form of transportation used to afford needed stabilization services to the patient, including but not limited to motor transport and air transportation.

Any questions regarding this bulletin should be directed to:

Office of Financial and Insurance Services
Health Plans Division
611 West Ottawa Street
P.O. Box 30220
Lansing, Michigan 48909-7720

Phone: (517) 241-4549
Toll Free (877) 999-6442