ABA Therapy Coverage in Michigan: What the Law Requires of Your Plan
Applied behavior analysis is the best-known treatment under Michigan’s autism insurance law. Here is who must cover it, what limits the statutes allow, which plans fall outside the mandate, and every law and rule behind it.
What Michigan requires insured plans to cover for ABA
The rule sits in two statutes: the Insurance Code for commercial insurers and HMOs, and the Nonprofit Health Care Corporation Reform Act, which governs Blue Cross Blue Shield of Michigan. Their wording is nearly identical.
ABA is named treatment
Treatment of autism spectrum disorders includes behavioral health treatment, and the statute defines behavioral health treatment to include applied behavior analysis. It also includes pharmacy care, psychiatric care, psychological care and therapeutic care such as speech and occupational therapy.
Who must provide it
Behavioral health treatment must be provided or supervised by a board certified behavior analyst or a licensed psychologist working within their training. The diagnosis must come from a licensed physician or a licensed psychologist.
No visit limits
An insurer cannot limit the number of visits for covered autism treatment, and cannot deny or limit coverage because the treatment is educational or habilitative in nature.
Cost sharing
Dollar limits, copays, deductibles and coinsurance cannot be stricter than those that apply to physical illness generally, apart from the age and annual maximum provisions covered below.
What the insurer may require
The insurer may require a treatment plan and a review of treatment, ask for the results of the autism diagnostic observation schedule, request that it be repeated no more than once every three years, and request an annual developmental evaluation. A treatment review the insurer asks for is at the insurer’s cost.
Where the mandate stops
Ordinary plan terms still apply, including coordination of benefits, participating provider rules, medical necessity review and case management. Prescription drugs are covered only if the member has a prescription drug plan, and short-term or one-time limited duration policies of six months or less are carved out.
Age limits and dollar caps: what the statute says and what the regulator says
The statute and the state’s consumer guidance do not read the same way. Ask your carrier for its autism provision in writing before you tell an employee what applies.
What the statute permits
An insurer may limit autism treatment coverage to members through age 18 and may apply annual maximums of $50,000 through age 6, $40,000 for ages 7 through 12, and $30,000 for ages 13 through 18. The language is permissive, so the policy controls.
What the regulator says
The Department of Insurance and Financial Services lists age limits and annual dollar limits among the restrictions insurers are prohibited from imposing, and treats ABA as a habilitative service within Michigan’s essential health benefits.
Why the two differ
The House Fiscal Agency describes the statute’s annual dollar limits as unenforceable once autism treatment, including ABA, became part of the essential health benefits. Autism Speaks also cites a 2014 state bulletin that removed annual dollar limits in fully insured plans. Federal rules on annual limits are the likely reason, in our reading.
Where the age question stays open
The state’s autism program page still says coverage may be limited through age 18. Read the certificate, then ask the carrier whether it applies any age cutoff and what happens to a member who turns 19.
Reviewed against the statutes and the state’s own pages on November 5, 2026. Confirm what applies to your policy with your carrier and your counsel.
Which plans the mandate reaches and which it does not
The mandate is a state insurance law, so what it reaches depends on how the plan is funded and sold.
Fully insured group plans
Large group and small group policies issued in Michigan must follow the mandate. The certificate should say how ABA is covered and what the carrier requires for authorization.
Self-funded plans
ERISA keeps self-funded plans outside state insurance mandates, so the plan document decides whether ABA is covered, for whom and with what limits.
Level-funded plans
Level-funded arrangements are generally self-funded with stop-loss coverage, so the same question applies. Check the plan document rather than assuming the mandate carries over.
Individual and Marketplace plans
The mandate reaches individual plans. A qualified health plan sold through the exchange does not have to cover autism benefits beyond the essential health benefits.
Short-term plans
Short-term or one-time limited duration policies of no longer than six months are excluded from section 3406s, so ABA coverage is not guaranteed.
