The State of Michigan has approved new laws requiring health insurance companies to cover the diagnosis and treatment of autism spectrum disorders (Public Acts 99 and 100 of 2012, enacted on April 18, 2012). The law will apply to any group or individual policy or certificate delivered, issued for delivery, or renewed in Michigan on or after October 15, 2012 (180 days after the date of enactment).
Insurers must generally cover the diagnosis and treatment of autism spectrum disorders on the same basis that physical illness is covered, except that coverage may be limited to children through age 18 and may be subject to the following maximum annual benefit limitations:
- $50,000 for a child through age 6;
- $40,000 for a child age 7 through 12; and
- $30,000 for a child age 13 through 18.
The types of treatments of autism spectrum disorders that must be covered include the following evidence-based treatments:
- Behavioral health treatment;
- Pharmacy care;
- Psychiatric care;
- Psychological care; and
- Therapeutic care.
An insurer is permitted to apply generally applicable exclusions and limitations of the policy, such as coordination of benefits, participating provider requirements, utilization review, including review of medical necessity and case management, and other managed care provisions.
A companion law, Public Act 101 of 2012, establishes the Autism Coverage Reimbursement Program, which will reimburse insurers and self-funded plans for the cost of paid claims for the diagnosis and treatment of autism spectrum disorders (up to the annual cap on benefits). The Program is intended to mitigate the cost of covering autism spectrum disorders; however, no funds were appropriated for the Program, so the amount of assistance that will be available is currently unknown.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
