Health Coverage Basics

As with other kinds of insurance, there are several types of health insurance policies and health care plans with many different features that are available to consumers in Michigan. Individual coverage can be purchased on your own, group health coverage can be obtained through an employer, or association coverage can be obtained through your membership in an organization or association. Additionally, there are government programs such as Medicare and Medicaid available to those who qualify.

Health insurers provide health coverage through several different entity types. The most common are health insurance companies and health maintenance organizations (HMOs). Throughout this web page, “health insurer” will mean any of these entity types. When specific differences occur for a given entity, we will specify the type of health insurer.

Group Coverage
If an employer offers group health coverage to employees and dependents, the coverage must be made available to all eligible employees. In accordance with state and federal law, the employer is the master policyholder and the employees are certificate holders. The master policyholder negotiates the terms of the group policy with the health insurer. The master policyholder can reduce or change the benefits and coverage, increase your share of the premium cost, switch health insurers, or stop providing coverage entirely. However, if an employer provides health coverage, the contract must include certain minimum benefits required by Michigan law. If you lose group health coverage through your employer, you may have federal Consolidated Omnibus Budget Reconciliation Act (COBRA) rights or you may be eligible for a special enrollment period through the Health Insurance Marketplace.

Many large employers provide health coverage for employees by creating self-funded health care plans. This means that the employer pays employees’ health claims instead of going through a health insurer. Typically, employers’ contract with entities such as insurance companies and third-party administrators to administer the self-funded health care plan by paying health claims on behalf of the employer. The Department of Insurance and Financial Services (DIFS) does not have authority over self-funded health care plans created by employers; however, DIFS has authority over the administrators of such plans and, in some cases, DIFS handles external appeals for these plans. The United States Department of Labor has authority over self-funded health care plans.

Any health insurer may offer wellness coverage. Many employer group plans include wellness programs as an option. The health insurer may offer a reduction in premium, copayments, coinsurance, or deductibles, or a combination of these incentives, in exchange for employees’ participation in any health behavior wellness, maintenance or improvement program offered by the employer. The employer and health insurer must agree to certain indicators of employees’ health status. The employer must then provide the health insurer with evidence of improvement or maintenance of the employees’ health status and health behaviors under the program. Health insurers are not required to continue indefinitely any wellness programs or incentives associated with the program. See MCL 500.3426.

Individual Coverage
If you do not have access to group health coverage and are not eligible for the Healthy Michigan Plan, Medicaid or Medicare, individual health coverage may be purchased through a licensed agent, directly from the health insurer or through the Health Insurance Marketplace. For more information on how to shop for coverage, see Shopping for Health Coverage. You are the policyholder on an individual policy. Your policy can cover you and your eligible dependents.

Individual policies must include specific minimum health care benefits required by the Michigan Insurance Code and federal law. Individual plans can have varying copayments, coinsurance and deductibles including health plans used in conjunction with Health Savings Accounts with high deductibles. These deductibles are subject to limits set by the Internal Revenue Service.

Medicare is a federal program providing health coverage for people age 65 or older, or under 65 with certain disabilities and any age with permanent kidney failure.

Medicaid is a federal program administered by the states currently providing health coverage to those meeting certain income requirements: pregnant women, people with disabilities, people in need of nursing home care and others.

The Healthy Michigan Plan
Some Michigan residents may be eligible for the Healthy Michigan Plan. To be eligible for the Healthy Michigan plan, you must be:

  • Ages 19-64
  • Not currently eligible for Medicaid
  • Not eligible for or enrolled in Medicare
  • Not pregnant when applying for the Healthy Michigan Plan
  • Earning up to 133% of the federal poverty level
    • The federal poverty level is adjusted annually.
    • In 2018, 133% of the poverty level for an individual was $16,146 or $33,383 for a family of four
  • A resident of Michigan

Student Health Plans
Student health plans are often purchased by students when coverage from parents is not available or is unaffordable. As with employer group coverage, the higher learning institution chooses the plan and benefits, with no individual options for students. The benefits covered by these student health plans, as well as how they are regulated, vary widely. Under the Affordable Care Act (ACA), student health plans must eliminate lifetime limits, can no longer drop coverage when an enrollee gets sick or because of an unintentional mistake on an application, cannot deny or exclude coverage for students because of a pre-existing condition, and must provide coverage for preventive services.

How Your Benefits are Delivered:

In the past, most individual health plans consisted of “traditional” fee-for-service plans where the patient had a great deal of freedom in choosing their doctors and other providers and medical expenses were incurred and then reimbursed by the health insurer. “Traditional” fee-for-service plans are not managed care plans. Fewer traditional types of individual plans exist now as managed care has become more common.

