mdhhs-6178, Adoption/Guardianship Medical Subsidy
Prior Approval Application

Michigan Department of Health and Human Services

(New 5-25)

Directions: Sections A and B of this application must be completed in its entirety. For the service(s) you are requesting, complete the specific section in this application.

Note: You may apply for more than one service on an application; however, you can only apply for one child on each application.

Applications will be processed within 30-calendar days, and written notice will be provided. If your application is incomplete, a letter will be sent detailing the information needed. The missing information must be submitted within 45-calendar days from the date of the letter. If approved, written notice will be provided to you with the effective date of coverage and the coverage amount.

If you need assistance completing this application utilize one of the methods below:

Email MDHHS-MedicalSubsidyClaims@michigan.gov.

Call the Adoption and Guardianship Assistance Office (AGAO) at (517) 335-7801.

Find your assigned adoption assistance analyst from the contact list at https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Adult-and-Childrens-Services/Adoption/DHS-AdoptionSubsidy-Contacts_253834_7.pdf.

section a - general information

Child’s Name	Date of Birth

Certified condition(s) for which funding is being requested

Adoptive Parent(s)/Legal Guardian(s) Name

Email	Telephone Number

Address	City	State	Zip Code

Is the child covered by private insurance? Yes No	Is the child covered by Medicaid? Yes No

Is the child receiving assistance from Children's Special Health Care Services (CSHCS)? Yes No

Adoptive Parent/Legal Guardian Signature	Date

section b - provider information

Provider Name

Provider Address

Provider FEIN ID#/SSN and DOB	License/Cert Number (if applicable)

Provider SIGMA Vendor Code	Telephone Number	Email

Signature	Date

section c

Directions: Check the box for the service being requested and check each box to indicate that the required documentation is attached.

Physical Care Services Physician’s prescription, including the total amount of hours needed and duration of treatment. Proof application was made to private insurance, CSHCS, Medicaid, and Home Help through MDHHS.

Durable Medical Equipment Letter from physician OR professional evaluation dated within the past 12 months, documenting medical necessity, type of equipment recommended, quantity, and frequency of usage. Proof other resources have been exhausted (Medicaid, private insurance, CSHCS).

Adaptive Equipment Physician’s prescription OR professional evaluation dated within 12 months. Proof other resources have been exhausted (Medicaid, private insurance, CSHCS).

Van Lift Proof other resources have been exhausted (Medicaid, private insurance, CSHCS).
Communication Aids Physician’s prescription OR professional evaluation dated within 12 months recommending the equipment. Proof other resources have been exhausted (Medicaid, private insurance, CSHCS).
Incontinence Supplies Child is 4 years or older Professional documentation of a medical need from a physician or physician’s assistant. Proof other resources have been exhausted (Medicaid, private insurance, CSHCS).

Mental Health/Developmental Assessment/Evaluation

Mental Health Assessment/Evaluation	Developmental Assessment/Evaluation

Required Documentation Proof other resources have been exhausted (Medicaid, private insurance).

Medication Review Proof other resources have been exhausted (Medicaid, private insurance).

Outpatient Counseling

Individual	Family	Group

Required Documentation Proof other resources have been exhausted (private insurance and Medicaid). Requesting more than 3 sessions per week: Proof services through Community Mental Health (CMH) have been utilized for Medicaid eligible children.

Note: Progress reports from outpatient counseling providers are required every 90-calendar days during the authorized coverage period.

Assisted Care Verification that the child is receiving mental health treatment, including parental involvement. Post Adoption Resource Center (PARC) Family Center Plan that includes a goal for assisted care.

Behavioral Services Treatment plan developed by a qualified treatment specialist (such as a licensed physician, psychologist, limited or fully licensed master social worker, or limited or fully licensed professional counselor) that includes: Assessment of the child’s behavior. Statement of intervention techniques to be used. Expected parental involvement. Expected outcomes at the end of the treatment period. Signatures of the following individuals: Treatment specialist Service provider Adoptive parent(s)/legal guardian(s) Treatment specialist’s signed recommendation of the service provider and the training and supervision plan. Copies of treatment specialist’s and service provider’s credentials. Proof other resources have been exhausted (private insurance and Medicaid).

Specialized Counseling Documentation from provider explaining the type of counseling to be provided, the expected benefit, frequency, duration, and cost. Proof other resources have been exhausted (Medicaid, private insurance).

Physical, Occupational, Speech Therapy

Physical Therapy	Occupational Therapy	Speech Therapy

Select appropriate option and include required documentation listed below. Child age 0-2: Proof adoptive parent(s)/legal guardian(s) has applied to Early On Michigan and received denial. Proof that services are needed above and beyond what is provided by the local school district. Child age 3 or older: Copy of current IEP/504 plan. Proof that services are needed above and beyond what is provided by the local school district. Proof other resources have been exhausted (Medicaid, private insurance, CSHCS).

Sensory Integration Physician’s prescription documenting a neurological condition. Proof other resources have been exhausted (private insurance and Medicaid).

Tutoring - Select appropriate option and include required documentation listed below. Child is 7 years of age or older, tutoring is for the purpose of raising a failing grade (C or below). Include most recent report card or progress report. Include copy of current IEP/504 Plan. Support for child who has below average standardized test scores. Include most recent standardized test scores. Include copy of current IEP/504 Plan.

Additional required documentation Verification that tutoring will occur outside regular school hours. Documentation that free tutoring is not offered by the school. Credentials of tutor.

Academic Credit Recovery/Summer School Documentation from child’s school that includes: Verification the course is required for graduation. Cost of course.

Note: Adoptive parent(s)/legal guardian(s) must provide proof of regular attendance and completion of course when claim is submitted.

Travel Expenses Travel is more than 30 miles round trip. Travel is more than 50 miles from the family residence and overnight stay is required. Proof other resources have been exhausted (Medicaid, private insurance, CSHCS).

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.