The national Medical Plans guide covers major medical design, managed care (HMO, PPO, POS), HSAs and the federal ACA rules. This guide covers the Michigan statutes that shape medical plans sold in Michigan. They are dependent and newborn coverage, child support orders, telehealth, genetic information, prompt payment and the Patient's Right to Independent Review Act.

Dependents and newborns (MCL 500.3403)

• Dependent coverage must be available until the child turns 26.
• Newborns are covered from the moment of birth, for injury and sickness, including congenital defects and birth abnormalities.
• A child can't be denied coverage because the child:
  • was born out of wedlock
  • isn't claimed on the insured's tax return
  • doesn't live with the insured or in the service area

Medical child support orders (MCL 500.3406h)

When an insurer is notified of a court or administrative order requiring a parent to cover a child:

• The child must be enrolled without regard to enrollment season restrictions.
• The insurer must accept claims from the custodial parent or the provider, without the other parent's approval, and pay them directly.

Other benefit and underwriting rules

• Telehealth: a plan must cover telehealth at least as it would cover the same service delivered face to face, subject to normal cost sharing (3476).
• Genetic information: an insurer can't require genetic testing or disclosure of genetic test results or genetic information to issue or renew a health policy (3407b).
• Unfair discrimination between people of the same class and essentially the same hazard is prohibited (MCL 500.2020).

Prompt payment (MCL 500.2006(8))

External review (Patient's Right to Independent Review Act, MCL 550.1907–550.1913)

• Generally, the covered person must first exhaust the plan's internal grievance process (550.1907).
• Standard review: request it from the DIFS Director within 120 days of the final adverse determination (550.1911).
• Expedited review: request it within 10 days if the standard timeline would seriously jeopardize the person's health (550.1913).
• The independent review organization gives its recommendation to the Director within 14 days of assignment, in a standard review.

Guaranty protection

The Michigan Life and Health Insurance Guaranty Association covers up to $500,000 in basic hospital, medical and surgical benefits per life (MCL 500.7704).

Common exam traps

• Newborns are covered at birth, including congenital defects. Dependents are covered to 26.
• A child can't be refused for being born out of wedlock or living elsewhere.
• Clean claims: 45 days, then 12% interest.
• External review goes to the DIFS Director: 120 days for standard, 10 days for expedited, after internal appeals.
• No required genetic testing.