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BAM 402 7 of 20 MA BENEFITS BPB 2021-026 10-1-2021

BRIDGES ADMINISTRATIVE MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

The beneficiary may change DHPs within 90 days of the DHP enrollment effective date. MDHHS gives beneficiaries the opportunity to change DHPs without cause during each beneficiary’s annual open enrollment period. ID Cards In addition to the MI health card, Healthy Kids Dental beneficiaries will receive a benefit ID care from their assigned DHP. If the card is lost the beneficiary must call their DHP customer service to request a replacement card. The beneficiary’s SSN is on the card, not the MA beneficiary ID number. Retroactive Enrollment The effective date of enrollment in the DHP will be the first day of the month that CHAMPS receives information that the beneficiary has been determined eligible for Medicaid. For example, if CHAMPS is notified that a beneficiary has been determined eligible on October 24, 2018, the beneficiary will have a DHP enrollment effective date of October 1, 2018. Covered Dental Services Healthy Kids Dental provides services that are applicable to persons under age 21. These services include: • Emergency services. • Diagnostic services. • Preventive services. • Restorative services. • Limited adjunctive services. • Endodontic services. • Limited crown coverage. • Prosthodontics. • Removable prosthodontics. • Oral surgery services. • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. • All medically necessary services. At a minimum, the DHP’s coverage of these services is the same as for fee-for-service MA. DHPs at their discretion may cover additional services.

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Page 7

Official source

BAM 402 7 of 20 MA BENEFITS BPB 2021-026 10-1-2021

BRIDGES ADMINISTRATIVE MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

The beneficiary may change DHPs within 90 days of the DHP enrollment effective date. MDHHS gives beneficiaries the opportunity to change DHPs without cause during each beneficiary’s annual open enrollment period. ID Cards In addition to the MI health card, Healthy Kids Dental beneficiaries will receive a benefit ID care from their assigned DHP. If the card is lost the beneficiary must call their DHP customer service to request a replacement card. The beneficiary’s SSN is on the card, not the MA beneficiary ID number. Retroactive Enrollment The effective date of enrollment in the DHP will be the first day of the month that CHAMPS receives information that the beneficiary has been determined eligible for Medicaid. For example, if CHAMPS is notified that a beneficiary has been determined eligible on October 24, 2018, the beneficiary will have a DHP enrollment effective date of October 1, 2018. Covered Dental Services Healthy Kids Dental provides services that are applicable to persons under age 21. These services include: • Emergency services. • Diagnostic services. • Preventive services. • Restorative services. • Limited adjunctive services. • Endodontic services. • Limited crown coverage. • Prosthodontics. • Removable prosthodontics. • Oral surgery services. • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. • All medically necessary services. At a minimum, the DHP’s coverage of these services is the same as for fee-for-service MA. DHPs at their discretion may cover additional services.