Priority Health v. Commissioner of the Office of Financial & Insurance Services
Priority Health v. Commissioner of the Office of Financial & Insurance Services
Opinion of the Court
This appeal involves the small employer group health coverage act,
BACKGROUND
Priority Health is a nonprofit corporation that the state of Michigan has licensed as a health maintenance organization. It offers health benefit plans to many employers in Michigan, including small-employer groups covered by the act. Its policies require minimum employer contributions.
In April 2006, Priority Health requested a declaratory ruling from OFIS.
The commissioner
Priority Health appealed the ruling in the circuit court, which affirmed it. Applying the standard of
Priority Health sought leave to appeal in the Court of Appeals, arguing that the OFIS ruling and the circuit court’s decision conflicted with the language of the act. It further argued that its minimum employer premium contribution requirement advances the act’s purposes because it encourages employee participation and protects against adverse selection. The Court of Appeals denied Priority Health’s application for leave to appeal, with Judge SMOLENSKI indicating that he would grant the application.
On remand, the Court of Appeals affirmed the decision of OFIS in a published opinion per curiam.
This Court granted leave to appeal to determine (1) whether, as part of a plan, an insurer or licensed health
STANDARD OF REVIEW
We review OFIS declaratory rulings in the same manner as any agency final decision or order issued in a contested case.
KEY PROVISIONS OF THE ACT
The act regulates small employer group health coverage in Michigan. The Legislature adopted it in 2003 in an effort to resolve problems specific to the small-employer market. The act requires every insurance carrier wishing to provide health care benefits to small employers in Michigan to offer all of its small-employer health plans to all small employers.
The act provides that the carriers of small-employer benefit plans must renew the policies they issue to small employers, except under very limited circumstances. At MCL 500.3711, it states:
(1) Except as provided in this section, a small employer carrier that offers health coverage in the small employer group market in connection with a health benefit plan shall renew or continue in force that plan at the option of the small employer or sole proprietor.
(2) Guaranteed renewal under subsection (1) is not required in cases of: fraud or intentional misrepresentation of the small employer or, for coverage of an insured individual, fraud or misrepresentation by the insured individual or the individual’s representative; lack of payment; noncompliance with minimum participation requirements; if the small employer carrier no longer offers that particular type of coverage in the market; or if the sole proprietor or small employer moves outside the geographic area.
Hence, MCL 500.3707 and MCL 500.3711 read together require every carrier of small-employer benefit plans to make all its plans available to all small employers. With six exceptions, the carrier must renew the coverage at the employer’s option.
ANALYSIS
The act does not expressly permit carriers of small-employer benefit plans to mandate a minimum em
In her ruling, the commissioner relied on her interpretation of the guaranteed-renewal provisions in MCL 500.3711. They require small-employer carriers to guarantee renewal of their health plans at the option of the employer, except in six expressly identified circumstances. Failure to comply with a minimum employer contribution requirement is not one of those circumstances. Hence, the commissioner concluded that a carrier must renew coverage without regard to the level of an employer’s contribution to the total cost of the plan.
She reasoned that it would be inconsistent to “allow a minimum contribution requirement at the time coverage is issued, yet mandate renewal without regard to the employer’s share.”
Likewise, the Court of Appeals based its decision on the guaranteed-renewal provisions in MCL 500.3711. Following a rationale similar to that of the commissioner, the Court found it “unreasonable and inconsistent to require [minimum employer] contributions as a prerequisite for initial coverage when renewal could not be denied on the basis of a failure to pay those contributions.”
If a minimum employer contribution requirement is included as a provision of the initial policy, it is part of the policy being offered for renewal. If the employer determines that it cannot or does not wish to make such a contribution, it is free to decline to renew the policy. This differs from a situation where the carrier refuses to renew the policy for a reason not among the permissible reasons enumerated in MCL 500.3711(2). Nothing in chapter 37 prevents an employer from declining to renew the policy.
Moreover, under the Court of Appeals’ rationale, any proposed health benefit plan provision which MCL 500.3711(2) does not expressly permit would be unreasonable and inconsistent with chapter 37. This means that a carrier could not require an employer to agree to an arbitration clause, merger or integration clause, or other common provision that it did not write into the initial policy. According to the Court of Appeals’ reasoning, small-employer carriers would not be able to include any provisions in their plans that the act does not expressly permit.
