Medicaid benefits
Medicaid benefits
The Michigan Department of Health and Human Services (MDHHS) 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, Healthy Michigan and MOMS beneficiaries.
Go to the MDHHS information now.
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.
- Go to the vaccine coverage list in this manual.
- Go to the VFC program information on the michigan.gov website.
Children's Healthcare Access Program (CHAP) in Kent and Kalamazoo County: The primary goal of the Children's Healthcare Access Program is to improve health outcomes among children and adults on Medicaid while better utilizing existing resources and decreasing costs.
Children's Special Health Care Services (CSHCS): This program of the Michigan Department of Health and Human Services provides certain approved medical service coverage to some children and adults with special health care needs, including:
- Persons up to the age of 26 with one or more qualifying medical diagnoses.
- Persons age 21 and older with cystic fibrosis or hereditary coagulation defects commonly known as hemophilia.
Members who qualify for Children's Special Health Care Services must choose a Medicaid health plan in their county. They have the same benefits as Medicaid, and may also be eligible for additional benefits through their local Health Department, Children’s with Special Needs Fund, and Family Resources.
Chiropractic
Check the fee schedules page for Medicaid fee schedules, which include chiropractic services.
Dental
- Adult Medicaid members (age 21 and older) and Healthy Michigan members (age 19 and older) have dental coverage through Delta Dental.
- Child Priority Health Medicaid members can have dental coverage through Healthy Kids dental program (administered by BCBS or Delta Dental) through the age of 20.
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 use disorder services
- Inpatient and outpatient hospital mental health services
- Treatment for severe mental illness and severe emotional disturbances
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
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.
Go to the drug prior authorization forms.
Vision
See Medicaid vision benefits in the Billing & Payment section of the Provider Manual.
Hepatitis C (HCV) Testing and Treatment
- The Michigan Department of Health and Human Services (MDHHS) launched a We Treat Hep C Initiative in an effort to eliminate Hepatitis C in Michigan by expanding testing and access to treatment.
- The CDC recommends all adults be screened for HCV at least once per lifetime and pregnant women during each pregnancy.
- Prior authorization is no longer required for Mavyret® which allows any providers with prescriptive authority the ability to prescribe Hepatitis C treatment to beneficiaries with HCV.
- Providers may enroll patients receiving treatment in the MAVYRET Nurse Ambassador program. To learn more visit MAVYRET Nurse Ambassadors Provide Support and Education
- See We Treat Hep C for additional resources on Hep C.
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.
- Custodial care in a nursing facility
- Personal care or home help services
- Home and community-based waiver program services