Benefit Plans
Benefit plan data is assigned by the CHAMPS Eligibility and Enrollment (EE) Subsystem based on the source of the data (e.g., Medicaid, CSHCS, etc.) and program assignment factors (e.g., scope/coverage codes, level of care codes, etc.).
| Plan ID | Name | Description | Type |
|---|---|---|---|
| ABW | Adult Benefits Waiver Program | This benefit plan, a.k.a. Adult Medical Program (AMP), provides basic medical care to low income childless adults who do not qualify for Medicaid. ABW medical coverages are limited (e.g., ambulatory benefit - no inpatient coverage). The ABW program covers individuals with income less than 35% of the Federal Poverty Level. Because this is a state program, the State provides the funding and defines the eligibility requirements and benefit structure. The state (Department of Human Services) also determines eligibility. | Fee-for-Service |
| ABW-ESO | Adult Benefits Waiver (Emergency Services) |
Benefits mirror Medical Assistance Emergency Services Only (MA ESO). Children who do not meet the Medicaid citizenship requirements to be eligible for full Medicaid may be eligible for Emergency Services Only (ESO). This benefit plan is funded by SCHIP. For the purpose of ESO coverage, federal Medicaid regulations define an emergency medical condition as a sudden onset of a physical or mental condition which causes acute symptoms, including severe pain, where the absence of immediate medical attention could reasonably be expected to:
|
Fee-for-Service |
| ABW-MC | Adult Benefits Waiver Program (Managed Care) | This benefit plan provides benefits similar to ABW benefits but on a capitated basis. | Managed Care Organization |
| ALMB | Additional Low Income Medicare Beneficiary | This benefit plan is part of the Medicare Savings Program (MSP), also known as the "Buyin" program. | No Benefits |
| APS | Ambulatory Prenatal Services | This program provides presumptive eligibility for pregnant women limited to ambulatory prenatal care services only. Covered services include physician visits for prenatal care, prescription drugs related to pregnancy, and prenatal laboratory tests. | TPL |
| AUT | Autism-Related Services | This plan is for beneficiaries who are at least 18 months and less than 21 years of age who are diagnosed with Autism Spectrum Disorder. The benefit includes Applied Behavioral Analysis services at two different levels: Level 2, or EIBI, is a higher level of benefit for benficiaries who have Autistic Disorder; Level 1, or ABI, is available to beneficiaries who do not qualify for Level 2. Effective 10/01/2017 Autism Services are reimbursed under PIHP and PIHP-HMP Benefit Plans. | Managed Care Organization |
| BCCCP | Breast and Cervical Cancer Control Program | The Breast and Cervical Cancer Control Program (BCCCP) covers uninsured low-income women of all ages especially, but not limited to, women aged 40-64. This benefit plan allows co-payment requirements to be suppressed for BCCCP services. | No Benefits |
| BHHMP | Healthy Michigan Plan Behavioral Health NOT Enrolled in an MHP | This plan covers Medicaid mental health and substance abuse services managed by the PIHP for Healthy Michigan (HMP) recipients who have a specialty level of need and are not enrolled in a Medicaid Health Plan (Fee For Service- FFS). | Managed Care Organization |
| BHHMP-MHP | Healthy Michigan Plan Behavioral Health Enrolled in an MHP | This plan covers Medicaid mental health and substance abuse services managed by the PIHP for Healthy Michigan (HMP) recipients who have a specialty level of need and are enrolled in a Medicaid Health Plan for Managed Care (MC). | Managed Care Organization |
| BHMA | Medicaid Behavioral Health NOT Enrolled in an MHP | This plan covers Medicaid mental health and substance abuse services managed by the PIHP for MA recipients who have a specialty level of need and are not enrolled in a Medicaid Health Plan (Fee For Service - FFS). | Managed Care Organization |
| BHMA-MHP | Medicaid Behavioral Health Enrolled in an MHP | This plan covers Medicaid mental health and substance abuse services managed by the PIHP for MA recipients who have a specialty level of need and are enrolled in a Medicaid Health Plan for Managed Care (MC). | Managed Care Organization |
| BIW | Brain Injury Waiver | The Brian Injury Waiver (BIW) is a program that provides services and support to persons aged 21 and older with a qualifying brain injury who, but for the provision of these services, would otherwise be served within an institutional setting. The program provides critical rehabilitation and support in the post-acute injury period with the goal of assisting the participant in becoming capable of living in the most independent setting. | Fee-for-Service |