The state reimbursement program
A state program was created to reimburse carriers and group health plan sponsors for paid autism claims. DIFS runs it, it works only as the legislature funds it, and it excludes claims for services that became essential health benefits after January 1, 2014. Ask whether funds are available before counting on it.
What to check in your plan before an employee asks
Families usually ask HR first. These steps put the answers in one place.
Read the certificate
Find the autism, ABA, behavioral health and habilitative sections together. Note the definitions, authorization steps and any age or dollar limit.
Check the network
ABA only helps if a family can find a provider. Ask how many licensed behavior analysts are in the network and what the wait is. Parity rules compare how behavioral health limits are applied against medical benefits.
Match the plan document
For a self-funded plan, the plan document and summary plan description define ABA coverage. A benefits guide is not a substitute for either.
Compare at renewal
Ask each carrier the same autism questions in writing and compare the answers beside price. Send us the renewal and we will set them side by side.
Prepare HR to answer
A one-page summary of what the plan covers, who to call and how authorization works helps HR answer a parent with confidence and kindness.
Know the appeal route
If a carrier denies ABA, the member has an internal appeal and then an external review with DIFS, which the statute says must be requested within 120 days of receiving the final decision (the DIFS page says 127 days).
Every law and rule behind ABA coverage in Michigan
Each card links to the official text, with Michigan law first and federal law after it.
MCL 500.3406s
Insurance Code of 1956, section 3406s. The autism mandate for insurers and HMOs. Added by Public Act 100 of 2012.
MCL 550.1416e
Nonprofit Health Care Corporation Reform Act, section 416e. The same mandate for health care corporation certificates. Added by Public Act 99 of 2012.
Public Acts 99 and 100 of 2012
Senate Bills 414 and 415, the autism insurance reform acts. In effect since October 15, 2012. Both acts are linked under Sources below.
Public Act 276 of 2016
The only amendment to section 3406s, which now carves out short-term and one-time limited duration policies of six months or less.
Public Act 101 of 2012
The Autism Coverage Reimbursement Act, MCL 550.1831 to 550.1841. Created the state reimbursement program and the autism coverage fund. Amended in 2014 and 2016.
Executive Reorganization Order 2013-1
MCL 550.991. Moved the autism coverage reimbursement program to the Department of Insurance and Financial Services.
Public Acts 403 and 404 of 2016
Senate Bills 1015 and 1016. License behavior analysts and assistant behavior analysts and create the licensing board. In effect since January 3, 2018. Both acts are linked under Sources below.
DIFS Bulletin 14-017-M
April 18, 2014. Autism Speaks cites it as removing annual dollar limits on autism coverage in fully insured plans. We have not located the bulletin itself, so confirm with DIFS.
Patient’s Right to Independent Review Act
Gives a member of an insured plan an external review by DIFS after the internal appeal, requested within 120 days of receiving the final decision (the DIFS page says 127 days).
ERISA, 29 U.S.C. 1144
The federal law that keeps self-funded plans outside state insurance mandates. The preemption rule is in section 1144.
ACA essential health benefits, 42 U.S.C. 18022
Habilitative services are an essential health benefit category, and DIFS classifies ABA as habilitative in Michigan’s essential health benefits.
ACA annual limits, 42 U.S.C. 300gg-11
Bars annual dollar limits on essential health benefits, which is why the statute’s annual maximums are in question.
Mental Health Parity and Addiction Equity Act
29 U.S.C. 1185a and 42 U.S.C. 300gg-26. Keeps group plans that cover mental health benefits from applying less favorable limits, including age and dollar caps, than they apply to medical and surgical benefits.
2025 parity non-enforcement statement
In May 2025 the federal Departments said they will not enforce the 2024 final parity rule while litigation is pending, plus 18 months. The 2008 law itself still applies. Check whether this has changed.
House Bill 4740 of 2025
Would amend the autism section. It was in committee when we last checked and is not law.
