Issued and entered this 23 rd day of December 2009 by Ken Ross Commissioner ORDER I PROCEDURAL BACKGROUND

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1 In the matter of STATE OF MICHIGAN DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION Before the Commissioner of Financial and Insurance Regulation XXXXX Petitioner File No v Blue Cross Blue Shield of Michigan Respondent / Issued and entered this 23 rd day of December 2009 by Ken Ross Commissioner ORDER I PROCEDURAL BACKGROUND On July 13, 2009, XXXXX, on behalf of her husband XXXXX (Petitioner), filed a request for external review with the Commissioner of Financial and Insurance Regulation under the Patient s Right to Independent Review Act, MCL et seq. The Commissioner reviewed the request and accepted it on July 20, The Commissioner notified Blue Cross Blue Shield of Michigan (BCBSM) of the external review and requested the information used in making its adverse determination. The Commissioner received BCBSM s response on July 23, The Petitioner is enrolled for health coverage through XXXXX, an underwritten group. The issue in this external review can be decided by a contractual analysis. The contract here is BCBSM s Community Blue Group Benefits Certificate (the certificate). The Commissioner reviews contractual issues pursuant to MCL (7). This matter does not require a medical opinion from an independent review organization.

2 Page 2 II FACTUAL BACKGROUND On March 2, 2009, the Petitioner had an accident while riding a snowmobile in the woods. He was transported by XXXXX EMS (XXXXX) to XXXXX Memorial Hospital in XXXXX. Because the accident occurred in a wooded area about a mile from the nearest road, XXXXX used its snowmobile and sled to bring Petitioner to a location where he could be transferred to a larger vehicle for the trip to XXXXX. The claims submitted to BCBSM for Petitioner s transportation by XXXXX were: DESCRIPTION SERVICE CODE AMT. BILLED AMT. PAID ALS-1 emergency A Ambulance 02 life sustaining A Ambulance ground mileage A Unlisted ambulance service A0999 1, XXXXX is a BCBSM-participating provider. BCBSM reimbursed XXXXX for the services rendered by the paramedic and the ambulance transportation to the hospital but not for the initial snowmobile/sled transportation. The Petitioner appealed BCBSM s denial of the snowmobile/sled transportation. BCBSM reviewed Petitioner s appeal following a managerial-level conference on June 18, 2009, and issued a final adverse determination dated June 26, 2009, upholding its position. III ISSUE Is BCBSM required to approve an additional amount for the Petitioner s March 2, 2009, transportation to the hospital? Petitioner s Argument IV ANALYSIS The Petitioner s wife argues that, because it was an emergency in the middle of the woods, the ambulance service had to utilize snowmobiles and a stretcher to initially transport him. She

3 Page 3 says there was no other way for him to receive immediate care and be transported to the hospital. BCBSM s Argument In its final adverse determination, BCBSM explained its denial of coverage, stating, We previously approved benefits for the ambulance and mileage charges. However, no benefits can be allowed for the rescue squad, and that charge remains your responsibility. BCBSM says that the benefits for the Petitioner s transportation are described in Section 5 of the policy, Coverage for Other Professional Health Care Services, Professional Ambulance Services which provides that coverage is only available for transportation by a vehicle qualified as an ambulance and part of a licensed ambulance operation. Commissioner s Review Under the Petitioner s health plan, ambulance services are a covered benefit. The issue to be resolved in this review is whether the snowmobile and sled constitute a vehicle qualified as an ambulance. The full text of the policy s ambulance provision follows (omitting the description of air ambulance coverage): Professional Ambulance Services We pay our approved amount for ambulance services to transport a patient up to 25 miles. We will pay for a greater distance if the destination is the nearest medical facility capable of treating the patient s condition. In either case the following condition must be met: The service must be medically necessary because transport by any other means would endanger the patient s health. The services must be to transport the patient to a hospital or to transfer the patient from a hospital to another treatment location such as another hospital, skilled nursing facility, medical clinic or the patient s home. NOTE: When ambulance service is used only to transfer the patient, the attending physician must prescribe the transfer. The service must be provided in a vehicle qualified as an ambulance and part of a licensed ambulance operation. (Services by fire departments, rescue squads or other emergency transport providers whose fees are in the form of a voluntary donation are not payable.) The fee must be only for the transportation of the patient, and not include additional services that may be provided by physicians or other professionals and billed as ambulance service....

4 Page 4 We pay the approved amount for ambulance service when the ambulance has responded and the patient is stabilized and transport is not necessary or is refused, and in instances where the ambulance company arrives but the person that needed transportation has expired. BCBSM considers the portion of the ambulance/transport services involving snowmobiles as rescue services that are excluded from coverage. (There is no specific provision of the certificate which addresses rescue services, beyond the statement that rescue services are not covered when fees are in the form of a voluntary donation.) The term ambulance is not defined in the Nonprofit Healthcare Corporation Reform Act, the statute under which BCBSM is regulated. Ambulance is, however, defined in Michigan s Public Health Code (MCL ) 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." Ambulance service benefits are the subject of a 2001 bulletin issued by this agency (Bulletin INS). The Bulletin s introduction states: 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.... 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.... The Bulletin provides standards of coverage for HMOs, commercial insurers, and nonprofit health care corporations such as BCBSM. The section pertaining to BCBSM includes the following: 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.... Nonprofit healthcare corporations must offer emergency services as defined in MCL Emergency medical services must include ambulance services without regard to the form of transportation used to afford needed

5 Page 5 stabilization services to the patient, including but not limited to motor transport and air transportation. The XXXXX snowmobile is a motorized vehicle with qualified staff and material to evaluate the patient and provide treatment on-scene. The vehicle carried medical equipment, including needed stabilization equipment. This is evidenced by the fact that, at the scene of the accident, the Petitioner was placed on a longback board with c-collar and straps. Finally, the snowmobile is not a private vehicle but is owned by XXXXX, a BCBSM participating provider, and is dispatched through the same system as other XXXXX emergency vehicles. The Commissioner finds that the XXXXX snowmobile does qualify as an ambulance when used under the remote off-road circumstances of the first phase of Petitioner s trip to the hospital. BCBSM did not correctly apply the provisions of the Petitioner s certificate in light of OFIR Bulletin INS. V ORDER BCBSM s final adverse determination of June 26, 2009, is reversed. BCBSM is required to provide coverage of the snowmobile portion of Petitioner s transportation to XXXXX. The Commissioner recognizes that this particular form of transportation does not have an approved amount listed in BCBSM s fee schedule. In this case, BCBSM must negotiate a payment amount with the provider (XXXXX) or, by some other means, arrive at a suitable price for this service. BCBSM shall, within seven days of providing coverage, submit to the Commissioner proof it has implemented this Order. To enforce this Order, the Petitioner may report any complaint regarding implementation to the Office of Financial and Insurance Regulation, Health Plans Division, toll free (877) This is a final decision of an administrative agency. Any person aggrieved by this Order may seek judicial review no later than 60 days from the date of this Order in the circuit court for the

6 Page 6 county where the covered person resides or in the circuit court of Ingham County. See MCL (1), made applicable by MCL (2). A copy of the petition for judicial review should be sent to the Commissioner of Financial and Insurance Regulation, Health Plans Division, Post Office Box 30220, Lansing, MI