| BMP | Beneficiary Monitoring Program | The objectives of the Benefits Monitoring Program (BMP) are to promote quality health care, identify beneficiaries that may be mis/over-utilizing Medicaid benefits, modify improper utilization of services through education and monitoring, and ensure that beneficiaries are receiving medically necessary services. Beneficiaries remain in BMP through changes in eligibility, including enrollment into managed care. For beneficiaries with managed care, the Medicaid Health Plan (MHP) coordinates the member's care. | Managed Care Organization |
| CCBHC | Certified Community Behavioral Health Clinic | The CCBHC Demonstration benefit plan will reimburse state certified CCBHC sites for providing a comprehensive array of quality behavioral health services. CCBHCs will receive a fixed daily clinicspecific rate (known as a PPS-1 rate) for all CCBHC services provided on a given day, and individuals are eligible for the benefit if they have a mental health or substance use disorder diagnosis, regardless of Medicaid eligibility. CCBHCs are federally required to provide nine core behavioral health services and must meet stringent standards for care coordination, quality and financial reporting, staffing, and governance. | Managed Care Organization |
| CMH | Community Mental Health | This is a carve out program that can be assigned to members from multiple eligibility sources, such as MiChild, etc. | Managed Care Organization |
| CSHCS | Children's Special Health Care Services | This benefit plan is designed to find, diagnose, and treat children under age 21 with chronic illness or disabling conditions. Persons over age 21 with chronic cystic fibrosis or certain blood coagulation blood disorders may also qualify. Covers services related to the client's CSHCS-qualifying diagnoses. Certain providers must be authorized on a client file. | Fee-for-Service |
| CSHCS-MC | CSHCS Managed Care | This plan is assigned to CSHCS beneficiaries who also have full Medicaid coverage and are enrolled in a Medicaid Health Plan (MHP). The MHP receives a capitated payment and provides the full range of covered services. Specific services carved out of the MHP contract will remain covered through MA Fee-For-Service. | Managed Care Organization |
| CSHCS-MH | CHSCS Medical Home | This is a capitated "case management" benefit plan for CSHCS members. CSHCS Medical Home clients are identified by the Medical Home Indicator in the Member's CSHCS eligibility file. CAP fee only is paid from this plan. | Managed Care Organization |
| CTS | Community Transition Service | Community transition services (CTS) are Medicaid funded services provided to qualified individuals who currently reside in a nursing facility, hospital, or other institution and have expressed a desire to return to the community, but who have barriers to a discharge that cannot be met by discharge staff. CTS may also be provided to individuals in the community who previously transitioned and are at risk for going back to the nursing facility or other institution. | Fee-for-Service |
| CWP | Children's Home and Community Based Services Waiver | This benefit plan provides services that are enhancements or additions to Medicaid state plan services for children under age 18 with developmental disabilities who are enrolled in the Childrens Home and Community-Based Services Waiver Program (CWP). The CWP is a statewide Fee-for-Service program administered by Community Mental Health Service Programs (CMHSPs). The CWP enables Medicaid to fund necessary home and community-based services for children with developmental disabilities who have challenging behaviors and/or complex medical needs, meet the criteria for admission to an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) and who are at risk for placement without waiver services. | Fee-for-Service |
| CWP-MC | Children’s Waiver Program Managed Care | This benefit plan provides services that are enhancements or additions to Medicaid state plan services for children under age 18 with developmental disabilities who are enrolled in the Children’s Waiver Program (CWP). The CWP is a statewide managed care program administered by Prepaid Inpatient Health Plans (PIHPs). | Fee-for-Service |
| DHIP | Foster Care and CPS Incentive Payment | This plan is designed to provide an incentive payment to the PIHPs to serve Medicaid Eligible children in foster care and Medicaid Eligible children in Child Protective Services, Risk Category I or II. There are two incentive payment options: Incentive Payment 1 - is at least two different non-assessment behavioral health services were provided in the eligible month. Incentive Payment 2 - is at least one of either home-based services or wraparound services were provided in the eligible month. If a PIHP provides services to a beneficiary in a given month meeting the criteria for both Incentive Payment 1 and 2, the PIHP will only receive payment for Incentive Payment 2. | Managed Care |
| ESRD | End Stage Renal Disease | Permanent kidney failure (End-Stage Renal Disease (ESRD)) is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of longterm dialysis or a kidney transplant to maintain life. Benefits on the basis of ESRD are for all covered services not only those related to the kidney failure condition. | Fee-for-Service |