Managed Care
Managed care is mostly seen in employer group health plans; however, many individual plans now have varying elements of managed care. Features of managed care include a health insurer’s control of access to providers, risk sharing of providers, utilization and quality management and preventive care. Managed care can be seen in several types of plans and variations of plans including those explained below.

  • HMOs - Health Maintenance Organizations: A type of health plan that usually limits coverage to care from doctors who work for or contract with the HMO. HMOs generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
  • HMO Point-of-Service Plan: These HMO plans are a hybrid arrangement that combines aspects of traditional insurance coverage with HMO coverage. At the time of medical treatment, the HMO member or enrollee can elect whether to receive treatment for specified services within the HMO’s network of contracted health care providers or outside of the network. There may be higher member out-of-pocket costs for health care services received outside of the HMO network.
  • PPO - Preferred Provider Organization: A PPO is not a specific type of health coverage; rather it is a contract between a health insurer and a PPO, or network of providers such as selected hospitals, physicians, and others who agree to provide services at an agreed to rate. PPOs may be less restrictive than an HMO in that it allows members or enrollees to receive benefits for services rendered by any provider (with increased benefits or lower out-of-pocket costs if a network provider is used).
  • PPA - Preferred Provider Arrangement: A PPA is not a specific type of health coverage, rather it is an optional feature of a health plan. The plan makes an identified network of participating providers or selected providers available to the insured to obtain cost-effective medical services.

Different Types of Health Plans
While there are many types of health plans approved for use in Michigan, not all plans will meet the "minimum essential coverage" requirements under the ACA that would exempt someone from paying a federal tax penalty for not obtaining health coverage. The following are types of medical and hospital plans available in Michigan:

  • Major Medical Coverage - Although not defined in Michigan law, major medical coverage usually pays the cost of inpatient hospital care and outpatient medical bills, such as lab tests, office visits, physical therapy, x-rays, and may include prescription coverage. You pay any appropriate copayments and deductibles. The policy covers only the eligible expenses listed in the contract or certificate of coverage. Make sure you read the contract carefully to determine your deductibles, copayments, coinsurance, covered benefits, and exclusions. The maximum out-of-pocket cost limit (deductibles, copayments, and coinsurance) for any 2019 individual plan is $7,900 for an individual plan and $15,800 for a family plan.
  • Short-Term Limited Duration Coverage - In Michigan, a short-term limited duration plan can only cover you for 185 days out of any 365-day period.

    For example, you might buy a short-term limited duration policy for the months that you are between jobs and without group health coverage.

    These policies do not cover pre-existing conditions, are not guaranteed renewable, and do not satisfy the requirement to have health insurance. They also do not have to comply with Affordable Care Act protections, including prohibitions on annual or lifetime limits, essential health benefits, protections against rescissions, and cost-sharing limitations.
  • Catastrophic Health Coverage - A medical expense coverage that provides benefits after an amount of medical expenses has been incurred, sometimes as high as $7,150. In the Marketplace, catastrophic plans are available only to people under age 30 and to some low-income people who are exempt from paying the federal tax penalty because other insurance is considered unaffordable or because they have received hardship exemptions. Catastrophic health plans are also offered off Marketplace, directly through a health insurer.
  • High Deductible Plans - These plans are major medical expense plans and are often sold in conjunction with Health Savings Accounts. They pay the cost of inpatient hospital care and outpatient medical bills with a high deductible of at least $1,350 for an individual or $2,700 for a family, that is paid from your federally tax-exempt Health Savings Account.

    High deductible plans also have a maximum out-of-pocket amount that is paid in deductibles, copayments, and coinsurance. For 2019, the maximum out-of-pocket amount for an individual is $6,750 or $13,500 for a family. This limit doesn’t apply to deductibles and expenses for out-of-network services if the plan uses a network of providers. Instead, only deductibles and out-of-pocket expenses for services within the network should be used to figure whether the limit applies. See Health Savings Accounts for more information.

Limited Purpose Indemnity Plans
While these types of plans are approved for use in Michigan, they may not meet the "minimum essential coverage" requirements under the ACA that would exempt you from paying the federal tax penalty for foregoing health coverage.

