Michigan Required Health Benefits for Insured Plans
The coverage the state insurance regulator lists as required under Michigan law, plus the claim payment rule, and where each one has its own guide.
Coverage Michigan Requires
This is the list DIFS publishes on its Required Coverage page. It cites no statute numbers, so treat it as a starting point and check your policy. It is not necessarily every mandate in the Insurance Code.
Ambulance
A health plan covering emergency services must also provide coverage for ambulance services. Employers should confirm in the plan documents how ambulance coverage is described, including any cost sharing that applies and how out-of-network transport is handled, since these details affect what an employee pays after an emergency.
Emergency Health Services
Payment cannot be denied based on diagnosis or lack of prior authorization. Employees who go to the emergency room should not have to decide in the moment whether a visit will be covered. Employers can remind staff of this protection and of how the plan handles follow-up care after the visit.
Autism Spectrum Disorder
See our autism guide. The statute text lets insurers limit coverage through age 18 and set annual dollar maximums by age, but not cap visits. DIFS states that insurers cannot impose age limits, visit limits or annual dollar limits on mandated treatments. The two readings differ, so read both and confirm with the carrier or counsel.
Breast Cancer Diagnostic Services
Covers diagnostic, outpatient treatment and rehabilitative services. Screening mammograms: one per 5-year period for women aged 35 to 39 and one per calendar year for women 40 or older. Cost sharing must be no less favorable than for physical illness generally. Confirm details with the carrier or counsel.
Mastectomy
Covers prosthetic devices and medical care for reconstructive surgery or prosthetic fitting. Employers should check how the plan describes these services in its benefit summary, since employees may not realize reconstruction and fitting are covered. A short note in enrollment materials can help staff and their families know what to expect.
Chemotherapy
Covers the drug and the reasonable cost of administration. FDA-approved drugs used for other cancer types are covered if conditions are met. See our oral chemotherapy guide. Employers should ask the carrier how the plan applies these provisions and whether prior approval or step requirements affect treatment, then share the answers with employees who are facing cancer care.
Diabetes
Covers a prevention program, glucose monitors, test strips, syringes, insulin pumps and supplies, and self-management training. Where prescription coverage exists, it also covers insulin and certain medications. Employers can help employees by explaining which supplies come through the medical benefit and which through the pharmacy benefit, since where an item is covered often determines what the employee pays.
Hospice Care
Must be offered if the insurer covers inpatient hospital care. Employers should confirm how hospice is described in the benefit summary and whether any limits or approvals apply. Families dealing with serious illness benefit from knowing the coverage exists before they need it, so share it plainly.
Off-Label Drug Use
Covers off-label use of FDA-approved drugs and the reasonable cost of medically necessary administration supplies. Employees may not know to ask about this protection when a treatment is prescribed outside its usual use. Employers can tell staff to work with their doctor and the carrier, and to appeal if a claim is denied.
Prescription Drugs
Plans must provide a formulary and exceptions for medically necessary alternatives not on the list. Ask the carrier how the exceptions process works, how long it takes and what the prescriber must submit. Employees who need a drug that is not listed benefit when HR knows where to send them for help.
Obstetrician-Gynecologist and Midwife
Where a primary care designation is required, the insured may use an OB-GYN or nurse midwife acting within their license. This is useful for employees who prefer to see a women’s health provider directly and do not want a referral step. Employers can point out the option in enrollment materials and confirm how the carrier handles it.
Pediatrician
Dependents may receive care from a pediatrician where a primary care designation is required. Parents may not realize they can choose a pediatrician as their child’s regular doctor. Employers can mention this in enrollment materials and confirm with the carrier how the directory shows pediatric providers and how a change is made.
Federal and Other Rules That Sit Alongside
Essential Health Benefits
DIFS also names the ten federal essential health benefit categories for individual and small group plans. Employers with fully insured small group plans should confirm with the carrier how its plans align with those categories, and review the benefit summary so employees understand what preventive, prescription and hospital services are included.
Mental Health Parity
The federal parity law applies, and Michigan has its own law. See our federal and Michigan parity guides. Employers should treat the two as complementary and ask the carrier how its plan design meets both. Counsel can advise on how the federal and state rules apply to a specific plan, especially where the funding method is not fully insured.
