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Autism Insurance Legislation

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Michigan's Autism Insurance Reform legislation (PA 99 and PA 100 of 2012) went into effect on October 15, 2012. For-profit, commercial, HMO, and non-profit health insurance companies regulated by the state of Michigan are mandated to provide an autism benefit to its insured members covering services related to the diagnosis and treatment of autism spectrum disorders (ASD) through 18 years of age. 

Self-funded insurance plans are regulated by Employee Retirement Income Security Act commonly referred to as ERISA through federal law. Self-funded insurance plans are not mandated to provide autism coverage.  However, if a self-insured company self-adopts an autism benefit whereby employees are offered autism coverage by the self-insured plan, then the self-insured company either directly or through its third party administrator (TPA) may submit reimbursement request(s) to cover the cost of the paid claims to the Autism Coverage Fund.

The Autism Coverage Fund was created to offset the cost of providing an autism benefit for health insurers, TPAs and self-insured companies. To participate in the Fund, paid claims must be for insured members who are residents of Michigan and who receive an ASD diagnosis and treatment by Michigan providers.

To learn more about the Autism Coverage Fund go to www.michigan.gov/autismfund.

As of October 15, 2012 state regulated health insurance plans, both for-profit and non-profit, are required to offer an autism benefit for their insured members.

PA 99 and 100 of 2012 includes the following highlights:

  1. Coverage for the treatment of ASD may be limited to a member through 18 years of age and may be subject to a maximum annual benefit as follows:
  • For a covered member through 6 years of age, $50,000.00.
  • For a covered member from 7 years of age through 12 years of age, $40,000.00.
  • For a covered member from 13 years of age through 18 years of age, $30,000.00.

  1. A covered member must receive a diagnosis of ASD by a licensed physician or a licensed psychologist to receive coverage for ASD services.
  • Insurance carriers may require an evaluation of the member be conducted every three years.

  1. Treatment of ASD must be evidence based and includes the following care as determined by a licensed physician or a licensed psychologist:
  • Behavioral health treatment (applied behavior analysis),
  • Pharmacy care,
  • Psychiatric care,
  • Psychological care, and/or.
  • Therapeutic care (speech therapy, occupational therapy).

Refer to Medicaid and MIChild Autism Benefit for health care services under those plans.

Review the legislation for additional details:

PA 99 of 2012 (Senate Bill 414)

PA 100 of 2012 (Senate Bill 415)

PA 101 of 2012 (Senate Bill 981)


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