Michigan MI

MI Medicaid Health Plan Common Formulary (5/1/2026) carves entire areas to FFS (marked '#'): ALL behavioral health (antidepressants, antipsychotics, ADHD stimulants, benzodiazepines, anticonvulsants, sedative-hypnotics), HIV antiretrovirals, Hepatitis C DAAs, most targeted oral oncology, enzyme-replacement, hemophilia factor, anti-VEGF, HAE agents, narcolepsy/oxybate/wakefulness, OUD/MAT, CFTR modulators, complement C5, urea-cycle. For these the MHP does NOT set PA — FFS Michigan Medicaid does (typically open-access, which is why they're carved). Captured in drug_pa_rules with note 'carved_out_ffs'. MHP-managed classes use PDL-NP PA (non-preferred require PA).

Michigan MDHHS expresses prior-authorization on its own terms: a SINGLE giant electronic Medicaid Provider Manual (MPM, ~22MB PDF, updated quarterly) carries coverage/billing/PA policy organized BY CHAPTER (service category). There is no standalone PA-required code list page; the canonical FFS PA criteria live inside the MPM, layered with supplemental MSA/MMP policy bulletins issued between quarterly manual updates. PA SUBMISSION for FFS is operational: providers enter single PA requests through the CHAMPS provider portal PA tab (tracking number becomes the PA number for billing); fax still accepted. Per MMP 26-02 (effective 2026-03-22) standard PA determinations are due within 7 calendar days (extendable +14), expedited within 72 hours. AUTHORITY SPLIT: FFS PA = MDHHS via CHAMPS. Managed-care PA = the members Medicaid Health Plan (9 MHPs). Specialty BH/IDD/SUD carved out to 10 regional PIHPs. Pharmacy uses a state-coordinated Common Formulary (MIPBM) administered by MDHHS across MHPs+FFS. MI Choice HCBS LTSS routed through Area Agencies on Aging. NOT a WISeR pilot state. URL DECAY: all five state_meta primary_source_urls returned HTTP 404 - michigan.gov restructured the provider-section path from /policy-forms-billing/ to /policyforms/ and moved PA under the CHAMPS portal accordion. Live replacements verified head_ok 200 (see repin_candidates). The MPM PDF is served from legacy mdch.state.mi.us and is live.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: 2024-04-08. Next due: 2028-10-30. Contracts extended through: None.

## 1. How MI requires PA Michigan's Medicaid program requires prior authorization (PA) through a process outlined in the Medicaid Provider Manual (MPM). The MPM — updated quarterly and available as a large (~22MB) PDF — is the primary document detailing coverage, billing, and PA policies organized by chapter for various service categories. Some medical conditions may bypass prior authorization, but additional information is generally required for claim processing. The CHAMPS portal is used to submit PA requests. The MPM does not provide a standalone list of PA-required codes; it references MMP 26-02 for specific PA requirements. ## 2. How MI publishes and reports PA Michigan's Medicaid program publishes its PA policies through the Medicaid Provider Manual (MPM), updated quarterly. The manual provides comprehensive coverage/billing policies organized by service category but does not offer a standalone list of PA-required codes; instead it references MMP 26-02. The CHAMPS portal is the submission platform for PA requests. Reporting on PA activities is likely integrated into broader MDHHS Medicaid reporting, though specific channels/frequency are not provided in the source documents. ## 3. MI's CMS-0057-F and PA-reform compliance posture Michigan's CMS-0057-F posture is unclear from the source documents. The state operates under several carve-outs (LTSS and behavioral health managed separately from medical MCOs) and has an 1115 waiver for the Healthy Michigan Plan plus a Behavioral Health/SUD §1115 Demonstration. There is no explicit mention of CMS-0057-F compliance or specific PA-reform initiatives in the corpus. Michigan is **not** a WISeR state. (WISeR = the federal "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization model, which applies only to AZ, NJ, OH, OK, TX, and WA — not Michigan.) No WISeR participation should be inferred for MI. ## 4. How MI runs its own program Michigan's Medicaid program is managed by the Michigan Department of Health and Human Services (MDHHS), operating under a Managed Care Organization (MCO) model with contracts awarded roughly every five years. The last MCO procurement-cycle award was April 8, 2024, with the next due date October 30, 2028. Michigan carves out long-term services and supports (LTSS) and behavioral health services from medical MCOs. The state also has an 1115 waiver for the Healthy Michigan Plan and a Behavioral Health/SUD §1115 Demonstration. The Medicaid Provider Manual (MPM) is the primary coverage/billing/PA reference. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Points: - **Medicaid Provider Manual (MPM):** Comprehensive resource for Medicaid policies including PA requirements. - **CHAMPS Portal:** Used for submitting PA requests (electronic submission). - **Carve-outs:** LTSS and behavioral health managed separately from medical MCOs. ### Missing/Uncertain: - **Specific PA Codes:** The MPM gives no standalone list of PA-required codes; it references MMP 26-02 (not in the corpus). - **CMS-0057-F Compliance:** No explicit mention of compliance or specific PA-reform initiatives. - **Foster Care Program:** Noted as "None," suggesting it may be managed differently or is not covered in the source documents. - **Documentation Requirements:** Additional information is required for claim processing, but specific documentation requirements are not detailed.