Services Medicare pays for
For treatment that Medicare would pay for, the cap is a percentage of the amount Medicare would pay for the same service in the same locality. For treatment rendered after July 1, 2023, the standard percentage is 190%. It was 200% for the first year of the schedule and 195% for the second. Higher caps apply in three situations: providers with a high share of indigent patients and designated freestanding rehabilitation facilities (MCL 500.3157(3) to (5)), and Level I and Level II trauma centers for emergency care before the patient is stabilized (MCL 500.3157(6)).
Services Medicare does not pay for
Where Medicare has no amount payable, the cap is a percentage of the provider’s charge for the service on January 1, 2019: 55%, then 54%, and 52.5% for treatment after July 1, 2023 (MCL 500.3157(7)). DIFS adjusts these amounts each July for inflation; the current adjustment is in Bulletin 2026-09-INS. Under every formula, payment cannot exceed the provider’s average charge for the service on January 1, 2019, as adjusted each year for medical inflation (MCL 500.3157(8) and (9)).
Where insurers get it wrong
- Using the wrong formula. The Court of Appeals’ October 2025 decision in West Michigan Home Care Services v. MEEMIC and DIFS Bulletin 2026-15-INS (April 2026) confirmed that home health aide and skilled nursing care fall under the Medicare-based cap because Medicare sets an amount payable. Agencies paid under the non-Medicare formula may be owed the difference.
- Wrong locality or year. The fee schedule in effect on the date of service, for the locality where it was rendered, controls.
- Applying Medicare payment limitations that are not part of the rate, such as utilization adjustments or sequestration, which MCL 500.3157(15)(f) excludes.
- Multiple procedure and assistant-at-surgery reductions applied without checking the correct Medicare rule.
Utilization review appeals
If an insurer decides that treatment was overutilized or inappropriate, the provider can appeal to DIFS under MCL 500.3157a. The appeal has its own deadlines and record. Whether to appeal, sue, or both depends on the amount and the reason for the denial.
This page summarizes MCL 500.3157, Mich Admin Code R 500.201 to 500.206, and DIFS Bulletins 2026-09-INS and 2026-15-INS as of October 2026.