  • Accident Only Policy
    This is a policy of limited medical coverage that provides cash payments in the event of injury or death resulting from a covered accident within a specified period. This type of policy pays only when you are treated for an accidental injury or if an accident causes death.
  • Hospital Indemnity Policy
    This is a policy of limited medical coverage featuring cash benefits in the event of hospitalization and/or surgery resulting from an illness or injury. This type of plan pays you a flat cash amount, such as $100 per day when you are hospitalized.
  • Specified (Dread) Disease Policy
    This policy provides per day, per service, expense-incurred, and/or lump-sum benefit payments upon the occurrence of medical events or diagnoses related to the treatment of a disease named in the policy. These are sometimes sold as cancer policies.
  • Incidental Policies
    Individual policies for dental and vision benefits, pay for care not covered by typical major medical policies and may be available on a limited basis.

Michigan’s Minimum Coverage Requirements:
Under the Michigan Insurance Code, there are certain benefits that most health plans issued in Michigan must include. There are other benefits that are not required to be included in a policy; however, if the benefit is included in the policy, the health insurer has certain responsibilities concerning that coverage. The minimum coverage benefits under the Michigan Insurance Code are listed below. The information below only applies to policies that are written on an “expense incurred” basis. This type of policy pays for the actual expenses incurred for health care services received.

The other type of policy is referred to as an “indemnity” based policy. This type of policy pays a pre-set amount for health care services received, regardless of the actual amount charged for those services. The information below does not apply to indemnity policies.

Diabetes Treatment
The health insurer must establish a program to prevent the onset of clinical diabetes and the contract must include coverage for equipment, supplies, and educational training for the treatment and clinical onset of diabetes.

This mandate includes coverage for:

  • Blood glucose monitors and blood glucose monitors for the legally blind
  • Test strips for glucose monitors, visual reading and urine testing strips, lancets, and spring-powered lancet devices
  • Syringes
  • Insulin pumps and medical supplies required for the use of an insulin pump
  • Diabetes self-management training

If the health plan includes prescription coverage directly or by rider, the health insurer must include the following coverage for the treatment of diabetes, if determined to be medically necessary:

  • Insulin, if prescribed by an allopathic or osteopathic physician
  • Non-experimental medication for controlling blood sugar, if prescribed by an allopathic or osteopathic physician
  • Medications used in the treatment of foot ailments, infections, and other medical conditions of the foot, ankle, or nails associated with diabetes, if prescribed by an allopathic, osteopathic, or podiatric physician

Diabetes includes: Gestational diabetes, insulin-dependent diabetes, and non-insulin-dependent diabetes. See MCL 500.3406p.

Breast Cancer and Diagnostic Services
The health insurer must offer or include coverage for breast cancer diagnostic services, breast cancer outpatient treatment services, and breast cancer rehabilitative services.

Breast screening mammography must be allowed using the following schedule:

  • A woman 35 years of age or older and under 40 years of age, coverage for 1 screening mammography examination during that 5-year period
  • A woman 40 years of age or older, coverage for 1 screening mammography examination every calendar year

See MCL 500.3406d.

The health insurer must offer benefits for prosthetic devices to maintain or replace the body parts of an individual who has undergone a mastectomy. This includes medical care for an individual who receives reconstructive surgery following a mastectomy or who is fitted with a prosthetic device. See MCL 500.3406a.

Hospice Care
If the health insurer provides coverage for inpatient hospital care, it must also offer coverage for hospice care and include a description of the coverage in the contract. See MCL 500.3406c.

Chemotherapy (Cancer Treatment)
In Michigan, a health insurer must provide coverage for a drug used in antineoplastic therapy (cancer treatment) and the reasonable cost of its administration. Coverage must be provided for any FDA approved drug regardless of whether the specific cancer for which the drug is being used as treatment is the specific cancer for which the drug has received approval by the FDA if all of the following conditions are met:

  • The drug is ordered by a physician for the treatment of a specific type of cancer
  • The drug is approved by the FDA for use in cancer treatment
  • The drug is used as part of any cancer drug regimen
  • Current medical literature substantiates its efficacy and recognized oncology organizations generally accept the treatment
  • The physician has obtained informed consent from the patient for the treatment regimen which includes FDA approved drugs for off-label indications

See MCL 500.3406e.

Emergency Health Services
If the policy provides coverage for emergency health services it must provide coverage for medically necessary services for the sudden onset of a medical condition with signs and symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health or to a pregnancy in the case of a pregnant woman, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

A health insurer cannot deny payment for emergency health services because of the diagnosis or the fact that prior authorization was not given before the emergency services were provided. See MCL 500.3406k.

If the policy covers benefits for emergency services, it must provide coverage for ambulance services. See Bulletin No. 2001-03-INS.