| HHBH | Health Home Behavioral Health | Medicaid Health Home services are intended for beneficiaries with Severe Mental Illness (SMI) who have experienced high rates of inpatient hospital admissions or high rates of hospital emergency department usage and who may or may not have other chronic physical health conditions that are amenable to care coordination and management by the health home (i.e., congestive heart failure, insulin dependent diabetes, chronic obstructive pulmonary disorder, seizure disorder). Individuals to whom these conditions apply may be determined by the state to be eligible to receive Health Home services. | TPL |
| HHMICARE | Health Home MI Care Team | MI Care Team services are intended for Medicaid beneficiaries with specific chronic behavioral and physical health conditions, which includes a diagnosis of depression and/or anxiety and at least one of the following: heart disease, COPD, hypertension, diabetes, or asthma. Individuals to whom these conditions apply may be determined by the State to be eligible to receive MI Care Team services. MI Care Team services include a personalized care management plan and intense care coordination that addresses the physical and social needs of the individual. | Managed Care |
| HHO | Opioid Health Home | Opioid Health Home (HHO) services are intended for Medicaid beneficiaries with a diagnosis of opioid use disorder in addition to having or being at risk of any other chronic condition. Individuals to whom these conditions apply may be determined by the State to be eligible to receive HHO services. HHO services include a personalized care management plan and intense care coordination that addresses the totality of a beneficiary's physical, social, and recovery-oriented needs. | Managed Care Organization |
| HK-DENTAL | Healthy Kids Dental | MDHHS contracts with dental health plans (DHPs) for the administration of dental services for Healthy Kids Dental (HKD) beneficiaries. The DHPs are paid a monthly capitation rate to provide covered services to enrolled Medicaid beneficiaries. The DHP is responsible for providing, arranging, and reimbursing covered dental services. DHPs may cover additional dental services not included on the MDHHS Dental Fee Schedule. Providers must contact the DHP for specific information about covered HKD benefits | Managed Care Organization |
| HK-EXP | Full Fee-for-Service Healthy Kids - Expansion | Benefits mirror fee for service Medicaid. This benefit plan covers children who are under the age of 19 from 100% FPL up to 160% FPL. This benefit plan is funded by CHIP. | Fee-for-Service |
| HK-EXP FFS DENTAL | Healthy Kids Expansion - FFS Dental | Fee-for-Service Dental associated with the HK-EXP Benefit Plan | Fee-for-Service |
| HK-EXP-ESO | Healthy Kids Expansion - Emergency Services | Benefits mirror MA ESO. Aliens who are not otherwise eligible for full coverage because of citizenship status may be eligible for Emergency Services Only (ESO). This benefit plan is funded by CHIP. For the purpose of ESO coverage, federal Medicaid regulations define an emergency medical condition (including emergency labor and delivery) as a sudden onset of a physical or mental condition which causes acute symptoms, including severe pain, where the absence of immediate medical attention could reasonably be expected to: Place the person''s health in serious jeopardy, or Cause serious impairment to bodily functions, or Cause serious dysfunction of any bodily organ or part. | Fee-for-Service |
| HOSPICE | Hospice | Hospice is a special way of caring for people who are terminally ill, and for their family. This care includes physical care and counseling. Hospice care is given by a public agency or private company approved by Medicaid. It is for all age groups, including children, adults, and the elderly during their final stages of life. The goal of hospice is to care for you and your family, not to cure your illness | Fee-for-Service |
| Hospice-18 | Hospice Medicare Benefit Plan | Hospice care is an elected Medicare benefit covered under Part A for a beneficiary who meets all the following conditions: The individual is eligible for Part A. The individual is certified as have a terminal disease with a prognosis of six months or less. The individual receives care from a Medicare approved Hospice program | Fee-for-Service |
| HOSPICE PPA | Hospice PPA | Patient Pay Amount associated with the HOSPICE Benefit Plan | Patient-Pay-Amount |
| HSW | Habilitation Supports Waiver Program | Beneficiaries with developmental disabilities may be enrolled in Michigan’s Habilitation Supports Waiver (HSW) and receive the support and services as defined. HSW beneficiaries may also receive other Medicaid state plan or additional/B3 services. | Fee-for-Service |
