What Does the Healthy Michigan Plan Cover: Costs and Exclusions

The Healthy Michigan Plan covers the ten essential health benefit categories required under the Affordable Care Act, which means enrollees get doctor and hospital care, emergency services, prescription drugs, mental health and substance use treatment, maternity care, rehabilitation, preventive screenings, and lab work, along with dental, vision, hearing, and non-emergency medical transportation. Most services carry no copay, and the copays that do apply are small.

Doctor Visits, Hospital Care, and Emergencies

Primary care, specialist visits, nurse practitioner and physician’s assistant appointments, and urgent care are all covered. So are inpatient hospital stays, outpatient hospital services, and outpatient surgical centers. Lab tests, X-rays, and other diagnostic imaging ordered by a doctor are included.¹

Emergency room care carries no copay when the visit qualifies as a true emergency, and ambulance services for emergencies are covered.¹

Rehabilitation benefits include physical, occupational, and speech therapy, plus chiropractic services, medical equipment, prosthetics, and orthotics.¹ Home health care, hospice, and skilled nursing facility stays of up to 45 days for restorative or rehabilitative care are also part of the plan.²

Maternity Care

Medical services during pregnancy and after birth are covered, and pregnant members are exempt from copays for pregnancy-related services.¹ Michigan’s Maternal Infant Health Program adds home visits from nurses, social workers, dietitians, and lactation consultants for Medicaid-enrolled pregnant individuals and families with infants.³ One boundary to keep in mind: people who are pregnant at the time of application cannot enroll in the Healthy Michigan Plan itself and are directed to pregnancy-specific Medicaid instead.⁴

Prescription Drugs

Prescriptions filled at approved pharmacies come at no cost to members. Plans follow the Michigan Common Formulary. Some medications require prior authorization from the prescribing doctor, and those drugs are flagged on the formulary. If a needed medication is not listed, the prescribing physician can request an exception or choose a similar drug that is on the formulary.⁵

In an emergency, members can get up to a 72-hour supply of a needed medication. Out-of-state pharmacy coverage is limited to emergency or urgent situations.⁵

Mental Health and Substance Use Treatment

Both inpatient and outpatient mental health and substance use services are covered.⁶ In Michigan, specialty behavioral health services are managed separately from the medical health plan, through regional Prepaid Inpatient Health Plans that coordinate treatment for conditions like serious mental illness and substance use disorders.⁷

Specialized programs serve particular populations. The Opioid Health Home program is for people with an opioid use disorder and at least one other chronic condition. Children’s waiver programs provide home and community-based services for those under 21 with serious emotional disturbances. Certified Community Behavioral Health Clinics offer a broad set of behavioral health services, including care for people with co-occurring mental health and substance use conditions, regardless of Medicaid status.⁷

Preventive counseling for anxiety, depression, and stress is available through members’ primary care networks at no out-of-pocket cost.⁸

Dental

Dental care is provided through the Delta Dental Healthy Michigan Plan network, with no copays for covered services.⁹ Benefits include:

Oral exams and cleanings every six months
Bitewing X-rays once a year and full-mouth X-rays once every five years
Fillings, extractions, and limited oral surgery
Emergency dental pain treatment
Dentures, one set every five years

Members under 21 get expanded benefits that include root canals, resin crowns, and stainless steel crowns.⁹

Bridges, implants, braces, cosmetic dentistry, removal of healthy wisdom teeth, TMJ treatment, and bite guards are not covered. Services generally must come from a dentist in the Delta Dental HMP network, with one exception: dental emergencies outside Michigan are covered even with an out-of-network dentist.⁹

Vision and Hearing

Vision benefits include a routine eye exam once every two years, with diabetic and glaucoma exams available annually for qualifying conditions. Frames and an initial pair of lenses are covered once every two years, with replacements allowed for damage, loss, or a significant prescription change. Medically necessary contact lenses are covered for specific conditions such as keratoconus or aphakia. Vision therapy is available for up to 12 visits per year when medically necessary.¹⁰

Hearing services carry no age limit for Healthy Michigan members.¹¹ Digital hearing aids are covered, limited to one per ear every five years, along with 72 batteries per year per aid, earmold replacements, repairs, and routine fittings and programming. A medical evaluation is required within six months before getting a hearing aid.¹²

Preventive Care and Family Planning

Preventive services are covered at no out-of-pocket cost. That includes annual physicals, immunizations (flu, COVID-19, hepatitis vaccines, and others), and screenings for blood pressure, cholesterol, diabetes, depression, and obesity. Cancer screenings like mammograms and colonoscopies are included, along with nutritional counseling, tobacco cessation support, and smoking cessation drugs and counseling.⁸¹

