Key Takeaways
- Michigan requires a 10-day free look period for individual health insurance policies
- Michigan operates its own health insurance marketplace through the federal platform (Healthcare.gov)
- Pre-existing condition exclusions are prohibited in individual and small group markets under ACA
- Michigan requires coverage for mental health parity and essential health benefits
- Michigan has specific mandated benefits including autism services and diabetic supplies
Michigan Health Insurance Policy Requirements
Michigan has health insurance regulations that work alongside federal requirements to protect consumers. Understanding these state-specific rules is essential for the licensing exam.
Regulatory Structure
DIFS regulates health insurance in Michigan:
| Coverage Type | Regulatory Framework |
|---|---|
| Individual Health | State and federal (ACA) |
| Small Group (1-50) | State and federal (ACA) |
| Large Group (51+) | State and federal |
| Self-Funded Plans | Federal (ERISA) primarily |
| Medicare Supplement | State regulated |
Free Look Period
Michigan provides a 10-day free look period for individual health insurance:
- Policyholder can return for full premium refund
- Begins when policy is delivered
- Applies to individual health policies
- Seniors 65+ may have extended periods for some products
Health Insurance Marketplace
Michigan uses the federal marketplace (Healthcare.gov) for individual coverage:
Key Features
- Open enrollment periods apply
- Special enrollment for qualifying life events
- Premium tax credits available based on income
- Cost-sharing reductions for Silver plans
- All plans must cover essential health benefits
Metal Tier Categories
| Tier | Actuarial Value |
|---|---|
| Bronze | 60% |
| Silver | 70% |
| Gold | 80% |
| Platinum | 90% |
| Catastrophic | For under 30 or hardship |
Essential Health Benefits
All individual and small group plans must cover:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative and habilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Michigan-Specific Mandated Benefits
Michigan requires coverage for additional benefits:
Autism Spectrum Disorder Coverage
Michigan law mandates coverage for:
- Applied behavior analysis (ABA)
- Diagnosis and treatment of autism
- Age and dollar limits have been expanded over time
- Applies to fully insured plans
Diabetic Supplies
- Insulin and diabetic supplies coverage required
- Equipment coverage mandated
- Cost-sharing limitations may apply
Other Mandates
| Mandate | Description |
|---|---|
| Mammography | Annual screening coverage |
| Prostate Screening | Coverage for screening |
| Mental Health Parity | Equal benefits for mental health |
| Maternity | Coverage for childbirth |
| Mastectomy | Breast reconstruction coverage |
Mental Health Parity
Michigan follows federal and state mental health parity requirements:
- Mental health benefits equal to medical benefits
- Same copays, deductibles, and limits
- Covers mental illness and substance use disorders
- Applies to group and individual plans
Pre-Existing Condition Protections
Under the ACA, Michigan prohibits:
| Protection | Description |
|---|---|
| Denial of Coverage | Cannot deny based on health status |
| Pre-ex Exclusions | Prohibited in individual and small group |
| Higher Premiums | Cannot charge more for health conditions |
| Waiting Periods | Limited in group coverage |
How long is the free look period for individual health insurance policies in Michigan?
Which platform does Michigan use for its individual health insurance marketplace?