| HSW-MC | HSW Habilitation Supports Waiver Program Managed Care | Beneficiaries with developmental disabilities may be enrolled in Michigan's Habilitation Supports Waiver (HSW) and receive the supports and services as defined. HSW beneficiaries may also receive other Medicaid state plan. | Managed Care Organization |
| ICF/MR-DD | Intermediate Care Facility for Individuals with Intellectual Disabilities | The facility primarily provides health-related care and services above the level of custodial care to mentally retarded individuals, but does not provide the level of care or treatment available in a hospital or SNF. This is an all inclusive program. | Fee-for-Service |
| ICO-MC | Integrated Care - MI Health Link | This capitated managed care program is for beneficiaries who are age 21 or older and who are dually eligible for Medicare and Medicaid. The benefit plan is active only in parts of the state. The benefit includes all Medicare and Medicaid physical health services, long term supports and services, and 1915b/c waiver services for qualifying individuals. | Managed Care |
| ICO-MC Deemed | Integrated Care - MI Health Link | This capitated managed care program is for beneficiaries who are age 21 or older and who are dually eligible for Medicare and Medicaid. The benefit plan is active only in parts of the state. The benefit includes all Medicare and Medicaid physical health services, long term supports and services, and 1915b/c waiver services for qualifying individuals. | Managed Care |
| INCAR | Incarceration - Other | A non-Medicaid funded benefit plan that restricts services to an off-site inpatient hospital while an otherwise eligible member is incarcerated. | Fee-for-Service |
| INCAR-ABW | Incarceration - ABW (No Benefits) | This program will not provide benefits after 3/1/05, while an otherwise ABW eligible member is incarcerated. | No Benefits |
| INCAR-ESO | Incarceration - Emergency Services | This benefit plan restricts services to inpatient hospital emergencies only while an otherwise ESO member is incarcerated. | Fee-for-Service |
| INCAR-MA | Incarceration - MA | A Medicaid funded benefit plan that restricts services to inpatient hospital while an otherwise eligible member is incarcerated. | Fee-for-Service |
| INCAR-MA-E | Incarceration - MA Emergency Services | This benefit plan restricts services to inpatient hospital emergencies only while an otherwise MA-ESO member is incarcerated. | Fee-for-Service |
| LTC-EXEMPT | Long Term Care Exempt | Beneficiaries that are excluded from Long Term Care and Support Services because of Divestment, not meeting LOCD or PASARR requirements, or not returning asset verification. | No Benefits |
| MA | Full Fee-for-Service Medicaid | Members are generally assigned to this benefit plan upon approval of their eligibility information and remain active even if eventually assigned to MA Managed Care [MA-MC]. Once assigned to a managed care plan, the health plan is the primary payer. | Fee-for-Service |
| MA FFS DENTAL | MA FFS Dental | Fee-for-Service Dental associated with the MA Benefit Plan | Fee-for-Service |
| FFS COPAY INFORMATION ONLY. | Fee-for-Service Co-Pay | Fee-for-Service Co-Pay information associated with the MA Benefit Plan | Co-Pay |
| MA-FTW | Medicaid Freedom to work | Freedom to Work is available to a client with disabilities, age 16 through 64 who has earned income. The client must be disabled according to the disability standards of the Social Security Administration except employment, earnings, and substantial gainful activity (SGA) cannot be considered in the disability determination. The client must be employed. . There may be temporary breaks in employment up to 24 months if they are the result of involuntary layoff or are determined to be medically necessary.FTW coverage is retained when a participant is relocated due to employment. | Fee-for-Service |
| MA-ESO | Medical Assistance Emergency Services |
Individuals who do not meet the Medicaid citizenship requirements to be eligible for full Medicaid may be eligible for Emergency Services Only (ESO). For the purpose of ESO coverage, federal Medicaid regulations define an emergency medical condition as a sudden onset of a physical or mental condition which causes acute symptoms, including severe pain, where the absence of immediate medical attention could reasonably be expected to:
|
Fee-for-Service |
| MA-MC | Medicaid Managed Care | Full Medicaid for Managed Care Organization enrollment. This capitated plan will be set to a higher priority than MA [Fee-for-Service]. The services not covered under this plan will be covered in MA. | Managed Care Organization |
| MA-MICHILD | MIChild Program (CHIP) | MA-MIChild is a health care program administered by the Department of Health and Human Services (MDHHS). It is for the low income uninsured children of Michigan's working families. Like Healthy Kids, MIChild is for children who are under age 19. Members are generally assigned to this benefit plan upon receipt of their eligibility information and remain active even if eventually assigned to MA Managed Care [MA-MC]. Once assigned to a Managed Care Organization, the health plan is the primary payer. | Fee-for-Service |
