Medicaid benefits

Benefits

The Michigan Department of Community Health website gives you detailed information on covered procedure codes, fee screens and other information related to billing and reimbursement for services to Medicaid, CSHCS, ABW, and MOMS beneficiaries. Go to the MDCH information now.

Copays

• Preventive care: Routine preventive care and screenings are 100% covered with no copay.
• Copays: Patients pay nothing for covered services and prescriptions, except when these low copays apply:
  • ER: $3 copay for certain non-emergency services provided in an emergency room
  • Urgent care: $1 copay for services provided in a hospital-based urgent care center
  • Prescription copays: Patients age 21 and older pay a $3 copay for a brand-name prescriptions, $1 copay for a generic

Children's coverage and programs

Vaccines for Children Program (VFC): This federally funded program provides vaccines at no cost to children who might not otherwise be vaccinated. Doctors participating in the VFC program also have the right to charge an administrative fee for giving a child a shot. However, they are required by law to administer the vaccine even if a child cannot afford to pay the administrative fee. This means that the administrative fee, unlike the office visit fee, must be eliminated if the patient is unable to pay.

Children's Healthcare Access Program (CHAP) in Kent County: The primary goal of the Children’s Healthcare Access Program is to improve health outcomes among children on Medicaid while better utilizing existing resources and decreasing costs. This partnership between Priority Health, Helen DeVos Children's Hospital, Cherry Street Health Services, private pediatric practices, numerous human service agencies, and private foundations covers 15,000 children in Kent County.

Children's Special Health Care Services (CSHCS): This program of the Michigan Department of Community Health provides certain approved medical service coverage to some children and adults with special health care needs, including:

• Persons under the age of 21 with one or more qualifying medical diagnoses.
• Persons age 21 and older with cystic fibrosis or hereditary coagulation defects commonly known as hemophilia.
• Go to the CHAP web page at michigan.gov to learn more.

Dental

Priority Health does not cover dental benefits. Find health care providers accepting Medicaid in the Priority Health Medicaid referral directory (971KB PDF).

Mental health and substance abuse services

We will arrange for outpatient short-term treatment for mental health.

The State of Michigan has contracted with local Community Mental Health agencies to provide the following services to Medicaid recipients:

• Services to persons with developmental disabilities
• Substance abuse services
• Inpatient and outpatient hospital mental health services
• Treatment for severe and persistent mental illness, or severe emotional disturbances when such treatment cannot be provided within the 20-
  visit benefit provided by the health plan.

To obtain services, contact the local Community Mental Health agency. If you need assistance in reaching this agency, you may contact the Priority Health Behavioral Health Department at 616 464-8500 or toll-free at 800 673-8043.

Prescription drug program

Member may be required to pay a $1 copay per generic prescription, and $3 copay for brand name prescriptions.

Priority Health uses a medication formulary. The formulary includes many kinds of drugs, but not every medicine is covered. Some drugs that are not covered are:

• Brand-name drugs when the Food and Drug Administration (FDA) has approved a generic medicine that can be used instead
• Appetite control drugs
• Drugs that are not prescribed by a doctor

Go to the formulary lookup tool now.

Go to the drug prior authorization forms.

Services covered by State of Michigan Medicaid

The following services are covered and/or arranged by the State of Michigan Medicaid program. If you have any questions about these services contact the State of Michigan Beneficiary Hotline at 800-642-3195.

• Dental services
• Custodial care in a nursing facility
• Personal care or home help services
• Home and community-based waiver program services