AUTISM INSURANCE COVERAGE IN MICHIGAN….

WHAT IT MEANS NOW

Senate bills 414, 415, and 981 passed the Michigan legislature on March 29, 2012. The bills will go to the governor for signature, and then the “immediate effect” period starts. Passing the autism insurance legislation is the first step to creating a network of qualified providers who will be able to service children with autism in Michigan. These services will include Applied Behavior Analysis (ABA)—behavior therapy that is the evidence-based treatment of choice for individuals with autism. The legislation will also cover occupational therapy (OT) for sensory-based interventions and speech therapy.

Overview of Legislation and Requirements

 Once signed, the bills take “immediate effect”. This means this law will go into effect 180 days from the date it is signed by the Governor. This means insurance companies are not required to cover these services until that time. Each family will need to check with their provider to see what is covered (i.e., copays, deductibles, etc. will vary).

Michigan currently lacks enough providers to immediately serve the needs of all of the children in the state with autism. There are currently about 115 Board Certified Behavior Analysts (BCBA’s) in Michigan, and only about 30 of those provide services to families with autism. There are over 15,000 kids in Michigan with the disability. Building the provider network is of greatest importance. Immediately upon passing this legislation many providers are hoping to expand intervention services. This will take some time, but the infrastructure is being put in place.

Families will need to check with their insurers about which therapists can be used for intervention. Insurers have the right to set up networks, or designate Centers of Excellence and require that you use those particular providers. We will be working with the insurance companies and will provide updates to you on this website.

Autism must be diagnosed by a PHYSICIAN (MD/DO) or a licensed psychologist using standard diagnostic tools.

  • Treatment ages: 0-18 years.
  • Caps/Scale: coverage will be provided for children with the medical diagnosis of Autism.
  • Therapies can only be provided by: Board Certified Behavior Analyst (BCBA) for Applied Behavior Analysis (ABA), Licensed Speech and Language Pathologist (SLP) for Speech Therapy; and an Occupational Therapist (OT) for occupational therapy services (i.e. sensory-based needs).
  • The following caps are a combined total, which means that the total of ALL intervention services in included. For example, a child 6 years or younger will be covered for $50,000 of combined Speech, OT, ABA, and other behavioral health services, such as psychiatry.
    • $50,000 (6 years and younger)
    • $40,000 (7-12 years)
    • $30,000 (13-18 years)

The law to mandate coverage only applies to State Legislated Insurance Companies. If you work for a large company, they might be a self-funded plan and is regulated by ERISA, a Federal law and the mandate does not apply. However, the State has created an incentive mechanism to essentially reimburse self-funded plans for autism coverage. In essence, there will be no cost to your employer. We will provide you an information kit for you to take to your company (if a self-funded plan) and ask them to self-adopt autism coverage. That is being developed and will be available soon.

If you are not certain if your company is on a self-funded plan or a State legislated plan, please contact your HR department. If you are on Medicaid or are looking for services, the State of Michigan is currently working on a plan to provide autism (behavior) therapy coverage. For more information on current Medicaid eligibility, contact your local Community Mental Health (CMH) agency. They can determine existing qualifications for Medicaid. More information will be forthcoming as we receive it from the Department of Community Health regarding coverage for autism.

Frequently Asked Questions

Additional Answers to FAQ

For continued information, go to www.michigan.gov/autism 

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