| MA-HMP | Healthy Michigan Plan | Provides health care benefits to adults 19 through 64 years of age, not covered by or eligible for Medicaid, with family incomes at or below 133% of the federal poverty level (FPL) and who are not eligible for or enrolled in Medicare. Eligibility is determined through the Modified Adjusted Gross Income (MAGI) methodology. | Fee-for-Service |
| MA-HMP-ESO | Healthy Michigan Plan Emergency Services Only | Individuals who do not meet the Healthy Michigan Plan citizenship requirements to be eligible for full coverage may be eligible for Emergency Services Only (ESO). | Fee-for-Service |
| MA-HMP-MC | Healthy Michigan Plan Managed Care | This capitated program provides benefits to the Healthy Michigan Plan members through enrollment in a Medicaid Health Plan (MHP). Certain services not covered under this plan could be covered through MA-HMP Fee-for -Service. | Managed Care Organization |
| MA-HMP-INC | Healthy Michigan Plan Incarceration | This program restricts services to an inpatient hospital setting while an otherwise Healthy Michigan eligible member is incarcerated. | Fee-for-Service |
| MC-EXEMPT | Managed Care Exempt | Beneficiaries that are excluded from MHP or ICO Health Plan Enrollment. | No Benefits |
| PCP | Primary Care Provider | The beneficiary's Primary Care Provider (PCP) as designated by their Medicaid Health Plan (MHP). | Other |
| MEDICARE | Medicare | Individual qualifies for or is enrolled in Medicare Part A, B, C and/or D. Medicare is a government-administered health care program for people 65 years of age and over, some disabled people under age 65, and people with kidney failure. | Third Party Liability |
| MI CHOICE | Home and Community Based Waiver Services | The MI Choice waiver is a program that provides home and community-based services for aged and other disabled adults who meet the nursing facility level of care. The program's goal is to provide long term services and supports that allow persons to remain at home or similar community-based settings. These persons qualify for nursing facility services but choose to receive services in their home. MI Choice beneficiaries are eligible to receive Medicaid state plan services but are excluded from enrollment in a Medicaid Health Plan. | Fee-for-Service |
| MI CHOICEMC | Home and Community Based Waiver Services-Managed Care | The MI Choice waiver is a managed care program that provides home and community-based services for aged and other disabled adults who meet the nursing facility level of care. The program's goal is to provide long term services and supports that allow persons to remain at home or similar community-based settings. These persons qualify for nursing facility services but choose to receive services in their home. MI Choice beneficiaries are eligible to receive Medicaid state plan services but are excluded from enrollment in a Medicaid Health Plan. | Managed Care Organization |
| MICHILD | MIChild Program (CHIP) | This healthcare program is administered by Michigan Department of Health and Human Services (MDHHS). It is for the low income uninsured children of Michigan's working families. Like Healthy Kids, MIChild is for children who are under age 19. The child must be enrolled in a MIChild health and dental plan in order to receive services. | Managed Care Organization |
| MICHILDESO | MIChild Program Emergency Services (CHIP) | Benefits mirror HK-EXP-ESO. Aliens who are not otherwise eligible for full coverage because of citizenship status may be eligible for Emergency Services Only (ESO). This benefit plan is funded by CHIP. For the purpose of ESO coverage, federal Medicaid regulations define an emergency medical condition (including emergency labor and delivery) as a sudden onset of a physical or mental condition which causes acute symptoms, including severe pain, where the absence of immediate medical attention could reasonably be expected to: Place the person's health in serious jeopardy, or cause serious impairment to bodily functions, or cause serious dysfunction of any bodily organ or part. | Fee-for-Service |
| MME-MC | Medicaid-Medicare Dually Eligible-Managed Care | Managed Care Organization enrollment for beneficiaries with dual Medicare and full Medicaid eligibility. | Managed Care Organization |
| MICHILD-D | MIChild - Dental | This benefit plan is for dental services administered by the Michigan Department of Health and Human Services (MDHHS). Only members eligible for MIChild can be assigned to this plan. | Managed Care Organization |