Assuredly, the guaranteed-renewal provisions could be said to conflict with, and thus preclude, the inclusion of certain provisions in a health benefit plan for initial coverage. MCL 500.3711(2) lists only six reasons why a carrier can terminate or refuse to renew a health plan that has already been issued. A provision that attempted to broaden those exceptions would conflict with MCL 500.3711 and would be impermissible in a policy for initial coverage.
For example, a termination-at-will provision cannot be reconciled with the guaranteed-renewal provisions and therefore would be prohibited. But MCL 500.3711 does not preclude a carrier from including a reasonable provision in a policy for initial coverage that does not conflict with the enumerated reasons for nonrenewal.
CONCLUSION
We give respectful consideration to the commissioner’s interpretation of chapter 37. But MCL 500.3711(2)
MCL 500.3701 et seq.
We decline to address the broader issue of whether such required contributions are unreasonable or inconsistent with the act for any other
OFIS has since been renamed the Office of Financial and Insurance Regulation.
Because this dispute involves an OFIS declaratory ruling, no administrative agency hearing was conducted, and the record consists of those facts specifically identified by Priority Health in its request for a declaratory ruling. Mich Admin Code, R 500.1043(2).
A minimum employer contribution provision requires an employer to contribute a portion of an employee’s premium. Minimum contribution requirements set a ceiling on the health insurance expenses an employer may pass on to its employees. This ceiling is often expressed as a percentage of the premium.
See In re Priority Health Declaratory Ruling Request, entered June 7, 2006, Order No. 06-021-M (OFIS Ruling), p 5.
See MCL 24.263, which permits an agency to issue a declaratory ruling on the application of a statute to particular facts.
At the time, the commissioner was Linda Watters. The current commissioner is Kevin Clinton.
The circuit court applied an improperly high standard when reviewing the OFIS ruling. The arbitrary-or-capricious standard does not apply to the interpretation of statutory provisions. In re Complaint of Rovas Against SBC Mich, 482 Mich 90, 103; 754 NW2d 259 (2008).
Priority Health v Comm’r of the Office of Fin & Ins Servs, unpublished order of the Court of Appeals, entered October 12, 2007 (Docket No. 278373).
Priority Health v Comm’r of the Office of Fin & Ins Servs, 480 Mich 1073 (2008).
Priority Health v Comm’r of the Office of Fin & Ins Servs, 284 Mich App 40; 770 NW2d 457 (2009).
Priority Health v Comm’r of the Office of Fin & Ins Servs, 485 Mich 1069 (2010).
MCL 24.263.
Hunter v Hunter, 484 Mich 247, 257; 771 NW2d 694 (2009).
In re Rovas Complaint, 482 Mich at 103.
MCL 500.3701(p) defines “small employer” as follows:
[A]ny person, firm, corporation, partnership, limited liability company, or association actively engaged in business who, on at least 50% of its working days during the preceding and current calendar years, employed at least 2 but not more than 50 eligible employees. In determining the number of eligible employees, companies that are*74 affiliated companies or that are eligible to file a combined tax return for state taxation purposes shall be considered 1 employer.
MCL 500.3707(1).
OFIS Ruling, p 16.
Id. at 30.
Priority Health, 284 Mich App at 47.
In re MCI Telecom Complaint, 460 Mich 396, 414; 596 NW2d 164 (1999).
MCL 500.3707(1).
Concurring Opinion
(concurring). I concur with the majority opinion because I believe that the Commissioner of the Office of Financial and Insurance Services (OFIS)
The petitioner in this matter, a Michigan health maintenance organization (HMO), requires that all small employers
The SEGHCA establishes various requirements for carriers
As a condition of transacting business in this state with small employers, every small employer carrier shall make available to small employers all health benefit plans it markets to small employers in this state. A small employer carrier shall be considered to be marketing a health benefit plan if it offers that plan to a small employer not currently receiving a health benefit plan from that small employer carrier. A small employer carrier shall issue any health benefit plan to any small employer that applies for the plan and agrees to make the required premium payments and to satisfy the other reasonable provisions of the health benefit plan not inconsistent with this chapter [chapter 37 of the Insurance Code, MCL 500.100 etseq.].[8 ]
Thus, under the SEGHCA, an insurer “shall issue” health insurance coverage to any small employer who does three things: (1) applies for the plan, (2) agrees to make the required premium payments, and (3) satisfies the other reasonable provisions of the health benefit plan not inconsistent with chapter 37, in which the SEGHCA is codified.
