Autism Spectrum Disorder Health Coverage

Most health plans issued in Michigan are required to provide autism benefits. This includes all individual health plans purchased on and off the Health Insurance Marketplace and fully insured group health insurance policies and certificates issued in this state. Generally, fully insured group health insurance policies are health policies purchased by an employer from an insurance company.

If you are unsure about what your plan covers, contact your health plan. For additional questions or concerns about your health plan’s coverage of autism diagnosis and treatment, contact DIFS.

Covered health care services include:

• Diagnosis and treatment of ASD.
• Applied behavioral analysis (ABA), which is categorized in Michigan’s essential health benefits as a habilitative service. Habilitative services help you keep, learn, or improve skills for daily living, such as speech therapy, physical therapy, and occupational therapy.

Limiting Treatment for ASD is Prohibited

Insurers are prohibited from limiting benefits for autism spectrum disorder such as:

• Subjecting coverage to age limits.
• Limiting the number of visits for any mandated type of treatment, including speech therapy, physical therapy, and occupational therapy.
• Denying or limiting coverage on the basis that it is educational or habilitative in nature.
• Subjecting coverage to annual dollar limits.
• Imposing co-payments, deductibles, or co-insurance provisions that are more restrictive than those for other medical care.

Insurers may apply reasonable medical management techniques such as:

• Reviewing the use of health care services to ensure they are medically necessary.  
• Reviewing and coordinating services through case management and other managed care services.
• Restricting services provided by family or household members.

• Michigan-Regulated Individual and Group Health Plans
  These plans include health plans purchased on the Health Insurance Marketplace at HealthCare.gov, purchased directly from a health insurance company, or a fully insured health plan offered through your or your spouse’s employer.
   
• Self-Funded Health Plans
  These plans are typically offered by large employers and you may not know whether your employer has provided coverage through a self-funded plan.
  Self-funded, or ERISA plans, are not regulated by the state and are not required by law to provide autism coverage. It is best to contact your employer to ask about your coverage, including age limits and other restrictions.

Contact your insurance company to find out:

• Whether your plan offers autism benefits.
• What autism benefits are included in your plan.
• The cost for services (co-payment, co-insurance, deductibles).
• The difference between in-network and out-of-network providers and the cost difference between the two.

Shop for coverage through the Health Insurance Marketplace at HealthCare.gov. You may also qualify for low- or no-cost coverage for yourself or your child through Medicaid, the Healthy Michigan Plan, or MIChild. Contact the Michigan Department of Health & Human Services (MDHHS) to learn more and apply for coverage. 

If your health insurance company denies a claim or ends your coverage, you have the right to appeal the decision. An attorney is not required to resolve most disputes. Start with contacting the health insurance company in writing and request a reconsideration of its decision.

If your dispute involves a decision your health insurer made regarding your health care claim, also known as an adverse determination, there are two levels of appeal – an internal appeal with your health insurer and an external review with DIFS. The external review process should only be initiated if:

• The covered person has exhausted the health carrier’s internal grievance process.

OR

• The health carrier fails to provide a determination within the timeframe dictated by law.

If you’ve exhausted your health carrier’s internal grievance process and you do not agree with its final adverse determination, you have 127 days to file an external review with DIFS under the Patient’s Right to Independent Review Act (PRIRA). For additional information related to DIFS’ external review process and to access the Health Care Appeals-Request for External Review form, visit Michigan.gov/PRIRA or contact DIFS Monday through Friday 8 a.m. to 5 p.m. at 877-999-6442. Upon receipt, DIFS will examine your external review request to determine if it meets the requirements under PRIRA.

In any case, you always have the right to file a written complaint with DIFS if you are unable to reach a satisfactory resolution. DIFS will send the health insurance company a copy of the complaint and ask it to explain its position. Health insurance companies are required by law to respond to DIFS. We will review the facts to ensure the health insurance company has complied with your contract language and all rules and regulations.

Complaints Can Be Submitted in the Following Ways:

• Online: www.michigan.gov/DIFScomplaints
• Email: DIFScomplaints@michigan.gov
• Fax: 517-284-8837
• Mail: DIFS, PO Box 30220, Lansing, MI 48909

Contact DIFS toll-free at 877-999-6442 for additional information or to request a complaint form be sent to you via mail, email or fax.