Medicaid and 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 Medicaid and Healthy Michigan Plan members discuss copays with members at the time of service.
Please note: Dentists treating Medicaid and Healthy Michigan Plan members should not collect copays from members. Instead, 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 Medicaid and Healthy Michigan Plan members do not collect copays, providers are required to discuss copays with members at the time of service. Dental offices treating Medicaid and Healthy Michigan Plan members should share the following information with members:
- A copay is required for each dental visit for Medicaid and Healthy Michigan Plan members ages 21 or older. Native American Indians and Alaska natives 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 a member or responsible party agrees to pay for a noncovered service, the Healthy Michigan Plan participating dentist will be held to the lesser of the submitted fee or the Delta Dental PPO™ 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 Medicaid and Healthy Michigan Plan patient is essential as eligibility for patients may change frequently. If a Medicaid or Healthy Michigan Plan provider’s office fails to check eligibility on the date of service for a Medicaid or 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 network 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 |
Immediately, 24/7 |
| Urgent care |
Within 48 hours |
| Routine care |
Within 21 business days of request |
| Preventive services |
Within six weeks of request |
| Initial appointment |
Within eight weeks of request |
Claims address
Delta Dental
PO Box 9298
Farmington Hills, MI 48333-9298
Healthy Michigan Plan network dental manual
Log in to Dental Office Toolkit® to download and view the Healthy Michigan Plan Network Dental manual.
Within this manual you can review policies and procedures, provider (and patient) rights and responsibilities, including the provider appeal and dispute process.