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Do you have medically related expenses not covered by your BadgerCare Plus or Medicaid Card? Health Check Other Services may be able to help.
This fact sheet will answer many of your questions about a Medicaid benefit called Health Check “Other Services” (HCOS) and will help you work with your child’s primary care provider to use this source of funding to pay for services or products that may not otherwise be covered by your Forward Health card.
What is Health Check “Other Services”(HCOS)? HCOS is a source of Medicaid funding for children under age 21 who already have Medicaid or BadgerCare Plus coverage. HCOS may cover medically necessary supplies and services not typically covered by Medicaid.
BadgerCare Plus Standard Plan and Benchmark Plan are eligible for this benefit. This includes individuals participating in Wisconsin Medicaid under the Katie Beckett Program.
How do I get HCOS to pay for a service or supply? In order for this benefit to cover a supply or service your child’s physician must decide that it is “medically necessary.” The physician needs to document this in the medical record and give you a prescription for the referred need. This service or supply can be identified during your child’s annual HealthCheck exam (a full physical exam) or within 365 days of that HealthCheck exam during another medical appointment. To learn more about HealthCheck exams go here . The provider of the referred supply or service must also submit a prior authorization (PA) to Wisconsin Medicaid in order for that service to be covered.
Please note – Some providers, pharmacies or other suppliers may not be familiar with this benefit. Others may not want to provide the product or service due to additional paperwork. It may take time and a little extra effort, but we encourage you to be persistent! Your Regional Center for Children and Youth with Special Health Care Needs may be able to work with you. You can call 1.800.642.7837 to find the closest Regional Center. ABC for Health, a public interest law firm, may also be able to assist you. They can be reached at 800-585-4222 or www.safetyweb.org.
What are some examples of supplies or services that can be covered by HCOS? If your child’s doctor has recommended over the counter (non-prescription) medications or supplies such as ointments or vitamins, these could be paid for through HCOS. Typically, Medicaid will not pay for a product or supply that you get at your pharmacy that is not a prescription. HCOS may pay for mental health or counseling services, including residential or day treatment, and medically necessary orthodontia (braces).
What Steps do I Need to Take to get Something Paid for through HCOS?
Step 1 Make an appointment for a Health Check Exam/Screen with your medical provider. The provider can be your child’s doctor, a nurse practitioner or a Physician Assistant. (They need to be a Medicaid certified provider). This appointment needs to be a complete physical exam. Many practices call this an annual physical or a well child exam. When you make the appointment make sure the clinic knows that you are requesting a HealthCheck exam.
Step 2 When you are at the exam talk to your provider about services or supplies that your child may need that are not covered by your child’s Medicaid or BadgerCare Plus card. If you are not sure whether something will be covered, talk to the clinic staff, call your pharmacy or call the Forward Health/BadgerCare Plus Hotline at 1-800-362-3002.
Step 3 Ask your child’s doctor (or other health provider) for a prescription for this service or supply. The prescription must state the date of the Health Check exam and who performed the exam. It is also a good idea to get a paper copy of the HealthCheck exam with the date of the appointment and the name of the medical provider. If there are any questions this can make the process go more smoothly.
Step 4 The provider of the service or supply must submit a prior authorization (PA) to Wisconsin Medicaid. The provider may be a doctor, pharmacist, therapist or other Medicaid certified professional. A family does not need to do any paperwork, but you can remind your provider that a PA will be needed to cover the supply or service
Step 5 If you are picking up a medical supply that you want covered by HCOS and it is an over-the-counter (non-prescription) supply, such as nutritional formula or an ointment or cream, remember that you will need to go to the pharmacy check out and not the general check out so Medicaid can be billed. The regular check out will not be able to do this. If you regularly go to a pharmacy and the pharmacist knows you, working with him or her may ease the process
What If My Child’s Doctor or the Clinic is not familiar with this benefit? You can refer the clinic staff or your doctor to the Regional Centers for Children and Youth with Special Health Care Needs (see telephone number below) or they can call the Forward Health Provider Services Hotline or go to the Forward Health Provider Handbook (see resources below) to learn more about the specific requirements.
Resources to learn more about HCOS for you and your provider: Forward Health Provider Handbook (provides definitions, examples and requirements of HCOS and links to prior authorization forms).