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, and MOMS beneficiaries.

Go to the MDHHS information now.

No copays apply for Medicaid members

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 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.

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 Priority Health Medicaid members can have dental coverage through the Fee For Service model.
  • 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.
  • Healthy Michigan Plan members covered by Priority Health can have dental coverage through Delta Dental.
  • Any pregnant Medicaid member can receive dental coverage for the duration of their pregnancy plus three months after their due date through Delta Dental.

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.

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