HealthCheck is a Medicaid health care benefit created for young people. The goal is to prevent illnesses and find and treat health issues early. HealthCheck is Wisconsin’s name for the federal benefit called Early and Periodic Screening, Diagnosis, and Treatment.
The benefit covers exams and certain special services or products for those under 21 who have:
If the child in your care is under 21 and needs a service Medicaid typically doesn’t cover, you may be able to use a benefit called HealthCheck “other services” to cover it.
Below are some FAQs (frequently asked questions) and answers about the HealthCheck benefit. We’ve divided them into two categories by subject:
- HealthCheck “other services”
No. You don’t need to sign up or register. If you have BadgerCare Plus, a ForwardHealth card, or Medicaid, you have coverage. There is nothing you need to do.
Exams and services are covered with your ForwardHealth card. If you typically pay a copay or deductible, you may need to pay that during your visit.
A well-child check is an exam that happens during a doctor visit to make sure your child is healthy.
The HealthCheck well-child exam includes:
- Dental checks.
- Growth and development checks.
- Head-to-toe physical exams.
- Health information.
- Hearing and vision checks.
- Lab tests.
- Nutrition checks.
If the doctor finds something concerning, they may recommend follow-up care.
How often you or your child should get a well-child check is based on the American Academy of Pediatrics’ Recommendations for Preventive Pediatric Health Care Periodicity Schedule (PDF).
The schedule lists the ages and types of exams children and teens should get. The doctor should know the schedule and can help you pick a date for your next visit.
An interperiodic screen, or exam, is a doctor visit that happens between scheduled well-child checks. Your child may need one if a doctor (or teacher or dentist) has a concern about their health or development.
You can schedule a well-child check with any doctor enrolled in Medicaid. If you don’t have a doctor and you’re:
- Enrolled in BadgerCarePlus, you can search for a doctor in your area or call ForwardHealth Member Services at 800-362-3002 between 8 a.m.–6 p.m., Monday through Friday.
- Enrolled in a BadgerCare Plus HMO (health maintenance organization), you can contact your HMO to get help finding a doctor in your network.
If you need help getting to a doctor visit, call 866-907-1493 or visit our non-emergency medical transportation page. You may be able to get a ride, bus tickets, or money for gas.
HealthCheck “other services”
If your child needs a service or product that Medicaid doesn’t typically cover, you may be able to use the HealthCheck “other services” benefit to cover it. Your doctor will write a prescription for it. The service or product must be medically necessary.
- Schedule a HealthCheck well-child exam with a doctor.
- If the doctor finds an illness or condition during the exam, they will write a prescription for the service or product your child needs. They can also help you with where to get the service or product. 3
- The doctor will send the prescription to ForwardHealth with information that explains what your child needs and why. This is called a prior authorization request.
- ForwardHealth will look at the request and decide if it is medically necessary.
- If ForwardHealth agrees that it’s medically necessary, it will cover the service or product.
- ForwardHealth will let the doctor who made the request know its decision. The doctor will then contact you.
To be a medical necessity, a service or product must:
- Be needed to help correct, improve, maintain, or prevent a condition.
- Be provided by a health care professional certified by the state.
Because every condition is different, each child’s personal needs will be considered by medical experts.
Scheduling a well-child check with a doctor is the first step to find out if your child has a condition that will need more services.
The benefit includes services such as:
- Dental care.
- Home health services.
- Medical equipment and supplies.
- Physician services.
The service must be:
- Able to be covered according to federal Medicaid law.
- Deemed medically necessary by ForwardHealth.
A person with different needs and circumstances may need different services. Services are covered based on each person’s unique condition.
If the request wasn’t approved, it was either denied or approved with changes. “Approved with changes” may mean a lower prescription dose, for example. Your doctor should be able to explain the reason for the decision.
You have the right to appeal. Follow the directions in the letter you received about fair hearing rights.
A well-child check is the same thing as a HealthCheck exam, or screen, so you don’t need another one to get services. If a doctor found a health or development concern during the well-child check that needs follow-up, they should have written a prescription. If they didn’t, but you think your child needs more care, call the doctor to discuss.
If the doctor agrees, Medicaid will cover the cost of the visit.
No, but you do need a prescription for the services.
Some may be covered by HealthCheck “other services.”
These include certain:
View the list of Over-the-Counter Drugs Covered by HealthCheck “Other Services” (PDF) to see what over-the-counter medicines you can get without prior authorization.
You will need to give the pharmacist a prescription from your doctor and your child’s ForwardHealth card for the medicine to be covered.
If your child needs a medicine not included on the list, your doctor can work with the pharmacist to submit a prior authorization request for coverage.
This information is in accordance with Wis. Admin. Code § DHS 107.22 Early and Periodic Screening, Diagnosis, and Treatment services.