Obstetrician-Gynecologist and Mid-Wife
If the health plan requires you to designate a participating primary care provider and provides for annual well-woman examinations and routine obstetrical and gynecologic services, the woman must be allowed to have these treatments performed by an obstetrician-gynecologist or a nurse mid-wife, as long as these providers are acting within the scope of their license. See MCL 500.3406m.

If a health insurer requires a designation of a primary care provider and provides coverage for dependents, the health insurer must allow the dependents to receive care from a pediatrician. See MCL 500.3406n.

Prescription Drug
If the health plan includes prescription drug coverage and the prescription drug coverage is limited to drugs included in a formulary, the health insurer must provide the formulary restrictions. It must also provide for exceptions when a non-formulary medication is medically necessary and an appropriate alternative. See MCL 500.3406o

Michigan Prior Authorization Request Form for Prescription Drugs

Off-Label Use of Approved Drug
If the contract provides prescription coverage the health insurer must provide coverage for an off-label use of an FDA approved drug and the reasonable cost of supplies medically necessary to administer the drug. “Off-label” means the use of a drug for clinical indications other than those stated in the labeling approved by the FDA. See MCL 500.3406q

Substance Abuse
The health insurer must include coverage for intermediate and outpatient care for substance abuse treatment. The financial requirements (such as copayments, coinsurance, and deductibles) cannot be less favorable than the maximum prescribed for any other comparable service. See MCL 500.3425.

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law requiring health plans to ensure that financial requirements and treatment limitations applicable to mental health and substance use disorder benefits are similar to medical/surgical benefits. For more information on MHPAEA, please visit DIFS’ MHPAEA webpage and Your Rights Under the Mental Health Parity and Addiction Equity Act of 2008 Consumer Counselor.

Autism Spectrum Disorder
Most policies that are issued, amended or renewed must provide coverage for diagnosis and treatment of autism spectrum disorder (ASD). Health insurers may not:

  • limit the number of visits a member, insured, or enrollee may use for treatment of ASDs covered under the law
  • deny or limit coverage on the basis that it is educational or habilitative in nature
  • subject autism coverage to dollar limits, copays, deductibles, or coinsurance provisions that do not apply to physical illness generally

Coverage for treatment of ASDs may be limited to an individual through age 18. Health insurers may impose certain restrictions on ASD coverage, subject to state law, MHPAEA, and the ACA. See MCL 500.3406s and Order No. 14-017-M.

Affordable Care Act Provisions:

Grandfathered Plans
Grandfathered plans are those that were in existence on March 23, 2010 and have stayed basically the same. But they can enroll people after that date and still maintain their grandfathered status. In other words, even if you joined a grandfathered plan after March 23, 2010, the plan may still be grandfathered. The status depends on when the plan was created, not when you joined it.

Check your plan’s materials or check with your employer to find out if your current plan is a grandfathered plan. Many provisions of the ACA do not apply to grandfathered plans.

Essential Health Benefits
The ACA ensures that health plans offered in the individual and small group markets, both inside and outside of the Marketplace, offer a comprehensive package of items and services, known as Essential Health Benefits. Essential health benefits must include items and services within at least the following ten categories:

  • ambulatory patient services
  • emergency services
  • hospitalization
  • maternity and newborn care
  • mental health and substance use disorder services, including behavioral health treatment
  • prescription drugs
  • rehabilitative and habilitative services and devices
  • laboratory services
  • preventive and wellness services and chronic disease management
  • pediatric services, including oral and vision care

Insurance policies must cover these benefits to become certified and offered on the Marketplace. All Medicaid state plans must cover these services as well.

Annual and Lifetime Limits
The ACA prohibits health insurers from setting a lifetime and annual dollar limit for coverage for essential health benefits.

Coverage for Young Adults
Most health insurers and employers providing dependent coverage to children are required to make coverage available to adult children up to age 26. This applies to adult children who do not have access to coverage from their own job and regardless if they are students, financially dependent on their parents, live with their parents, or are married.

If you are in a health plan for retirees, also known as a retiree-only plan, these plans are exempt from this requirement and do not have to offer coverage for children up to age 26. If you are in a retiree-only plan, check with your plan to determine its policy for covering young adults.

Preventive Services
Under the ACA, health plans cannot impose any cost-sharing for certain preventive services. Health insurers cannot charge a deductible, copayment, or coinsurance for preventive care services such as flu shots and other immunizations, mammograms and other cancer screenings, diabetes screenings and more.

No Denial for People with an Illness or Chronic Condition
An insurance company can no longer turn you down, charge you more or impose a waiting period for coverage because you have a pre-existing medical condition.

Glossary Links: