DCH-669-Final-2-2024.pdf

Healthy Michigan Plan, MIChild & Fee-for-Service

Medicaid Handbook

TABLE OF CONTENTS

Health Checkups

Disorder Treatment Services

INTRODUCTION

Medicaid, Healthy Michigan Plan and MIChild are health care programs provided through the Michigan Department of Health and Human Services (MDHHS). This handbook tells how you get care and services covered under Fee-for-Service Medicaid, Healthy Michigan Plan and MIChild. It also lists your rights and responsibilities under these programs.

Fee-for-Service Fee-for-service is the term for Medicaid paid services that are not provided through a health plan. This means that Medicaid pays for the service. You will use your mihealth card to receive services.

Health Plans Most people must join a health plan. The health plan will pay for most of your services.

If you need to join a health plan you will get a letter with more information.

After you enroll with a health plan, they will send you their handbook and health plan ID card. You will use both your mihealth card and your health plan card for services.

MIHEALTH CARD

When you have Medicaid, Healthy Michigan Plan or MIChild, you will get a mihealth card. This is a plastic card with a magnetic strip. The front of the card contains your name and ID number.

The mihealth card does not guarantee you have coverage. Your provider will check to make sure you have coverage at each visit. Always keep this card, even if you lose coverage. You will need this card if you get coverage again. If you need a replacement card, call the Beneficiary Help Line at 1-800-642-3195.

myHealthPortal The myHealthPortal is an online application that allows you to access information about your health care coverage by computer. The free myHealthButton application (for iPhone or Android) lets you access your information using a smartphone or tablet.

VIEWING INFORMATION

ABOUT YOUR COVERAGE

You can access information like:

• Current health plan and primary care physician;

Go to www.michigan.gov/myHealthPortal to sign up. Signing up is free.

Michigan Enrolls Michigan Enrolls offers the following services online for current Medicaid, Healthy Michigan Plan and MIChild beneficiaries:

health plan enrollment status

• Order a mihealth card

The Michigan Enrolls portal is available online at https://healthcare4mi.com.

MI Bridges MI Bridges is an online portal that can be used to:

• Apply for assistance programs such as Medicaid, WIC, and food assistance

• View benefit information such as application status and benefit amounts

• Report changes that may affect coverage like address changes, pregnancy and birth of a child

determine your eligibility for a program MI Bridges is available online at www.michigan.gov/mibridges.

Notify your local MDHHS office if you have other health insurance or if your insurance changes.

You can visit the myHealthPortal website to make updates or call the Beneficiary Help Line at 1-800-642-3195 to report other health insurance.

http://www.michigan.gov/myHealthPortal

GETTING CARE

When you are not enrolled in a health plan, you must go to a provider who takes Michigan Medicaid. You must show your mihealth card each time before you receive services.

Providers need to know you have Medicaid, Healthy Michigan Plan or MIChild in order to know which health services are covered for you. Tell your provider if you have other health insurance (private insurance) that covers all or part of your care.

You do not have to pay the full cost of covered services; however, you may have to pay a small amount called a co-pay.

Co-Pays If you are age 21 and older, you may have a co-pay for the services listed below:

Covered Services Co-Pay Physician Office Visits (including Free-Standing Urgent Care Centers) $2

Outpatient Hospital Clinic Visit $2 Emergency Room Visit for Non-Emergency Services

• Co-payment ONLY applies to non-emergency services

• There is no co-payment for true emergency services

$3

Inpatient Hospital Stay (with the exception of emergent admissions)

$50

Pharmacy $1 generic/ preferred brands $3 brand/non-preferred brands Chiropractic Visits $1 Dental Visits $3 Hearing Aids $3/aid Podiatric (foot care) Visits $2

Vision Visits $2

PAYING FOR SERVICES

Some people may also have to pay a part of the cost of nursing home or inpatient hospital services. This is called a patient-pay amount.

Your local MDHHS office will tell you if you have a patient-pay amount.

Cost-Sharing Limits Cost-sharing includes co-pays and means the amount you have to pay for the coverage or services you receive. You and other members of your household that have health care coverage through MDHHS have a limit on how much cost-sharing can be charged. This limit is based on your household income and will apply to most types of health care coverage through MDHHS. Medicaid will keep track of the limit and cost-sharing charged to you. You do not have to keep track of your costs.

The limit is set at 5% of your household’s income during a three month period, or quarter. For more information on this limit, you can sign up for the myHealthButton/ myHealthPortal applications or call the Beneficiary Help Line.

MIChild Before a service is provided, your doctor, or other provider, must tell you if the service is not covered by Medicaid or MIChild. You can then decide if you want to pay for the service yourself. If the provider tells you after you have received the service that it is not covered, you do not have to pay for it.

Medicaid, Healthy Michigan Plan and MIChild cover medically necessary services such as:

post-partum)

A yearly health exam is covered. Some of these services are limited and may not be covered for beneficiaries age 21 and older.

Some of these services may require prior approval.

Your provider can tell you what is covered.

COVERED SERVICES

NON-EMERGENCY

MEDICAL TRANSPORTATION

If you are financially eligible and you need to receive long-term care services in a nursing facility or in a home setting, you have to meet Medicaid’s medical requirements.

Medicaid’s medical requirements are different than Medicaid’s financial requirements.

The Medicaid medical requirements are determined by a health care professional completing the Michigan Medicaid Nursing Facility Level of Care Determination (LOCD).

If you do not have a way to get to and from a doctor or dentist visit or to get other covered items or services, you can get help with a ride.

Non-emergency medical transportation must be approved before your visit.

How will I get help with a ride for non-emergency medical transportation?

• If you are not in a health plan and you live in Wayne, Oakland, or Macomb County, you will need to call ModivCare Solutions at (866) 569-1902 to schedule your ride.

• If you are not in a health plan and do not live in Wayne, Oakland, or Macomb counties contact your local MDHHS office to get help.

• If you are in a health plan you must contact your health plan to schedule your ride.

Services in an urgent care center are covered.

Emergency rooms are for serious medical conditions only. A medical emergency is a condition where delay in treatment may result in the person’s death or permanent impairment of the person’s health. Call your provider first for routine care or non-serious conditions.

Medicaid, Healthy Michigan Plan and MIChild cover care in an emergency room, and related medical emergency transportation. This also includes emergency services, if needed, outside of Michigan.

Medications prescribed by your doctor are covered, but if you have private insurance you must use that benefit first. Medicaid, Healthy Michigan Plan and MIChild will pay your co-pays for medicines covered by your private insurance even if your private insurance requires a mail order pharmacy benefit. For more information, call the Beneficiary Help line at 1-800-642-3195.

If you have Medicare and Medicaid, Medicaid will not pay your Medicare Part D co-pays.

Medicaid will also not pay your medicine co-pays if you choose to keep your private insurance and do not join a Medicare Part D plan.

URGENT AND

EMERGENT CARE

PHARMACY

If you are under age 21, you may receive your dental benefits through the Healthy Kids Dental Program, Dental Health Plan, regular Medicaid or a Medicaid Health Plan. If you are over age 21, you may receive your dental services through regular Medicaid or a Medicaid Health Plan. People with regular Medicaid may go to any dentist that accepts Medicaid. To find a dentist for regular Medicaid you can search at www.insurekidsnow.gov, log-in to your myHealthPortal account, or check a phone directory for local dentists to ask if they accept Medicaid.

If you have Healthy Kids Dental, you must contact your selected Dental Health Plan for a list of participating dentists. Healthy Kids Dental Health Plans are:

Blue Cross Blue Shield of Michigan (BCBSM) 1-800-936-0935 (TTY users call 711) www.bcbsm.com/healthykids Delta Dental of Michigan 1-866-696-7411 (TTY users call 711) www.dentaldentalmi.com/HKD

DENTAL

Well-child and free health checkups are covered for people under age 21. A checkup can find problems you may not know about, such as lead poisoning, or hearing or vision problems. Early treatment may prevent you or your children from getting sick later.

