Opinion ID: 867565
Heading Depth: 2
Heading Rank: 3

Heading: The admissions form

Text: ¶ 23 Lisa signedand does not challenge her signing ofa UMC admission form in which she accepted financial responsibility for the services UMC provided her. She argues, and the court of appeals held, that in accepting financial responsibility for those services, she actually incurred expenses within the meaning of the Allstate medical payments provision and was authorized to do so by the plain language of A.R.S. § 20-1072(E). But Allstate contends that for HMO enrollees, A.R.S. § 20-1072(A) to (C) amount to a statutory immunity from payment for HMO-covered medical expenses, and that taken solely on its face, subsection (E) would eviscerate that immunity, a result the legislature could not have intended. Allstate also argues that A.R.S. § 20-1072 was enacted without indication of legislative intent to allow enrollee acceptance of financial responsibility in the manner for which the Samsels argue and the court of appeals permitted. Allstate further argues that A.R.S. § 20-1072(E) must instead be read to relate back to subsection (D)'s provisions permitting health care providers to bill enrollees for such expenses as copayment or coinsurance amounts, health care services not covered by the HMO, out-of-area claims, and health care services rendered after termination of the HMO-provider contract. Since subsections (A) to (C) provide immunity from liability for HMO-covered expenses, Allstate says Lisa could never have actually incurred them. ¶ 24 The court of appeals found no authority for Allstate's interpretation and held that subsection (E)'s express language allows an HMO enrollee to accept financial responsibility for services provided by either contracting or non-contracting providers. It further held that to ignore this explicit language would violate the rule that requires us to give words `their natural, obvious, and ordinary meaning.'  Samsel, 199 Ariz. at 483 ¶ 10, 19 P.3d at 624 ¶ 10. ¶ 25 We do not agree with the court of appeals on this issue. A.R.S. § 20-1072 was enacted in 1988 as part of a bill addressing HMO insolvency, capitation, and regulatory issues. There is no doubt that subsections (A) to (C) are important components of Arizona's HMO regulatory scheme. They are substantially similar to the hold harmless provisions of the Health Maintenance Organization Model Act, promulgated by the National Association of Insurance Commissioners (NAIC) following a 1988 NAIC advisory report on HMO regulation and insolvency issues. The relevant section of the HMO Model Act reads as follows: 13. Protection Against Insolvency D. Hold Harmless (1) Every contract between a health maintenance organization and a participating provider of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the contract, the subscriber or enrollee shall not be liable to the provider for any sums owed by the health maintenance organization. (2) In the event that the participating provider contract has not been reduced to writing as required by this subsection or that the contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from the subscriber or enrollee sums owed by the health maintenance organization. (3) No participating provider, or the provider's agent, trustee or assignee, may maintain an action at law against a subscriber or enrollee to collect sums owed by the health maintenance organization. National Association of Insurance Commissioners, Health Maintenance Organization Model Act (NAIC 430-1). ¶ 26 At least forty-seven states (and the District of Columbia) have adopted legislation on HMO capitation and insolvency. Over half adopted the NAIC Model Act; other states adopted portions or substantially modified the Model Act. See Jay M. Howard, The Aftermath of HMO Insolvency: Considerations for Providers, 4 ANNALS HEALTH L. 87, 95-96 (1995); Craig P. Druehl, HMO and Insurance Insolvency: The Benefits and Detriments of a Federal System, 23 AM. J.L. & MED. 487, 498-99 (1997). At least thirty-five of these states appear to have some type of hold-harmless provision. None appears to have a provision such as Arizona's subsection (E). ¶ 27 In light of all of the foregoing and the text of A.R.S. § 20-1072(A) to (C), we believe the proper interpretation of the statute is that the enrollee is immunized from actions by the provider for recovery of charges for services provided and covered by the enrollee's agreement with the HMO. By the remaining subsections, however, especially subsection (E), the enrollee remains liable for co-insurance, co-payments, non-covered services, services of a non-contracting provider, and similar costs. And, as noted, the insured's property remains subject to a lien for recovery of the provider's full charges. But we believe the legislature clearly intended that the provider, not the enrollee, would run the risk of HMO non-payment for covered services and also that the enrollee was immunized from direct action for the difference between the provider's usual fees or charges and the lesser amount payable pursuant to the contract between the provider and the HMO. Thus, we disagree with the court of appeals' view that when Lisa signed UMC's form, she became directly liable for the HMO-covered services she later received. See Samsel, 199 Ariz. at 482-83 ¶¶ 10-11, 19 P.3d at 623-24 ¶¶ 10-11. We conclude, however, that A.R.S. § 20-1072(E) permits the provider to obtain the enrollee's enforceable promise to pay for all amounts and services not covered, including co-payments, services different from or in excess of those permitted by the HMO contract, and similar types of liabilities. And under Andrews, the insured's property and property interest in a tort recovery remain subject to a lien for the provider's full additional charges. Thus, as the court of appeals stated, subsection (E) encourages providers to furnish services by giving them assurance they will be paid, even though, at the time, the existence or extent of coverage may be doubtful or disputed. Id.