Getting Autism Therapy Covered by Insurance in Michigan

Michigan’s mandate

MCL § 500.3406s, enacted 2012, requires state-regulated health plans in Michigan to cover the diagnosis and treatment of autism spectrum disorder, including applied behavior analysis.

Ages covered: An insurer MAY limit coverage to age 18. Note the permissive wording — it is a ceiling the insurer is allowed to apply, not one it must.

Dollar cap: Three bands, if the insurer chooses to apply them: $50,000 a year through age 6, $40,000 from 7 to 12, and $30,000 from 13 to 18. The Department of Insurance and Financial Services separately ordered in 2014 that issuers may not convert annual dollar limits into visit, hourly or daily limits, so a plan cannot swap one cap for another.

Michigan writes three prohibitions into the statute that are worth quoting verbatim. An insurer may not limit the number of visits. It may not deny or limit coverage on the basis that treatment is EDUCATIONAL OR HABILITATIVE in nature — the single most common denial reason for an autistic child. And it may not terminate or refuse to renew coverage solely because someone is diagnosed with or treated for autism. One quirk to expect: the insurer may ask for the results of an Autism Diagnostic Observation Schedule, but no more often than once every three years.

Whether the mandate applies to your plan

This is the question to settle first, because the answer decides whether anything above is enforceable for you. State insurance mandates bind fully insured plans. Self-funded employer plans — where the employer pays claims itself and an insurer only administers them — are generally exempt under federal ERISA, and they cover roughly six in ten people with employer coverage.

Ask your HR department, in writing, which type your plan is. If it is self-funded, MCL § 500.3406s does not compel coverage — but federal parity law may still help, and many large self-funded employers cover ABA voluntarily. Ask what the plan actually covers rather than assuming the answer is no.

The Medicaid route

Michigan Medicaid covers ABA for members under 21 through EPSDT, without the banded caps.

How Medicaid waivers work covers the route for families who do not qualify on income alone.

When you are denied

1. Get the denial reason in writing. Insurers must give a specific reason, and the appeal has to answer that reason rather than restate the diagnosis.
2. File the internal appeal within the deadline on the denial letter, with a letter of medical necessity that addresses the stated reason directly.
3. Request external review if the internal appeal fails. Fully insured plans carry external review rights, and an independent reviewer overturns denials more often than families expect.
4. Complain to the Michigan Department of Insurance and Financial Services on 1-877-999-6442 if you believe MCL § 500.3406s is being violated. Their consumer pages are here.