Michigan No-Fault Fee Schedule: Provider Caps and Attendant Care

The Michigan no-fault fee schedule caps what medical providers can bill your auto insurer for treating crash injuries, and for most services rendered after July 1, 2021, that cap is a set percentage of what Medicare pays for the same procedure. The 2019 reform to the Insurance Code replaced the old reasonable-and-customary standard with these fixed ceilings, which vary by provider type, service category, and in some cases the calendar year.¹ Services delivered before July 1, 2021 still follow the old standard.

The Default Cap for Most Providers

Under MCL 500.3157(2), a general provider treating an auto injury cannot be paid more than a set percentage of the Medicare rate for the same procedure.¹ The percentage started at 200% when the schedule took effect in July 2021 and has phased down through statutorily scheduled reductions.

The calculation itself is mechanical. Start with the Medicare payment amount for the billed procedure code, apply the statutory percentage, and that is the ceiling. If a provider’s usual private-pay charge is higher, the insurer still owes only up to the cap. Anything billed above the ceiling is not the insurer’s obligation.

Higher Rates for Qualifying Hospitals

Not every facility is stuck at the general rate. The statute carves out higher tiers for hospitals that serve a large share of low-income patients and for specialized rehabilitation providers. Two categories qualify under MCL 500.3157(4):¹

Hospitals with 20% to 29% indigent volume, measured using the same methodology the Department of Health and Human Services applies for Medicaid disproportionate share payments. These hospitals started at 230% of Medicare in the first year and phased down to 220% for services rendered after July 1, 2023.
Designated freestanding rehabilitation facilities, capped at two per year, that demonstrate specialized rehabilitation expertise, sophisticated technology, participation in research and clinical education, and existence before May 1, 2019. These facilities receive the same subsection (3) rates.

A separate tier goes higher still. Providers with 30% or more of their total treatment volume in the indigent-care population qualify for 250% of the Medicare rate, and this tier has no scheduled phase-down.¹ The DIFS director certifies qualifying providers annually and publishes the list for insurers.

Services That Have No Medicare Code

Some treatments, specialized equipment, and rehabilitative training do not have a Medicare billing code. For these, the statute swaps the Medicare benchmark for a different anchor: the provider’s own pricing as of January 1, 2019. The cap is a percentage of whatever amount appeared in the provider’s charge description master on that date. If the provider had no charge master, the fallback is the average amount that provider individually charged for the service on that date.¹

The percentage depends on which provider tier applies and has phased down over time:

General providers under subsection (2): 52.5% of the 2019 charge, down from 55% in the first year.
Qualifying hospitals with 20–29% indigent volume: 66.5% of the 2019 charge, down from 70%.
Hospitals with 30% or more indigent volume: 78% of the 2019 charge, with no scheduled reduction.

The statute does not look to other providers’ pricing or regional averages. Only the individual provider’s own 2019 record counts, which is why accurate historical billing documentation matters when a payment is disputed.

Attendant Care Hourly Rate and the 56-Hour Rule

Attendant care covers help with daily activities like bathing, dressing, and eating for someone seriously injured in a crash. The fee schedule limits both the hourly rate and, for certain caregivers, the weekly hours an insurer must cover.

The hourly rate cap is tied to the limitation in section 315 of Michigan’s worker’s disability compensation act.¹ The hour cap is separate: when care is provided in the injured person’s home by someone with a pre-existing relationship to the patient, the insurer is only required to pay for up to 56 hours per week. That cap applies to three caregiver categories:²

Relatives of the injured person.
Household members living with the injured person.
Individuals with a pre-existing business or social relationship with the injured person before the accident.

Care provided beyond 56 hours per week by someone in these categories does not require insurer reimbursement. Professional caregivers hired through outside commercial agencies, without a prior relationship to the patient, are not subject to the 56-hour cap. For a catastrophically injured person who needs around-the-clock care, the gap between 56 hours and a full week can be significant.

How Your PIP Coverage Level Interacts With the Caps

The fee schedule controls the per-service ceiling. Your Personal Injury Protection coverage level controls the total dollar pool. Since the 2019 reform, Michigan drivers choose from several PIP options rather than receiving unlimited lifetime medical coverage automatically:³

Unlimited coverage, with no dollar cap on allowable medical expenses.
$500,000 per person, per accident, available to all policyholders.
$250,000 per person, per accident, available to all policyholders.
$50,000 per person, per accident, only available if the policyholder is enrolled in Medicaid and all household members have qualifying health coverage or Medicaid.
No PIP medical coverage, only available if the policyholder has both Medicare Part A and Part B and all household members have separate qualifying coverage.

If you selected a capped PIP level, the fee schedule still controls what providers can charge per service, but your total payout stops once you hit the coverage limit. Inflated or improperly coded charges can burn through a $250,000 or $500,000 cap quickly, which is why the per-service ceilings matter to policyholders and not just to providers.

Interest When an Insurer Pays Late

Once the cap is calculated, the insurer still has to pay on time. A PIP benefit becomes overdue if it is not paid within 30 days after the insurer receives reasonable proof of the loss.⁴ Medical bills carry a wrinkle: if the provider does not send the bill to the insurer within 90 days after the service, the insurer gets an additional 60 days on top of the standard 30-day window before payment is considered overdue.

Overdue payments accrue simple interest at 12% per year.⁴ That rate creates real pressure to pay promptly and can add up quickly on a stalled bill.

Appealing a Reduced Payment Through DIFS

When an insurer cuts a payment below what was billed, whether based on the fee schedule caps, a medical-necessity determination, or a utilization review finding that the treatment was excessive, the provider can appeal through the Department of Insurance and Financial Services. The appeal must be filed within 90 days of the disputed determination, on a DIFS-prescribed form.⁵

The timeline moves relatively quickly. DIFS notifies the insurer within 14 days and requests any additional information needed. The insurer then has 21 days to file a reply. The DIFS director issues a written decision within 28 days after the reply is filed, with the option to extend by another 28 days. Decisions are based entirely on written submissions; there is no oral hearing. If either side misses a deadline, the director decides on whatever is in the file.⁵

One boundary to keep in mind: this administrative appeal resolves billing and utilization disputes between providers and insurers. An injured person fighting a denied claim, rather than a reduced billing amount, is on a different track through the court system under MCL 500.3145.

1
Michigan Legislature. Michigan Code 500.3157
2
Department of Insurance and Financial Services. Bulletin 2021-33-INS – Contracts for Attendant Care
3
State of Michigan. Frequently Asked Questions
4
Michigan Legislature. Michigan Code 500.3142
5
Legal Information Institute. Michigan Administrative Code R 500.65 – Appeals to the Department