Checkups may include: head-to-toe exam, health history, height, weight and head measurements; tests for normal growth and development, blood pressure check, needed immunizations (shots), health education and information, nutrition history, dental check, blood lead testing and other lab tests as needed. You may be referred to a dentist or other medical provider if medically necessary.

CHILDREN’S WELL-

CHILD VISITS AND FREE

HEALTH CHECKUPS

MDHHS wants your child to be as healthy as possible from the day he or she is born. To be healthy, your child needs protection from serious diseases. Your doctor can give your child the best protection with shots given at birth and other times throughout their childhood. Ask your doctor to keep your child’s shots up-to-date.

The State requires that all children entering Michigan child care programs and schools have all the required shots. Michigan Medicaid, Healthy Michigan Plan and MIChild follow all the recommendations and guidelines issued by the Advisory Committee on Immunization Practices through the Centers for Disease Control and Prevention (CDC). Contact your doctor or local health department to get an immunization schedule.

Some immunizations or shots may also be covered for adults.

Both men and women can get family planning services. These services help you plan when to have a baby and prevent unwanted pregnancies.

Family planning services may include doctor visits, medical exams, pregnancy testing, birth control counseling, birth control methods (such as condoms, birth control pills, foams, etc.), testing for sexually transmitted infections (STIs), HIV/AIDS testing, and education and counseling.

FAMILY PLANNING

SERVICES

IMMUNIZATIONS (SHOTS)

Pregnancy Care If you think you may be pregnant, see your doctor as early as possible. Medical services are covered while you are pregnant and after your baby is born. Notify your local MDHHS office of your pregnancy.

Inpatient and outpatient mental health and substance use disorder treatment services are covered.

MENTAL HEALTH

AND SUBSTANCE USE

DISORDER TREATMENT

SERVICES

RIGHTS AND

RESPONSIBILITIES

It is important that you know your rights and responsibilities under Medicaid, Healthy Michigan Plan and and MIChild. You have the right to:

• Choose your primary provider

• Receive quality health care

• Be treated with respect

• Be seen by a primary provider who will arrange your care

• Get all the facts from your primary provider about your health and treatment

• Know about alternative procedures or treatments other than what has been offered to you

• Say no to any medical services you disagree with

• Get a second medical opinion

• Be told what services are covered

• Know if a co-pay premium or is required

• Know the names, education and experience of your health care providers

• Get help with any special disability needs

• Get help with any special language needs

• Tell your primary provider how you wish to be treated if you become too ill to make your care decisions yourself

• Be told in writing when and why benefits are being reduced, denied or stopped

• Have your medical records kept confidential

• Get a free copy of your medical records

• Voice your concern about the service or care you receive

• Contact MDHHS with any questions or complaints you have

• Appeal a denial or reduction of eligibility or service

• Get help with transportation if you do not have a way to get to and from a doctor’s office or other medical service.

Under Medicaid and MIChild, you have the responsibility to:

• Report other insurance benefits to your local

MDHHS office and the Beneficiary Help Line at 1-800-642-3195.

• Show your mihealth card to all providers before receiving services

relationship with the provider you have chosen

• Make appointments for routine checkups and immunizations (shots)

• Keep your scheduled appointments and be on time

• Tell your transportation provider when you need to cancel or reschedule your ride

• Provide complete information about your past medical history

• Provide complete information about current medical problems

care workers

• Use emergency room services only when you believe an injury or illness could result in death or lasting injury

• Notify your primary provider if emergency treatment was necessary and follow-up care is needed

• Make prompt payment for all cost-sharing responsibilities

• Report changes that may affect your coverage to your local MDHHS office. This could be an address change, pregnancy, birth of a child, death, marriage or divorce, or change in income

• Promptly apply for Medicare when you are eligible.

REPORTING

BENEFICIARY FRAUD

You may be prosecuted for fraud if you:

• Withhold information on purpose or give false information when applying for Medicaid, Healthy Michigan Plan, MIChild or other assistance programs; or

• Do not report to your local MDHHS office changes that affect your eligibility.

