ForwardHealth: HealthCheck FAQs for Members and Participants

Yes. These are all names for the same thing:

• Well-child check
• Well-child visit
• HealthCheck exam
• HealthCheck screen

No. Members don’t need to sign up or register. HealthCheck is a covered benefit for Medicaid members under age 21.

Well-child checks, follow-up visits, and special appointments are covered with the member’s ForwardHealth card.

How often a member under 21 should get a well-child check is based on age. Different exams are done at different ages. Check with the member’s provider about what they recommend and they can set up the next visit.

See the American Academy of Pediatrics’ Preventive Care Schedule.

Families can call the member’s provider and ask for a well-child check, follow-up visit, or special appointment. (For the visit to be covered under HealthCheck, the provider must accept Medicaid.)

If the member doesn’t have a provider and they’re:

• Enrolled in BadgerCare Plus, families can search for a provider in their 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), contact their HMO to get help finding a provider in their network.

If a member needs a ride to a medical appointment or pharmacy, they can use our non-emergency medical transportation benefit. Members may be able to get a ride, bus tickets, or money for gas. Call 866-907-1493 to schedule a ride or visit our non-emergency medical transportation page for more information.

HealthCheck Other Services is coverage of services or items for members under 21 that Medicaid typically doesn’t cover. This includes:

• Needing a type of service or item that isn’t typically covered.
• Needing a higher number of services or items than what is typically covered.

Some common services or items included under HealthCheck Other Services are:

• Behavioral and mental health treatment
• Durable medical equipment
• Disposable medical supplies
• Orthodontia
• Over-the-counter items
• Personal care services

To be covered, the service or item must be:

• Prescribed by the member’s provider
• Able to be covered according to federal Medicaid law.
• Approved by their health plan or Wisconsin Medicaid, based on information submitted by the member’s health care provider.

Most of the time, yes. HealthCheck Other Services covers services or items not typically covered by Medicaid, so they need prior approval. Prior approval determines if something is medically necessary. The process of getting prior approval is called prior authorization.

A service or item is medically necessary if:

• The member needs it to help correct, improve, maintain, or prevent a health condition.
• It is provided by a health care professional enrolled with Wisconsin Medicaid.

Every condition is different. The member’s health plan or Wisconsin Medicaid will consider each member’s personal needs to decide if a service is medically necessary.

Scheduling a well-child check or a special appointment with a provider is the first step to find out if the member has a condition that will need more services or items. Their provider will write a prescription for any extra recommended services or items.

If the member’s provider finds an illness or condition that needs extra services or items during a visit, they will ask the member’s health plan or Wisconsin Medicaid to review information about why the member needs the services or items. Their health plan or Wisconsin Medicaid will look at the request and decide if it is medically necessary. This process is called prior authorization.

If their health plan or Wisconsin Medicaid agrees that it’s medically necessary, it will send a letter to the provider saying the services or items are approved. The provider will let the member know the decision.

People have different needs and circumstances. Some people may need different services or items, which are covered based on each member’s unique condition.

The member’s health plan or Wisconsin Medicaid will send a letter if they:

• Deny a request. This means the service or item is not covered.
• Approve the request with modifications. This means they will cover the service or item but have changed something about the request. For example, it may cover a service, but for a different number of times than was in the original request.

Members can appeal if they disagree with the decision. The letter will have next steps and options.

No. Members do not need specific types of appointments before seeing if HealthCheck Other Services can cover a service or item. However, a provider prescription for the service or item is almost always needed.

Some over-the-counter medicines, supplements, or other items may be covered by HealthCheck Other Services. These lists show what over-the-counter items members can get without prior approval:

• Over-the-Counter Drugs Covered by HealthCheck Other Services (PDF): over-the-counter items members under 21 can get without prior approval
• Over-the-Counter Drugs Covered by BadgerCare Plus and Medicaid (PDF): over-the-counter items members of all ages can get without prior approval

The pharmacist will need to see the member’s ForwardHealth card and a prescription from the member’s provider for the items listed to be covered.

If the member needs an item not included on these lists, their provider can work with the pharmacist to submit a prior authorization request to see if it can be covered.