| MOMS | Maternity Outpatient Medical Services | The Maternity Outpatient Medical Services (MOMS) program provides immediate health coverage for the unborn child of an undocumented pregnant woman. The MOMS program is available to provide immediate prenatal care. Prenatal health care services will be covered by MOMS for the entire pregnancy and for two calendar months after the pregnancy ends. Family Planning Services and supplies are covered under this plan using State of Michigan General Funds. | Fee-for-Service |
| NEMT | Non-Emergency Transportation | This benefit plan provides Non-Emergency Transportation (NEMT) for MA covered services. The NEMT benefit plan is administered by MDHHS through a contractor and is available in selected counties. NEMT Services for MA-MC covered services are provided under the Medicaid Health Plan Benefit Plans (MA-MC, MME-MC, and CSHCS-MC). | Transportation |
| NH | Nursing Home | This benefit is for qualifying members residing in a nursing home. A facility or institution must be licensed, certified, or otherwise qualified as a nursing home or long term care facility by the state in which services are rendered. This term includes skilled, intermediate, and custodial care facilities which operate within the terms of licensure. | Fee-for-Service |
| NH PPA | Nursing Home PPA | Patient Pay Amount associated with the NH Benefit Plan | Patient-Pay-Amount |
| PACE | Program All-Inclusive Care for Elderly | This program is an innovative model of community-based care that enables elderly individuals, who are certified by their state as needing nursing facility care, to live as independently as possible. PACE provides an alternative to traditional nursing facility care by offering pre-paid, capitated, comprehensive health care services. | Managed Care Organization |
| PIHP | Prepaid Inpatient Health Plan | This benefit plan provides specialty behavioral health services for individuals enrolled in MA. | Managed Care Organization |
| PIHP-HMP | Prepaid Inpatient Health Plan - Healthy Michigan Plan | This benefit plan provides managed care specialty behavioral health services for individuals enrolled in Healthy Michigan. | Managed Care Organization |
| PENDING ELIGIBILITY | Pending Eligibility | Individual has a pending MA application with the Department of Human Services (DHS) and is waiting for their determination. The normal standard of promptness for MA is 45 days. | No Benefits |
| PLAN FIRST | Family Planning Waiver | This waiver program allows MDHHS to provide family planning services to women who otherwise would not have medical coverage for these services. | Fee-for-Service |
| QDWI | Qualified Disabled Working Individual | Qualified Disabled Working Individual (QDWI) - A client must have applied for or be enrolled in Medicare Part A as a working disabled person who has exhausted Premium-free Part A and whose SSAdisability benefits ended because the clients earnings exceeded SSA's gainful activity limits. Medicaid pays the clients' Medicare Part A premium only. | No Benefits |
| QMB | Qualified Medicare Beneficiary - All Inclusive | This benefit plan is part of the Medicare Savings Program (MSP), also known as the "Buy-In" program. A client must be entitled to Medicare Part A. Under certain income limits, Medicaid pays for Medicare Part B premiums, deductibles and co-payments. This is an all-inclusive benefit plan. | Fee-for-Service |
| SA | Substance Abuse | This is a carve out program that can be assigned to members from multiple eligibility sources, such as MiChild, etc. | Managed Care Organization |
| SED | Children's Serious Emotional Disturbance Waiver Program | The Waiver for Children with Serious Emotional Disturbances (SEDW) provides services that are enhancements or additions to Medicaid state plan services for children under age 21. MDHHS operates the SEDW through contracts with Community Mental Health Service Programs (CMHSPs). The SEDW is a fee-for-service program administered by the CMHSP in partnership with other community agencies and is currently available in a limited number of counties and CMHSPs. The SEDW enables Medicaid to fund necessary home and community-based services for eligible children. The CMHSP is responsible for assessment of potential waiver candidates. Application for the SEDW is made through the CMHSP, and the CMHSP is responsible for the coordination of the SEDW services. | Fee-for-Service |
| SED-DHS | Children's Serious Emotional Disturbance Waiver - DHS | The Waiver for Children with Serious Emotional Disturbances (SEDW) provides services that are enhancements or additions to Medicaid state plan services for children under age 21. MDHHS operates the SEDW through contracts with Community Mental Health Service Programs (CMHSPs). The SEDW is a fee-for-service program administered by the CMHSP in partnership with other community agencies and is currently available in a limited number of counties and CMHSPs. The SEDW enables Medicaid to fund necessary home and community-based services for eligible children. The CMHSP is responsible for assessment of potential waiver candidates. Application for the SEDW is made through the CMHSP, and the CMHSP is responsible for the coordination of the SEDW services. The SED-DHS Benefit Plan implements a collaborative agreement to expand behavioral health services for children in the foster care system. | Fee-for-Service |