If you are found guilty of fraud under federal law, you can be fined as much as $10,000 or you can be sent to jail for up to a year or both.

You can also be prosecuted for fraud under state law. If you are found guilty, you can be sent to jail, fined and ordered to repay the state monies paid on your behalf for health care. If you are convicted of a felony under state law, your jail sentence may be for up to four years.

Report cases of suspected fraud to your local MDHHS office or online at mdhhs.michigan.gov/Fraud. You do not have to give your name.

A health care provider who is enrolled in Medicaid is also subject to federal and state penalties for Medicaid fraud. Report any provider you suspect of:

• Billing for a service he or she did not perform

• Providing a service that is not needed

Report suspected provider fraud to:

Michigan Department of Health and

Human Services Inspector General

PO Box 30062 Lansing, MI 48909-7979

You may call the 24-hour hotline:

1-855-MIFRAUD (1-855-643-7283) toll free, or visit the website at: www.michigan.gov/fraud.

You do not have to give your name.

REPORTING PROVIDER

FRAUD

http://www.michigan.gov/fraud

If you have complaints or concerns with your health care or your health care providers, call or write the Michigan Department of Health and Human Services.

If you are in a managed care plan and have complaints about your health care or providers, call the plan for help or to file a complaint. See your managed care member handbook, plan website, or call the number on the back of your plan ID card, for how to do this.

If you are not in a managed care plan or still have complaints with your health care or providers, call or write the Michigan Department of Health and Human Services.

Michigan Department of Health and Human Services

PO Box 30479 Lansing, MI 48909-9753

Beneficiary Help Line:

1-800-642-3195 TTY 1-866-501-5656

COMPLAINTS

HEARINGS OR APPEALS

If Medicaid or a managed care plan denies, reduces, or stops a covered benefit or service, or if your enrollment in a MI Choice waiver or PACE program is denied, you have the right to ask for an appeal or hearing. You will get a notice on the action taken and a hearing request form with the steps and time frames to appeal or ask for a hearing. If you are in a managed care plan (Medicaid Health Plan, Healthy Kids Dental plan, Community Mental Health Services Plan, MI Choice Waiver program or MI Health Link plan) you must go through the plan’s appeals process before asking for a hearing in most cases. Your managed care plan can help with the appeals and hearings processes.

If you are not in a managed care plan, or your application to enroll or continue enrollment in a MI Choice Waiver or PACE program was denied, you can ask for a hearing directly to the Michigan Office of Administrative Hearings and Rules (MOAHR).

You have the right to represent yourself or have someone represent you. You will need to tell us in writing who that person is and you both must sign the request. You can use legal counsel, a relative, a friend or other spokesperson for an appeal or hearing.

MDHHS does not pay for a lawyer, legal fees or give legal advice.

Hearing requests must be in writing. There are different hearing request forms depending on the action taken and who took it. You do not have to use a hearing request form, but the forms have information, instructions and phone numbers to help you. If you need a hearing form call the Beneficiary Help Line: 1-800-642-

3195, TTY 1-866-501-5656.

Mail or fax hearing forms to: The Michigan Office of Administrative Hearings and Rules, Michigan Department of Health and Human Services, PO Box 30763, Lansing, MI 48909;

Fax 517-763-0146.

The hearing forms are also online at:

• michigan.gov/mdhhs >> Assistance Programs >> Medicaid >> Go to Medicaid >> Program Resources >> Michigan Office of Administrative Hearings and Rules for the Department of Health and Human Services.

OR

• michigan.gov/LARA >> Bureaus >>

Michigan Office of Administrative Hearings and Rules >> Benefit Services Hearings>> Michigan Department of Health and Human Services (MDHHS) Public Assistance >> How do I request a hearing.

22MDHHS PUB-669 (02/24)

Previous Versions Obsolete

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

800-642-3195

800-642-3195

(TTY 866-501-5656).

.(866-501-5656