The Healthy Michigan Plan Handbook

The Healthy

Michigan Plan

Handbook

Introduction

The Healthy Michigan Plan is a Medicaid health

care program through the Michigan Department of

Health and Human Services (MDHHS).

The Healthy Michigan Plan provides health care

coverage for individuals who:

n Are age 19-64 years

n Have an income at or below 133% of the

federal poverty level under the Modiﬁed

Adjusted Gross Income methodology

n Do not qualify for or are not enrolled in

Medicare

n

Do not qualify for or are not enrolled in

other Medicaid programs

n Are not pregnant at the time of application

n Are residents of the State of Michigan

Eligibility for this program will be determined

using the Modiﬁed Adjusted Gross Income

methodology. All criteria for Modiﬁed Adjusted

Gross Income eligibility must be met to be

eligible for this program.

Most people who have the Healthy Michigan

Plan must enroll in a health plan. MICHIGAN

ENROLLS will send you a letter about the health

plan choices in your county.

This handbook tells you how to get care and what

services are covered under the Healthy Michigan

Plan. It also lists your rights and responsibilities

under the Healthy Michigan Plan.

Visit www.michigan.gov/healthymichiganplan

or call the Beneﬁciary Help Line

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

if you have questions or need help.

1

Contents

Getting Care ................................................... 2

Covered Services

............................................2

Other Services and Beneﬁts .........................6

Costs ...............................................................7

Your Healthy Michigan Plan Rights

and Responsibilities ...................................10

Reporting Healthy Michigan Plan

Beneﬁciary Fraud

........................................12

Reporting Healthy Michigan Plan

Provider Fraud

.............................................13

Complaints ..................................................13

Appeals .........................................................14

2

Getting Care

When you have health care coverage through the

State of Michigan you will get a mihealth card

(a plastic card with your name and ID number).

You must show your mihealth card before you get

services. Your health care provider will check to

make sure you are covered through the Healthy

Michigan Plan or other state health care programs

at each visit. If you do not show your card, you may

have to pay for the service. Always keep this card;

you will need it if you qualify for other health care

programs through the state. If you lose your card,

call the Beneﬁciary Help Line at 1-800-642-3195 or

TTY 1-866-501-5656.

Tell your health care provider and local Michigan

Department of Health and Human Services ofﬁce

if you have other insurance or if your insurance

changes. You can also call the Beneﬁciary Help

Line at 1-800-642-3195

or TTY 1-866-501-5656

to

report other insurance.

Covered Services

The Healthy Michigan Plan covers the federal

healthcare law essential health beneﬁts, as well

as other services and beneﬁts. These include:

Ambulatory Patient Services

The Healthy Michigan Plan covers:

n

Visits to see your primary care physician,

clinical nurse specialist, physician’s assistant or

a specialist

n Outpatient hospital visits

n Surgical centers

n Home health care

n Hospice

n Podiatry (foot) care

n Chiropractic care

3

Emergency Services

The Healthy Michigan Plan covers ambulance

transport and care in an emergency room. While

not emergency care, treatment at an Urgent Care

Center is also covered.

Emergency rooms are for serious medical

conditions only. Call your doctor about routine

care. The Healthy Michigan Plan deﬁnes a

medical emergency as a condition where delay

in treatment may result in the person’s death or

permanent impairment of the person’s health.

Hospitalization

The Healthy Michigan Plan covers inpatient

hospital services such as a hospital stay,

physician and surgical services.

Maternity Care

If you think you may be pregnant, see your

doctor as early as possible. If you ﬁnd out that

you are pregnant while in the Healthy Michigan

Plan, the plan will cover medical services while

you are pregnant and after your baby is born.

Pregnant women do not have to pay co-pays for

pregnancy-related services.

Pregnant women may choose to receive

medical services through the Medicaid

program; to do so, contact your local Michigan

Department of Health and Human Services

ofﬁce to report your pregnancy and due date.

Mental Health and Substance Use

Disorder Treatment Services

The Healthy Michigan Plan covers inpatient

and outpatient mental health and substance use

disorder treatment services.

4

Prescription Drugs

The Healthy Michigan Plan will pay for most

medicines prescribed by your doctor. Ask your doctor

if you have questions about medication coverage.

Rehabilitative and Habilitative

Services and Devices

The Healthy Michigan Plan will cover services

ordered by your doctor such as:

n

Physical therapy

n Occupational therapy

n Speech therapy

n Prosthetics

n Orthotics

n Medical equipment

n Medical supplies

Preventive and Wellness Services and

Chronic Disease Management

Preventive care is a key factor in wellness. Healthy

Michigan Plan beneﬁciaries should call to schedule

an appointment with their Primary Care Provider

within 60 days of choosing or being assigned to a

health plan. The Healthy Michigan Plan covers:

n Yearly check-ups

n Immunizations (shots)

n Doctor visits

n Mammograms

n Dentist visits

n Hearing check-ups

n Eye exams

n Lab tests

n Medications

If you are age 19 or 20, these services are covered

through the Early, and Periodic Screening,

Diagnosis and Treatment (EPSDT) program.