| SED-MC | Serious Emotional Disturbances Managed Care | The Waiver for Children with Serious Emotional Disturbances (SEDW) provides services that are enhancements or additions to Medicaid state plan services for children under age 21. The SEDW is a statewide managed care program administered by Prepaid Inpatient Health Plans (PIHPs). The SEDW enables Medicaid to fund necessary home and community-based services for eligible children with a serious emotional disturbance who meet the criteria for admission criteria for Psychiatric Hospitalization. | Fee-for-Service |
| SLMB | Specified Low Income Medicare Beneficiary | A client must have applied for or be enrolled in Medicare Part A. Under certain income limits, Medicaid pays the client''s Medicare Part B premium only; Expanded Specified Low-Income Medicare Beneficiary (ESLMB): A client must have applied for or be enrolled in Medicare Part B and not be eligible for any other Medicaid coverage. Under certain income limits, Medicaid pays the client's Medicare Part B premium only. No specific benefits are defined for this plan. This is a no benefit plan | No Benefits |
| SPENDOWN | Medical Spend-down | If the family's or individual's net income is over the Medicaid limit, the amount in excess is established as a "spend-down amount." In order for the person to qualify for Medicaid during the months, he/she must incur medical bills equal to the spend-down amount. Medicaid will pay expenses incurred above this amount. If a group member is liable for bills incurred before the spend-down period began, these bills can be used to meet the spend-down. | No Benefits |
| SPF | State Psychiatric Facility | This benefit plan allows claims adjudication for offsite inpatient medical care provided to beneficiaries who are between the ages of 22 and 64 and otherwise reside in a State Psychiatric Facility. | TPL |
| TCMF | Targeted Case Management | The benefit describes Targeted Case Management (TCM) services provided to pregnant women and children up to age 21 with household income up to and including 400% of the federal poverty level (FPL) who were served by the Flint water system on or between April 1, 2014 and the date the water is deemed safe by the appropriate authorities. Pregnant women will remain eligible throughout their pregnancy and will receive two months of post-partum coverage. Once eligibility has been established for a child, including those children born to pregnant women, the child will remain eligible until age 21 as long as other eligibility requirements are met. TCM services assist individuals in gaining access to appropriate medical, educational, social, and/or other services. TCM services include assessments, planning, linkage, advocacy, coordination, referral, monitoring, and follow-up activities. | Fee-for-Service |
| TMA-PLUS | Full Fee-for-Service Transitional Medical Assistance - Plus | This benefit plan is available to families after Transitional MA (TMA) ends to assist families who are unable to purchase employer-sponsored healthcare. TMA-Plus offers a way to extend medical coverage through a premium-payment plan. Funding for this program is General Fund. Benefits mirror Fee-for-Service Medicaid. | Fee-for-Service |
| TMA-PLUS FFS DENTAL | Transitional Medical Assistgance- Plus - FFS Dental | Fee-for-Service Dental associated with the TMA-PLUS Benefit Plan | Fee-for-Service |
| TMA-PLUS-E | Transitional Medical Assistance - Plus - Emergency Services |
Benefits mirror MA ESO. Individuals who are not otherwise eligible for full TMA-PLUS because of citizenship status may be eligible for Emergency Services Only (ESO). Funding for this benefit plan is General Fund. For the purpose of ESO coverage, federal Medicaid regulations define an emergency medical condition as a sudden onset of a physical or mental condition which causes acute symptoms, including severe pain, where the absence of immediate medical attention could reasonably be expected to:
|
Fee-for-Service |
| TPL | Third Party Liability | Third Party Liability (TPL) refers to an insurance plan or carrier (e.g., individual, group, employer-related, self-insured or selffunded plan), commercial carrier (e.g., automobile insurance and workers* compensation), or program (e.g., Medicare) that has liability for all or part of a beneficiary*s medical coverage. The terms "third party liability" and "other insurance" are used interchangeably to mean any source, other than Medicaid, that has a financial obligation for health care coverage. Medicaid is considered the payer of last resort. | Third Party Liability |
| INACTIVE COVERAGE | Inactive Coverage | Beneficiary does not have active coverage. | No Benefits |