Laws



What does the Michigan law say about coverages for newborns?

Insurance Bulletin 86-8 states that maternity or pregnancy benefits are medical benefits which cover care arising from pregnancy and childbirth. Medical or hospital care for a healthy infant following delivery is considered part of the care for pregnancy and delivery and should be covered the same as the care for the mother. Well baby care is covered under the mother’s coverage even if the baby has not been added to the mother’s coverage. Michigan law also requires that an employer must offer to add a newborn to a health benefit plan that includes family coverage. The employer or insurer can require that they receive notice within 31 days of the birth if the parents want to add the child to the coverage.

What does the Michigan law say about coverage for mammograms?

Michigan law requires that health insurance companies, Blue Cross Blue Shield of Michigan, and HMOs provide or offer to provide coverage for breast cancer screening mammography. The coverage must include one mammogram in a five-year period for a woman at least 35 years of age and less than 40 years of age. For women 40 years of age and older, they must pay for one mammogram per year. The law requires that this coverage must be offered, however, a group, such as an employer, is allowed to choose not to purchase the mammography coverage.

What does the Michigan law say about coverage for chemotherapy (antineoplastic) drugs?

Michigan law requires health insurance companies, Blue Cross Blue Shield of Michigan and HMOs to pay for FDA approved drugs used in antineoplastic therapy (chemotherapy) and the reasonable cost to administer them. When the FDA approves a drug to be used in chemotherapy, it does so for the treatment of a specific type of cancer. Since the drug is FDA approved, it can be used for the treatment of other types of cancer. This is known as an “off label” use of a drug. The FDA will not review or approve these multiple uses for drugs. There have been problems with third party payers denying payment for “off label” chemotherapy drugs. Michigan law provides that an antineoplastic (chemotherapy) drug is covered if it is FDA approved, the current medical literature substantiates its efficacy to treat the type of cancer and the patient is informed that the treatment is an “off label” use.

What does the Michigan law say about coverage of diabetes?

Michigan law requires health insurance companies, health maintenance organizations, and Blue Cross Blue Shield of Michigan to provide benefits for blood glucose monitors, visual reading and urine testing strips, lancets, spring-powered lancets, syringes, insulin pumps and medical supplies required for use of an insulin pump. They must also provide payment for self-management training and education if prescribed by an allopathic or osteopathic physician and determined to be medically necessary. There are some limitations on the educational training reimbursements.

A health insurance company and a health maintenance organization that provides a benefit plan including outpatient prescription coverage must also pay for insulin, nonexperimental medication for controlling blood sugar, medications used for foot ailments, infections, and other medical conditions of the foot, ankle, or nails associated with diabetes. Blue Cross Blue Shield must cover these same medications regardless of whether outpatient prescription drugs are otherwise provided in the health benefit plan.

Individuals who receive their health insurance coverage through a self-insured employer may have different benefits for diabetes treatments and education than those listed above. Self-insured employers are regulated under federal laws and do not have to meet the requirements of Michigan law.

What are Michigan’s licensure requirements for utilization review firms?

Michigan has no licensure requirements for utilization review firms.

What are Michigan’s licensure requirements for preferred provider organizations (PPOs)?

Michigan does not require licensure of PPOs that bear no insurance risk, that is PPOs that accept fee-for-service reimbursement with no risk pooling or transfer. Licensed risk bearers and licensed claim processors (insurers and third party administrators) that condition the delivery of benefits upon the use of a particular panel of healthcare providers are subject to Michigan’s Prudent Purchaser Act (PPA).

What are Michigan’s licensure requirements for multiple employer welfare arrangements (MEWAs)?

Michigan requires licensure of MEWAs that do business with Michigan employers and are not fully insured. To obtain licensure, a MEWA must be controlled by its members, have adequate cash reserves, and purchase excess loss insurance. A complete description of MEWA licensure requirements can be found in Chapter 70 or the Michigan Insurance Code.