Which formula applies to home care
MCL 500.3157 has two main caps. Where Medicare provides an amount payable for a service, subsection (2) caps payment at a percentage of that amount: 190% for treatment after July 1, 2023. Where Medicare pays nothing, subsection (7) caps payment at a percentage of the provider’s charge on January 1, 2019: 52.5% after July 1, 2023. Under either formula, subsection (8) caps payment at the provider’s average January 1, 2019 charge, as adjusted each year for medical inflation.
After the fee schedule began on July 2, 2021, many insurers paid agencies under subsection (7), arguing that Medicare pays home health through a bundled prospective payment system and has no fee-for-service amount for individual visits.
West Michigan Home Care Services v. MEEMIC
The Court of Appeals rejected that argument in a published opinion on October 20, 2025. MEEMIC had cut payment for home health aide care from about $31 an hour to about $19 an hour under subsection (7). The court held that subsection (2) applies to home health aide and skilled nursing care because Medicare covers those services; the payment method does not matter. The question is whether Medicare covers the service at issue, and the insurer’s own explanation of benefits used Medicare billing codes.
Two limits on the ruling matter for agencies:
- It addressed home health aide and skilled nursing care. It did not decide how unskilled attendant care, such as companionship or supervision, is priced.
- It left open whether the subsection (8) average-charge ceiling reduces payment in a given case. Subsection (2) is a cap, not a guaranteed rate.
DIFS Bulletin 2026-15-INS
DIFS issued Bulletin 2026-15-INS on April 24, 2026. It gives guidance on home health aide and skilled nursing claims after West Michigan and sets out how disputes are handled:
- Ask the insurer to reprocess claims you believe were underpaid under West Michigan.
- Work with the insurer to set the Medicare-based amount.
- If that fails, contact DIFS or file a utilization review appeal.
For a DIFS appeal, you must supply either the documented Medicare rate for the services or the data needed to run the CMS Home Health PPS Web Pricer: CCN, admission date, from-through dates of service, beneficiary CBSA, state and county FIPS codes, and the patient-specific HIPPS code. DIFS decides only on what is filed on time. Agencies that never billed Medicare may need help assembling this data.
Family and friend care: the 56-hour cap
MCL 500.3157(10) limits insurer payment for in-home attendant care to 56 hours per week when the caregiver is a relative, a household member, or someone with a prior business or social relationship with the patient. Under subsection (11), an insurer may contract to pay for more. The cap does not apply to unrelated agency employees. If a family member is on your payroll, though, insurers may argue the cap still applies. Document how each caregiver was recruited and whether they knew the patient before the crash.
For patients injured before June 11, 2019, while covered by a policy issued before that date, the Michigan Supreme Court held in Andary v. USAA (July 31, 2023) that the fee schedule and the 56-hour cap do not apply. See Andary explained.
Collecting the difference
- Watch the one-year-back rule. Underpayments from more than a year before suit are lost unless tolling under MCL 500.3145(3) applies. Reprocessing requests do not stop the clock by themselves. See the one-year-back rule.
- Interest runs on the shortfall. A partial payment leaves the unpaid part overdue, and MCL 500.3142 adds 12% a year. See interest and attorney fees.
- Attorney fees have a three-year limit on future care. MCL 500.3148(4) bars fee awards on future attendant care or nursing payments ordered more than three years after the judgment, with a new three-year window if care is later suspended and a new order entered.
- Timesheets are your reasonable proof. Daily logs signed by the caregiver, the plan of care, and the prescribing physician’s order carry most home care cases. See reasonable proof.
Each month of underpaid visits ages out a year later. If your agency was paid under the 52.5% formula, send us remittances by date of service so we can sort what is still collectable.
Sources: MCL 500.3142, 500.3145, 500.3148 and 500.3157; West Michigan Home Care Services, Inc v Meemic Ins Co (Mich App, published, Oct 20, 2025); DIFS Bulletin 2026-15-INS (Apr 24, 2026); Andary v USAA Cas Ins Co (Mich, July 31, 2023); Mich Admin Code R 500.65.
Questions people ask us
Our agency was paid 52.5% of our 2019 rate for home health aide visits. Are we owed more?
Possibly. West Michigan Home Care Services v MEEMIC (Oct 20, 2025) held that home health aide and skilled nursing care fall under the Medicare-based cap in MCL 500.3157(2), and DIFS Bulletin 2026-15-INS tells providers to ask insurers to reprocess claims on that basis. Whether more is owed depends on the Medicare amount for each claim and on the January 1, 2019 average-charge ceiling.
Does the 56-hour limit apply to our agency staff?
No. The 56-hours-per-week limit in MCL 500.3157(10) applies to in-home attendant care by a relative, a household member, or someone with a prior business or social relationship with the patient. Care by unrelated agency staff is not subject to it.
Can we appeal a home care rate cut to DIFS?
Yes, as a cost dispute through the utilization review appeal process, within 90 days of the determination. Bulletin 2026-15-INS says the appeal must include the documented Medicare rate or the data needed to run the CMS Home Health PPS Web Pricer.
Do attorney fees work differently for attendant care cases?
Yes, for future payments. MCL 500.3148(4) bars attorney fee awards on future attendant care or nursing payments ordered more than three years after the judgment, unless the care is later cut off and a new order is entered.