What changed
The fee schedule has two main formulas. Where Medicare sets an amount payable for a service, the cap is a percentage of that amount. Where it does not, the cap is a percentage of the provider’s January 1, 2019 charge. Many insurers treated in-home care as having no Medicare amount and paid under the second formula.
In West Michigan Home Care Services v. MEEMIC (October 2025), the Michigan Court of Appeals rejected that approach for home health aide and skilled nursing care. In Bulletin 2026-15-INS, issued in April 2026, DIFS issued guidance applying the decision and explained how providers should document utilization review appeals.
What DIFS tells providers to do
- Ask the insurer to reprocess claims you believe were underpaid.
- Work with the insurer to determine the correct Medicare-based rate.
- For a utilization review appeal, submit the documented Medicare rate for the services, or all the data the CMS Home Health PPS pricer needs to calculate it.
What we recommend
Reprocessing requests do not stop the one-year-back rule unless they amount to a pending claim the insurer has not formally denied. Pull every underpaid home care claim, sort it by date of service, and put the oldest ones into suit first. Interest at 12% runs on overdue amounts.
Sources: MCL 500.3157(2) and (7); DIFS Bulletin 2026-15-INS; DIFS Bulletin 2025-11-INS.