Telemedicine
MCL 500.3476 covers telemedicine services at least as well as in-person services. See our telemedicine guide. Employers should check how virtual visits are described in the plan, including cost sharing and any approved platforms. Telemedicine can help employees in remote areas or with busy schedules, so make sure staff know how to use it.
Prior Authorization Timelines
Public Act 60 of 2022 sets response deadlines. See our prior authorization guide. Employers can ask the carrier how it meets those timelines and what employees should do when a request is delayed. Sharing a simple instruction sheet helps staff follow up with their provider and escalate to HR when needed.
Denied Claims
Insured members can take a denial to external review. See our external review guide. Employees should keep their denial notice and any deadlines, and HR can help them understand the next steps. External review is an additional route after the carrier’s own appeal process, and the notice usually explains how to request it.
Self-Funded Plans
DIFS says it does not have authority over employers or self-funded plans. State mandates generally do not apply to self-funded plans. Employers with self-funded plans should rely on their plan documents and administrator, and ask counsel which federal and state rules still apply. Employees in those plans may have different protections than those in insured plans, so communicate clearly.
The Clean Claims Rule
This rule governs how fast a health plan pays providers, not members. Employers feel it indirectly through provider relations.
45 Days
Under MCL 500.2006(8), a health plan must pay a clean claim within 45 days after receipt. What counts as a clean claim is defined in the statute, so employers should not assume every claim qualifies for the deadline. Ask the carrier how it tracks receipt dates and how it handles claims that need more information.
12 Percent Interest
A clean claim not paid within 45 days bears simple interest at 12 percent per annum. The interest provision is meant to encourage timely payment to providers, not to create a benefit for employees. Employers can treat it as background when asking a carrier how often claims are paid late and how problems are corrected.
Who Is Covered
Subsections 7 through 14 cover payments to health professionals, health facilities, home health care providers and durable medical equipment providers, and exclude pharmacies. Because pharmacies are outside the listed provisions, employers should not assume the same timing rules apply to prescription claims. Counsel or the carrier can explain how pharmacy payments are handled under the plan.
What Is a Health Plan
The definition includes insurers offering health insurance policies and certain multiple employer welfare arrangements. Employers should confirm whether their coverage comes through an insurer or another type of arrangement, since the definition may not reach every structure. Counsel can help determine whether these payment rules apply to a particular plan.
Exclusions
The provisions do not apply to people regulated under the workers disability compensation act or to Medicaid claims covered under section 111i of the social welfare act. These exclusions show the provisions are limited in scope and do not apply to every payer. Employers should confirm with counsel how the exclusions work in practice before relying on the timelines in any dispute.
Why Employers Should Know
Slow provider payment can cause balance billing disputes and provider network friction. It is a fair question for a carrier at renewal. Employees often feel these disputes first, through calls from providers or surprise bills. HR can ask the carrier about its payment performance, network satisfaction and the steps it takes to resolve disagreements before they reach the employee.
Questions Michigan Employers Ask
Do Michigan Mandates Apply to Our Plan?
They apply to insured plans. Self-funded plans answer to ERISA and the U.S. Department of Labor.
Is This the Complete List of Mandates?
No. It is the list DIFS publishes. Check your policy and ask your carrier to confirm.
Where Does Autism Coverage Stand?
See our autism guide for the statute and DIFS wording, which differ.
Does the 45-Day Rule Help Employees?
It governs provider payment, not member claims. See our external review guide for member appeals.
How Often Does the List Change?
The legislature adds mandates from time to time. We update our guides as we verify each one.
Do Mandates Affect Premiums?
Mandated benefits are built into insured plan pricing. Ask your carrier how a new mandate affects your renewal.
Where Is the Full Compliance List?
Our Michigan benefits compliance hub links every guide.
Is This Legal Advice?
No. This is general information from benefits advisors. Consult your attorney.
Related Guides
Related reading: Michigan Benefits Compliance Hub · Autism Insurance Mandate · Oral Chemotherapy Coverage · Michigan External Review Law
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