5

Laboratory and X-Ray Services

The Healthy Michigan Plan covers radiology

services and lab tests when ordered by your doctor.

Dental Services

The Healthy Michigan Plan covers:

n

Dental check-ups

n Teeth cleaning

n X-rays

n Fillings

n Tooth extractions

n Dentures and partial dentures

You can receive dental services from a dentist

who accepts Medicaid until you are enrolled in

a health plan. Once you are enrolled in a health

plan, you will get your dental services from a

dentist that works with your health plan.

Vision Services

The Healthy Michigan Plan covers:

n

Eye exams

n A complete pair of eyeglasses

n A replacement pair of eyeglasses if criteria

is met

n

Glaucoma screenings

6

Other Services

and Benets

Non-Emergency Medical

Transportation Services

You can get help with a ride if you do not have

a way to get to and from a provider visit that

is covered by the Healthy Michigan Plan. You

must get approval for non-emergency medical

transportation before your visit.

To get help with a ride:

n

If you are in a health plan you must contact

your health plan to schedule your ride.

n 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 866-288-3133 to schedule your ride.

n

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 HAVE AN EMERGENCY – CALL 911

Family Planning Services

The Healthy Michigan Plan covers family

planning services with no out-of-pocket cost.

Both men and women can get family planning

services. These services help you plan when to

have a baby or help prevent a pregnancy. The

Healthy Michigan Plan covers:

n Doctor visits

n Pregnancy testing

n Birth control counseling

7

n Birth control methods (condoms, birth

control pills)

n

Testing for sexually transmitted infections

n HIV/AIDS testing and services

Programs to Help You Quit Smoking

The Healthy Michigan Plan will cover some

medications and counseling services to help you

stop smoking. If you are ready to quit, talk to your

doctor.

Long-Term Care Services

For long-term care services, there are more

requirements. Medical requirements must be met

to have these services covered in a nursing facility

or in a home setting.

COSTS

MI Health Account Fees

The Healthy Michigan Plan requires those with

annual incomes over 100% of the federal poverty

level to pay up to 2% of annual income for cost-

sharing. You will get more information about the

MI Health Account (MIHA) and fees after joining

a health plan.

Reducing Payments

You can reduce your MIHA fees and co-pays

by participating in healthy behavior activities

which includes completing an annual Healthy

Michigan Plan health risk assessment and

agreeing to stay healthy or work on getting

healthier. Make sure to complete a new Healthy

Michigan Plan health risk assessment each

year to continue to receive any incentives or

reductions in MIHA fees.

8

Co-Pays

The Healthy Michigan Plan has co-pays. If you see

the doctor before you are enrolled in a health plan,

you will pay the co-pay to the provider. After you

are enrolled in a health plan, most co-pays will be

paid through the MI Health Account (MIHA).

MIHA fee exemptions for the Healthy Michigan

Plan are consistent with Medicaid and can be found

online at www.healthymichiganplan.org.

Covered Services

Co-Pay

Income less than or

equal to 100% FPL

Income more than

100% FPL

Physician Ofﬁce Visits

(including Free-Standing

Urgent Care Centers)

$ 2 $ 4

Outpatient Hospital Clinic

Visit

$ 2 $ 4

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 $ 8

Inpatient Hospital Stay

(with the exception of

emergent admissions)

$ 50 $ 100

Pharmacy

$1 generic/

preferred brands

$3 brand/

non-preferred

brands

$4 generic/

preferred brands

$8 brand/

non-preferred

brands

Chiropractic Visits

$ 1 $ 3

Dental Visits

$ 3

$ 4

Hearing Aids

$ 3 per aid $ 3 per aid

Podiatric Visits

$ 2

$ 4

Vision Visits

$ 2 $ 2

9

Cost-Sharing Limit

Cost-sharing, which includes co-pays and MIHA

fees, 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. The limit is set at 5% of your

household’s income during a three month

period, or quarter. MDHHS will keep track of the

limit and any cost-sharing charged. You do not

have to keep track of your costs.

You will get more information on your cost-

sharing limit from MDHHS in the future. If

you want more information on this limit,

you can also sign up for the myHealthButton/

myHealthPortal applications or call the

Beneﬁciary Help Line.

10

Your Healthy Michigan

Plan Rights and

Responsibilities

It is important that you know your rights and

responsibilities under the Healthy Michigan

Plan. You have the right to:

n

Choose your primary provider

n Receive quality health care

n Be treated with respect

n Be seen by a primary provider who will

arrange your care

n

Get all the facts from your primary

provider about your health and treatment

n

Know about alternative procedures or

treatments other than what has been

offered to you

n

Say no to any medical services you

disagree with

n

Get a second medical opinion

n Be told what services are covered by the

Healthy Michigan Plan

n

Know if a co-pay or MIHA fee is required

n Know the names, education and experience

of your health care providers

n

Get help with any special disability needs

n Get help with any special language needs

n Tell your primary provider how you wish

to be treated if you become too ill to make

your care decisions yourself

n

Be told in writing when and why beneﬁts

are being reduced, denied or stopped

n

Have your medical records kept conﬁdential

n Get one free copy of your medical records

from a health care provider, health facility,

or medical records company

11

n Voice your concern about the service or care

you receive

n Contact your local health plan or local

MDHHS ofﬁce with any questions or

complaints you have

n

Appeal to your health plan when they deny,

reduce or stop a covered service

n Ask for a State Fair hearing when your health

plan appeal or eligibility has been denied

n 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 the Healthy Michigan Plan, you have the