Family planning gets especially broad coverage. Doctor visits, exams, pregnancy testing, birth control counseling and methods, STI testing, and HIV/AIDS testing and services are all provided with no out-of-pocket costs.¹

Telehealth

Telemedicine has been a covered service under the Healthy Michigan Plan since October 2020. Coverage includes medical, dental, behavioral health, and substance use services delivered by video or audio-only communication. The plan cannot require you to use telehealth instead of an in-person visit and cannot impose tighter limits on a telehealth visit than it would on the same service delivered in person.¹³

Non-Emergency Transportation

Rides to doctor’s offices, pharmacies, and other covered appointments are a plan benefit. Each managed care health plan contracts with a transportation provider to arrange rides, and most plans require at least three business days’ notice for scheduling. Members who drive themselves can submit for mileage reimbursement.¹⁴

What Is Not Covered

Some services are excluded from Healthy Michigan Plan and Medicaid coverage entirely: elective abortions, cosmetic surgery, experimental drugs or treatments, infertility treatment, unnecessary care, and care that required a referral but was obtained without one. Services received outside the United States are also excluded.¹⁵

A separate group of services is not covered by your managed care health plan but is still available through Medicaid directly, using your Medicaid ID card. This category includes inpatient psychiatric care, substance abuse treatment managed through Community Mental Health, personal care and home help services, custodial nursing home care, developmental disability services, and traumatic brain injury program services.¹⁵ These services are not absent from your coverage; they are billed and accessed differently than the services your health plan manages.

What You’ll Pay

For most enrollees, the Healthy Michigan Plan costs little or nothing out of pocket. Copays apply to some services, but several categories are exempt: children under 21 pay no copays for doctor visits and immunizations, and family planning and emergency services carry no copay at any age.¹⁶ Representative copays include:

$2 for a doctor or urgent care visit
$1 for outpatient hospital clinics
$50 for an inpatient hospital stay
$1 for generic prescriptions
$3 for brand-name drugs

Those amounts are drawn from the member handbook.¹

Members with income between 100 and 133 percent of the federal poverty level were historically required to contribute 2 percent of their annual income toward cost sharing, with total out-of-pocket costs capped at 5 percent of household income.¹⁷ The MI Health Account that tracked those contributions was discontinued as of January 2024, and unpaid balances are no longer collected.¹⁶

Reducing Costs With the Healthy Behaviors Incentive

You can lower what you pay by participating in the Healthy Behaviors Incentive program. Within 60 days of enrollment, members complete a Health Risk Assessment with their primary care doctor, a confidential survey covering health history and lifestyle.¹⁵ Members who complete the assessment and engage in healthy behaviors, such as getting recommended vaccinations, attending annual preventive visits, or participating in screenings, qualify for reductions to their copays or contributions.¹⁸

For members with income above 100 percent of FPL who have been enrolled for 48 months or longer, completing the assessment or a qualifying healthy behavior within the past year is a condition of continued eligibility.¹⁸

1
Lenawee Community Mental Health Authority. Healthy Michigan Plan Member Handbook
2
Aetna Better Health of Michigan. Medicaid Member Handbook
3
Michigan Department of Health and Human Services. Maternal Infant Health Program
4
Michigan Department of Health and Human Services. Healthy Michigan Plan Eligibility Policy
5
Molina Healthcare. Prescription Drugs – Healthy Michigan
6
Mid-Michigan District Health Department. Healthy Michigan Plan
7
Michigan Health Plan Benefits. Behavioral Health Benefit Plans
8
McLaren Health Plan. Medicaid Preventive Services in Michigan
9
McLaren Health Plan. HMP Dental Handbook
10
March Vision Care. Michigan Vision Provider Reference Guide
11
Molina Healthcare. Dental, Vision, and Hearing Aid Bulletin
12
Michigan Department of Health and Human Services. Hearing and Audiology Services
13
Michigan Legislature. MCL Section 400.105h – Telemedicine Services
14
Priority Health. Transportation Services
15
McLaren Health Plan. Healthy Michigan Plan Member Handbook
16
Michigan Department of Health and Human Services. Healthy Michigan Plan
17
Genesee Health Plan. Healthy Michigan Plan Frequently Asked Questions
18
Centers for Medicare and Medicaid Services. Healthy Michigan Plan Section 1115 Waiver