No-fault fee caps for post-2019 amendment services; Whether home-health-aide & skilled-nursing care are subject to the Medicare-based cap or the non-Medicare cap; MCL 500.3157(2) vs MCL 500.3157(7); Definition of “Medicare” under MCL 500.3157(15)(f); Central Home Health Care Servs v Progressive MI Ins Co; Possible applicability of MCL 500.3157(8); Explanation of Benefits (EOBs)

Holding that the Medicare-based cap in MCL 500.3157(2) applies to home-health-aide and skilled-nursing care because Medicare provides an “amount payable” for those services, the court affirmed partial summary disposition for plaintiff-provider. The provider billed for 24/7 home-health-aide and skilled-nursing care for a catastrophically injured insured. After the 2019 amendments took effect, defendant-insurer reduced reimbursement from about $31 to about $19 per hour, invoking the 55% cap in MCL 500.3157(7). On appeal, the court rejected the insurer’s position that Medicare has no “amount payable” for these services on a fee-for-service basis because it pays under a home health prospective payment system. Adopting the straightforward approach articulated in Central Home Health Care, the court explained that the “simple question” is whether Medicare covers the service, and “nothing in the two subsections or the definition of Medicare indicates that the method of calculation of the amount that Medicare would pay is relevant to determining which cap applies.” Further, the Legislature’s directive to disregard “limitations unrelated to the rates” confirms that experts need not “‘plow through a vast dataset’” to find a Medicare payable number. The record showed that Medicare covers home-health-aide and skilled-nursing services and has billing codes and amounts payable that the insurer itself used on its EOBs, so the 200% cap in subsection (2) governs rather than the 55% cap in subsection (7). The court also addressed the insurer’s argument that even if subsection (2) applies, the additional cap in MCL 500.3157(8) may limit recovery to the provider’s average 1/1/19 charge, noting that subsection (8) “may be applicable,” but the trial court did not err by not deciding it on the motion for partial summary disposition because reasonableness and subsection (8)’s applicability remain for later proceedings.