responsibility to:

n

Report other insurance beneﬁts to your local

Michigan Department of Health and Human

Services ofﬁce and the Beneﬁciary Help Line at

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

n Show your mihealth card to all providers

before receiving services

n Never let anyone use your mihealth card

n

Choose a primary provider, call to schedule

an appointment within 60 days of enrollment

in a health plan and build a relationship with

the provider you have chosen

n Make appointments for routine checkups

and immunizations (shots)

n Keep your scheduled appointments and be

on time

n Tell your transportation provider when you

need to cancel or reschedule your ride

n Provide complete information about your

past medical history

n Provide complete information about current

medical problems

n Ask questions about your care

n Respect the rights of other patients and

health care workers

n Use emergency room services only when you

believe an injury or illness could result in

death or lasting injury

12

n

Notify your primary provider if emergency

treatment was necessary and follow-up care is

needed

n

Make prompt payment for all cost-sharing

responsibilities

n

Report changes that may affect your coverage to

your local Michigan Department of Health and

Human Services ofﬁce. This could be an address

change, a pregnancy, birth of a child, death,

marriage or divorce, or change in income

n Promptly apply for Medicare or other

insurance when you are eligible.

Reporting Healthy

Michigan Plan

Beneciary Fraud

You may be prosecuted for fraud if you:

n Withhold information on purpose or give false

information when applying for the Healthy

Michigan Plan or other assistance programs; or

n Do not report changes that affect your

eligibility to your local Michigan Department

of Health and Human Services ofﬁce. If you are

found guilty of fraud under federal law, you

can be ﬁned as much as $10,000 or 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 up

to four years.

Report cases of suspected fraud to your local Michigan

Department of Health and Human Services ofﬁce, or call

1-800-222-8558. You do not have to give your name.

13

Reporting Healthy

Michigan Plan

Provider Fraud

A health care provider who is enrolled in

Medicaid is also subject to federal and state

penalties for Healthy Michigan Plan fraud.

Report any provider you suspect of:

n

Billing for a service he or she did not perform

n Providing a service that is not needed

Report Suspected Provider Fraud to:

Michigan Department of

Health and Human Services

Ofﬁce of Health 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.

Complaints

If you have questions, complaints or concerns

about your health care or your health care

provider, there are things you can do.

1. You can call or write a letter to your health

plan about your complaint or concern.

Often, they can help you immediately. If you

are not satisﬁed, you have the right to ﬁle a

grievance. Be sure to read your health plan’s

member handbook for more instructions.

2. You can call the Michigan Department of

Health and Human Services Beneﬁciary Help

Line if you have questions, complaints or

concerns. You can ask for a change in health

plans or ask questions about a Medical

Exception, Special Disenrollment for Cause or

a Beneﬁciary Complaint Form.

14

Appeals & Hearings

You can ask for an internal appeal if you receive

a notiﬁcation from your health plan indicating a

decision to deny, reduce or stop a covered beneﬁt

or service and you disagree. The notice sent by the

health plan must explain any action that has been

taken and tell you about your right to an internal

appeal and how to ask for one. You can appeal by

telephone or in writing.

After reviewing your internal appeal request, the

health plan will mail you a notice telling you the

decision of the internal appeal or a notice denying

your request for appeal. If your request for internal

appeal is denied, the health plan will send you an

Internal Appeal Decision–Denial Notice that explains

their decision and will include a hearing request form.

The notice will also tell you about any other rights you

have. Be sure to read the notice from your health plan

and your member handbook for more information.

You can ask your health plan for help if you need it.

If you do not receive a response from the health

plan or if your internal appeal is denied, you can ask

for a State Fair Hearing with the Michigan Ofﬁce of

Administrative Hearings and Rules (MOAHR). You

must complete the internal appeals process before

you can ask for a State Fair Hearing with MOAHR.

If the Michigan Department of Health and Human

Services takes an action to deny, reduce or stop a

covered beneﬁt, or denies your eligibility for health

care coverage or change in enrollment, you will get

a notice on why that action was taken. The notice

from MDHHS will tell you about your right to ask

for a hearing with MOAHR and include a hearing

request form.

If you have any questions or need another hearing

request form, you can call the Beneﬁciary Help Line:

1-800-642-3194, TTY users call 1-866-501-5656.

15

NOTES

__________________________________________

16

NOTES

__________________________________________

17

DCH 3913

(2/22)

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.

Additional information may be found on the

Michigan Department of Health and Human Services website:

www.michigan.gov/healthymichiganplan

800-642-3195

(TTY 866-501-5656).

.(866-501-5656