The issue in this case is whether requiring a minimum employer contribution as a condition of coverage is a “reasonable provision” that is not “inconsistent with” chapter 37 of the Insurance Code. By including the adjective “reasonable,” the Legislature has indi
However, it is not within the purview of the judicial branch to determine whether a particular insurance provision is “reasonable.” Rather, “the explicit ‘public policy’ of Michigan is that the reasonableness of insurance contracts is a matter for the executive, not judicial, branch of government.”
Moreover, the commissioner’s determination regarding the reasonableness of a contractual provision is entitled to great deference under the limited standard of review that Michigan courts apply when reviewing the decisions of administrative agencies..
Because it is the responsibility of the commissioner to make the determination in the first instance regarding whether a minimum employer contribution requirement is a “reasonable provision” that is not “inconsistent with” the SEGHCA, I concur with the majority opinion and concur in remanding this case for reconsideration of petitioner’s motion for declaratory judgment.
Executive Order 2008-02 changed the name of the agency from the Office of Financial and Insurance Services (OFIS) to the Office of Financial and Insurance Regulation (OFIR).
MCL 500.3701 et seq., which is chapter 37 of the Insurance Code.
MCL 500.3711.
A “small employer” is defined as a
person, firm, corporation, partnership, limited liability company, or association actively engaged in business who, on at least 50% of its working days during the preceding and current calendar years, employed at least 2 but not more than 50 eligible employees. In determining the number of eligible employees, companies that are affiliated companies or that are eligible to file a combined tax return for state taxation purposes shall be considered 1 employer. [MCL 500.3701(p).]
Petitioner requested a declaratory ruling after OFIS posted its informal opinion under the “Small Employer Group Health Coverage Act FAQ” section of its website:
Q. Can a small employer carrier require a minimum contribution level (either dollar or percentage) by the employer as a condition of coverage?
A. No, Chapter 37 does not allow small employer carriers to require a contribution level that must be paid by the employer sponsor.
<http://www.michigan.gOv/dleg/0,1607,7-154-10555_13648-82698— ,00.html#Q17> (accessed April 29, 2011) (emphasis added).
A “carrier” is defined as including commercial insurance companies, HMOs, nonprofit health care corporations, and multiple employer welfare arrangements. MCL 500.3701(d):
A “health benefit - plan” or “plan” means “an expense-incurred hospital, medical, or surgical policy or certificate, nonprofit health care corporation certificate, or health maintenance organization contract.” MCL 500.3701(k).
Emphasis added.
In considering whether minimum employer contribution requirements are consistent with the SEGHCA, I note that the Legislature has identified only one circumstance under which a small employer carrier may impose “a condition of coverage” and “deny coverage to a small employer” if the condition is not met: when the small employer had failed to meet the minimum participation rules described in MCL 500.3709.
Rory v Continental Ins Co, 473 Mich 457, 476; 703 NW2d 23 (2005).
Id. at 475; see also MCL 500.2236; MCL 500.2242.
MCL 500.244(1) provides that judicial review of the commissioner’s actions is provided by the Administrative Procedures Act, MCL 24.201 et seq.
It is unclear whether petitioner has a “substantial right” to require minimum employer contributions as a condition of coverage in its health insurance contracts. Black’s Law Dictionary (8th ed), p 1349, defines “substantial right” as “[a]n essential right that potentially affects the outcome of a lawsuit and is capable of legal enforcement and protection, as distinguished from a mere technical or procedural right.” (Emphasis added.)
MCL 24.306(1)(e) provides that a court shall set aside a decision of an administrative agency “if substantial rights of the petitioner have been prejudiced because the decision or order” is “[ajrbitrary, capricious or clearly an abuse or unwarranted exercise of discretion.” Any factual findings in support of the reasonableness determination are affirmed if “supported by competent, material and substantial evidence on the whole record.” MCL 24.306(1)(d).
Reference
- Full Case Name
- Priority Health v. Commissioner of the Office of Financial and Insurance Services
- Cited By
- 1 case
- Status
- Published