Healthy Michigan Plan (HMP) provider copay obligations
As approved by DCH January 5, 2014
The Centers for Medicare and Medicaid Services requires that all providers treating HMP members discuss copays with HMP members at the time of service.
Please note: Dentists treating HMP members should not collect copays from HMP members. Instead, HMP members receive a quarterly statement for their MI Health Account outlining their copay obligations. Members make their copays to their MI Health Account rather than to providers. If members have questions about these statements, they should call the beneficiary helpline at 800-642-3195 for assistance.
Even though providers who treat HMP members do not collect copays, providers are required to discuss copays with HMP members at the time of service. Dental offices treating HMP members should share the following information with HMP members:
- A copay of $3 is required for each dental visit for HMP members ages 21 or older. Native American Indians, Alaska natives and pregnant women are exempt from copays.
- When more than one covered service is provided during a visit, only one copay will be charged. If several visits are required to complete a dental service, only one copay will be charged.
If a procedure does not appear on your fee schedule, it is not a covered benefit. Payment for noncovered services is the responsibility of the member or responsible party; however, the fee must be discussed with the individual in advance and treatment should only be rendered if they agree to pay for noncovered (or alternate) procedures. The member’s or responsible party’s approval to proceed with treatment, knowing they will be financially responsible, should be noted in the patient record. If an HMP member or responsible party agrees to pay for a noncovered service, the HMP participating dentist will be held to the lesser of the submitted fee or the Delta Dental PPOSM fee schedule for any charges to the member or responsible party. Due to federal Medicaid requirements, covered services that are denied by Delta Dental (example: a procedure that exceeds a frequency limitation) cannot be charged to the member or responsible party unless the member or responsible party has agreed to pay for it.
IMPORTANT ELIGIBILITY INFORMATION
Verification of eligibility on the date of service of each Healthy Michigan Plan patient is essential as eligibility for Healthy Michigan Plan patients may change frequently. If a Healthy Michigan Plan provider’s office fails to check eligibility on the date of service for a Healthy Michigan Plan patient and delivers services to an ineligible patient, the provider will not receive reimbursement from Delta Dental and cannot bill the patient for the services.
Healthy Michigan Plan requirements
It’s important to remember the appointment access standards for your HMP patients.
These standards are as follows:
Dental plan appointment and timely access to care standards
|Type of care
||Length of time
|Emergency dental services
||Within 48 hours
||Within 21 business days of request
||Within six weeks of request
||Within eight weeks of request