Michigan Court of Appeals; Docket #357787; Unpublished
Judges Cavanagh, Garrett, and Yates; Per Curiam
Official Michigan Reporter Citation: Not Applicable; Link to Opinion
Amount Owed by No-Fault Insurer in Medicaid Reimbursement Cases [Medicaid Benefits]
In this unanimous, unpublished, per curiam decision, the Court of Appeals reversed the trial court’s order granting partial summary disposition to Defendant Bristol West Preferred Insurance Company (“Bristol West”) in Plaintiff Linda Trent’s first-party action against it. The Court of Appeals held that a question of fact existed as to whether Trent’s injuries were caused by the subject motor vehicle accident, resolution of which was necessary to determine whether Bristol West or Medicaid was responsible for Trent’s medical bills. If the former, Trent would be entitled to no-fault PIP benefits and, therefore, not “medically indigent” for purposes of Medicaid entitlement, in which case Bristol West would have to pay the reasonable charge for Trent’s treatment pursuant to the No-Fault Act—it would not be allowed to merely reimburse Trent’s providers for the highly discounted amounts they originally accepted from Medicaid.
Linda Trent was injured in a motor vehicle accident and subsequently sought treatment for back injuries she alleged were caused by the crash. Her injuries ultimately required that she undergo spine surgery, after which she applied for no-fault coverage related to the surgery and her various other treatments with Bristol West. Bristol West denied her claim, resulting in Trent’s medical providers seeking reimbursement from Medicaid, instead, as Trent was a Medicaid recipient. At some point thereafter, Trent filed suit against Bristol West, who moved for summary disposition, arguing that Trent’s injuries were not caused by the accident and that, even if they were, Bristol West would only be liable for the amounts Trent’s providers originally accepted as payment in full from Medicaid—which were highly discounted in accordance with the Medicaid fee schedule. The trial court originally denied Bristol West’s motion, but granted it on reconsideration.
The Court of Appeals reversed the trial court’s partial summary disposition order, holding that a question of fact existed as to whether Trent’s injuries arose out of the accident. The Court of Appeals noted that if they did, then under Hicks v Citizens Ins Co of America, 204 Mich App 142 (1994), Trent would be entitled to PIP benefits and, therefore, not medically indigent for purposes of the applicable Medicaid statute. Furthermore, Hicks established that when Medicaid benefits are mistakenly paid on behalf of an injured person who is later determined to be entitled to no-fault benefits, the injured person maintains “responsibility for the medical expenses incurred but not paid for”—i.e., for the balance between their provider’s charge and the discounted amount paid by Medicaid—and the injured person’s medical provider is not bound “to limits its claim to the statutory amount allowed for Medicaid benefits.” Thus, if Trent’s injuries arose out of the accident, Bristol West would have to pay her providers the reasonable charges for her treatment under the no-fault act, and would not be liable only for the amounts originally, mistakenly paid by Medicaid.
“[The Hicks Court held] that because no-fault benefits were available, the claimant was not eligible for Medicaid benefits. Id. at 145-146. Moreover, the fact that Medicaid benefits were mistakenly paid by DSS did not release the injured claimant’s responsibility for the medical expenses incurred but not paid for, and further, did not bind the hospital to limit its claim to the statutory amount allowed for Medicaid benefits. Id. at 146.
. . .
It is undisputed in this case that plaintiff was a Medicaid recipient, and Medicaid became the only source to cover medical bills when Bristol West refused to pay. However, plaintiff argues, her medical treatment was required because of injuries sustained in a motor vehicle accident, and therefore, Medicaid is not the primary payor of medical benefits. That is, she would not be considered medically indigent because she had no-fault insurance to pay her medical expenses. As set forth in MCL 400.106(1)(b)(ii), and following this Court’s reasoning in Hicks, plaintiff is correct.
The issue here is whether plaintiff was medically indigent with respect to the medical costs incurred in this case. The resolution of the issue depends on whether plaintiff’s medical bills arose from or are attributable to injuries received in the motor vehicle accident. This is a question of fact for the fact-finder—in this case, a jury. If plaintiff prevails, she is entitled to PIP benefits under the no-fault act and is medically nonindigent. As a medically nonindigent person, plaintiff would not be protected by the Medicaid statutes because of the availability of PIP benefits. Plaintiff’s no-fault insurer would be liable for PIP benefits, including medical expenses.”