The questions that come up when an employee’s child is diagnosed
Ten questions employers and HR teams ask about ABA coverage, answered from the statutes.
Does Michigan require health plans to cover ABA therapy?
Yes, for insured plans. Section 3406s of the Insurance Code and section 416e of the Nonprofit Health Care Corporation Reform Act require covered autism treatment to include behavioral health treatment, which the statutes define to include applied behavior analysis. Self-funded plans are not required to follow them.
Does the mandate apply to our self-funded plan?
No. ERISA keeps self-funded plans outside state insurance mandates, so the plan document decides. Some self-funded plans cover ABA by design, and the terms are the plan sponsor’s choice.
Can an insurer limit ABA coverage by age?
The statute lets an insurer limit autism treatment coverage to members through age 18. The state insurance regulator’s consumer page lists age limits among the restrictions insurers cannot impose. Ask the carrier for its autism provision in writing and have counsel review any age cutoff.
Are there annual dollar caps on ABA?
The statute lists annual maximums of $50,000 through age 6, $40,000 for ages 7 through 12 and $30,000 for ages 13 through 18. The regulator’s consumer page says insurers cannot apply annual dollar limits, and the House Fiscal Agency has described the caps as unenforceable now that ABA is an essential health benefit. Confirm what your policy applies.
Who can provide ABA under the mandate?
Behavioral health treatment must be provided or supervised by a board certified behavior analyst or a licensed psychologist working within their training. Michigan also licenses behavior analysts and assistant behavior analysts under Public Acts 403 and 404 of 2016.
Can the carrier require a diagnosis, a treatment plan or reauthorization?
Within limits, yes. A licensed physician or licensed psychologist must diagnose the autism spectrum disorder. The insurer may require a treatment plan and a review of treatment, ask for the results of the autism diagnostic observation schedule, repeat it no more often than every three years, and request an annual developmental evaluation.
Can a plan cap the number of ABA visits?
No. The statutes bar insurers from limiting the number of visits for covered autism treatment and from denying coverage because treatment is educational or habilitative in nature. Medical necessity review and other managed care practices are still allowed.
Does the mandate cover short-term plans?
No. Section 3406s does not apply to short-term or one-time limited duration policies of no longer than six months.
Is ABA covered for adults?
The statute allows an insurer to limit coverage to members through age 18, and the state’s autism program says coverage may be limited that way. Whether your plan covers older members depends on the policy, and a self-funded plan decides for itself. Ask the carrier or plan administrator.
What can an employee do if ABA is denied?
Start with the carrier’s internal appeal. If the member has exhausted it or the carrier misses its deadline, the member has 120 days from receiving the final decision under the statute (the DIFS page says 127 days) to request an external review from DIFS under the Patient’s Right to Independent Review Act. Complaints can also go to DIFS. A self-funded plan follows its own plan document and federal ERISA claims rules.
Ready? Send us your renewal and we will check how it handles autism coverage, or talk it through with someone first. No cost, no obligation. Send us your renewal
General information about ABA coverage, not legal advice. Plan-specific questions belong with your counsel, and we will bring them in.
Where these details come from
MCL 500.3406s, Insurance Code of 1956
MCL 550.1416e, Nonprofit Health Care Corporation Reform Act
Autism Coverage Reimbursement Act, Public Act 101 of 2012
Executive Reorganization Order 2013-1, MCL 550.991
State of Michigan: Autism Legislation
DIFS: Autism Spectrum Disorder Health Coverage
Michigan House Fiscal Agency: Autism Spectrum Disorder fiscal forum
Autism Speaks: Michigan state-regulated insurance coverage
29 U.S.C. 1144 (ERISA preemption)
42 U.S.C. 18022 (essential health benefits)
42 U.S.C. 300gg-11 (annual and lifetime limits)
CMS: Mental Health Parity and Addiction Equity Act
U.S. Departments of Labor, HHS and Treasury: 2025 parity enforcement statement
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