Health insurers pay for medically necessary health care services identified in the health plan. "Medically necessary" is defined in the health plan or Summary of Benefits and Coverage (SBC). Insurers typically do not pay for medical treatments that are considered experimental or investigational.
The Affordable Care Act (ACA) requires individual and small group health plans to offer a comprehensive package of items and services known as essential health benefits.
Essential health benefits are required to include items and services within the following 10 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
Under the ACA, most health plans are required to provide free preventive services. Insurers cannot charge a deductible, co-payment, or co-insurance for preventive care if it is provided by an in-network provider. Preventive care includes services such as:
Breast and colon cancer screenings
Screenings for diabetes, high cholesterol, and high blood pressure
Routine vaccines
Regular pediatrician visits
Vision and hearing screening
Counseling to address obesity
A comprehensive list of free preventive services is available at www.healthcare.gov/prevention.
The following are benefits most health plans issued in Michigan are required to include under Michigan law:
A health plan covering emergency services is required to also provide coverage for ambulance services.
Insurers are prohibited from limiting benefits for autism spectrum disorder such as:
Insurers may apply reasonable medical management techniques such as:
An insurer is required to include coverage for breast cancer diagnostic services, breast cancer outpatient treatment services, and breast cancer rehabilitative services. Breast screening mammography must be covered using the following schedule:
For women between the ages of 35 and 40, coverage for one mammogram during a 5-year period
For women over 40, coverage for one mammogram every calendar year
In Michigan, it is mandatory for an insurer to provide benefits for a drug used in antineoplastic therapy (cancer treatment) and the reasonable cost of administration. Coverage must be provided for any FDA-approved drug even if the treatment is for a different type of cancer than originally approved to treat, when 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
In this section, “diabetes” includes gestational diabetes, insulin-dependent diabetes, and non-insulin-dependent diabetes.
An insurer must establish a program to prevent the onset of clinical diabetes and include coverage for equipment, supplies, and educational training.
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 a rider, the 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
A health plan providing emergency health services should provide coverage for medically necessary services of:
The sudden onset of a medical condition with signs and symptoms of sufficient severity. This includes severe pain and if immediate medical attention is not received, 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.
Serious dysfunction of any bodily organ or part.
An insurer cannot deny payment for emergency health services because of the diagnosis or because prior authorization was not given before emergency services were provided.
If the insurer provides coverage for inpatient hospital care, the insurer must also offer coverage for hospice care and include a description of the benefit in the health plan.
The 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.
Individual and small group health plans must provide mental health and substance use disorder (MH/SUD) coverage as essential health benefits. Any plan offering MH/SUD benefits must comply with MHPAEA. MHPAEA requires health plans to apply similar financial and treatment limits to MH/SUD benefits and medical/surgical benefits.
Insurers requiring the designation of an in-network primary care provider that also provides annual well woman examinations, as well as routine obstetrical and gynecologic services, must allow the insured 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.
An insurer providing prescription drug coverage must provide coverage for the off-label use of FDA-approved drugs and the reasonable cost of medically necessary supplies 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.
An insurer requiring the designation of a primary care provider and providing dependent coverage must allow the dependents to receive care from a pediatrician.
A health plan must provide a list, also referred to as a formulary, of covered prescription drugs and a list of restrictions. The health plan has to provide exceptions for a prescription drug that is not on the insurer’s list of covered drugs and has been deemed to be a medically necessary alternative.
