Ohio Department of Medicaid

Healthchek And Pregnancy Related Services Information Sheet

Ohio Medicaid Managed Care Plans

HealthChek - Check It Out!

Did you know Ohio’s Medicaid program include Healthchek services for children up to 21 years of age? (These services are also called EPSDT sometimes.) Healthchek services help children stay healthy and reduce the chances of sickness by treating health problems early. All Healthchek services are free. You can get help and information by contacting your county Healthchek Coordinator, or your managed care plan, and by going to: http://medicaid.ohio.gov/FOROHIOANS/Programs/Healthchek.aspx

Screening Services

Doctors want children to have well-child check-ups (exams or screenings) while they are growing up so that health problems can be found early. Check-ups covered by Healthchek include:

physical exams
nutrition screenings
vision exams
mental health screenings
dental exams
developmental screenings
hearing exams
immunizations, if needed

Mothers should have prenatal exams and children should have exams at: birth, 3 to 5 days of age, and at 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months of age. After that, children should have at least one exam per year. All children should have tests for lead poisoning.

Treatment Services

If the doctor finds a problem during a check-up, the doctor may provide the treatment, or may refer you to another doctor. Healthchek covers treatment services. Some services may need prior approval. Your doctor will request prior approval from your managed care plan. If you disagree with the decision made by your managed care plan, you can ask for an appeal. Check with your managed care plan for more information about appeals.

Support Services

The names, addresses, and phone numbers of Healthchek Coordinators for all counties can be found at: http://medicaid.ohio.gov/Portals/0/For%20Ohioans/Programs/CountyCoordinators.pdf or by calling your County Department of Job and Family Services. If you need to find a doctor, dentist, or other health care provider, your managed care plan can help you. The managed care plan can help make doctors’ appointments, and may provide transportation to the doctor. You can go to the managed care plan’s website for more information.

You can ask your Healthchek Coordinator to make referrals for you to Head Start, the Women, Infants, and Children (WIC) program, Help Me Grow, and the Bureau for Children with Medical Handicaps. Your Healthchek Coordinator, and your managed care plan, can give you the names of other agencies that can help you get clothing, housing, food, and other services. You may also submit questions using an online form found at: http://medicaid.ohio.gov/CONTACT.aspx.

Please fill out the following information in order to help us provide Healthchek services to you and/or your child. If you do not understand some or all of this form, please contact CareSource Member Services at 1-800-488-0134 (TTY: 1-800-750-0750 or 711) or your county Healthchek Coordinator.

Your Information

First Name:

Last Name:

Case Number:

Address:

City:

State:

Zip:

County:

Date of Birth:

Email:

Phone:

Your Child’s Information – Only fill out for children enrolled in CareSource

Child’s Name

SSN or Medicaid Billing No.

Healthchek Screening Services

Healthchek covers medical exams, immunizations (shots), health education, and laboratory tests for everyone on Medicaid and under 21 years of age. It also covers complete medical, vision, dental, hearing, nutritional, psychological, and mental health exams. These exams are important to make sure that your child is healthy and is developing physically and mentally. Mothers should have prenatal exams and children should have exams at birth, 3 to 5 days of age and at 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months of age. After that, children should have at least one Healthchek exam per year until 21 years of age. Please check all services you or your child enrolled in CareSource would like to receive.

A comprehensive medical exam A hearing exam A vision (eye) exam A mental health exam A dental (tooth) exam A specialist exam

Specialist Exam

Healthchek Treatment Services and Transportation to Health Care Appointments

Healthchek covers tests and treatment services to treat problems or conditions found by an exam. Some tests and treatment services require prior-approval. If you need prior-approval, your provider must ask your managed care plan.

Your Healthchek Coordinator can help you make medical, dental and other appointments and provide free transportation to those appointments, if needed. CareSource can help with appointments and provide transportation. We can also give you a list of doctors available to you. Please check everything you or your child enrolled in CareSource would like to receive.

A list of doctors Transportation to medical or dental appointments A list of dentists Referrals to Help Me Grow A list of other healthcare professionals Referrals to the Bureau for Children with Medical Handicaps Other help getting treatment Other information about where to get treatment

Please fill out the following information for you and your child enrolled in CareSource.

Do you or your child have any problems that need attention or treatment (for example, a medical problem, a mental health problem, a child who is not developing normally, etc.)? If so, please tell us more about this.

Other information about your child’s history

My child has been tested for lead poisoning

Yes No Don't Know

My child’s immunizations (shots) are up-to-date

Yes No Don't Know

My child has had developmental exams

Yes No Don't Know

Support Services

Your Healthchek Coordinator can also give you information about available services like the Women, Infants, and Children (WIC) program and other support services offered through your local health department and other local agencies.

Would you like more information about other support services? Please check all that apply.

Other Support Service

Is anyone (including yourself) pregnant?

Yes No

If YES, give the name(s) of the pregnant woman.

If known, give the date(s) the baby is due:

Month

Year

Is the pregnant woman now going to a doctor or clinic for the pregnancy?

Yes No

If YES, give the name of the doctor or clinic.

Do you need other social services?

Yes No

If YES, what services:

Acknowledgement

I have been given information about Healthchek. I understand that I can ask for Healthchek services or assistance at any time. I understand that I will be asked to sign a separate release form if my medical information needs to be shared with others.

Signature

Date

OH-MMED-2136 ODM 6/13/2019