Benefits Overview

Comprehensive Long Term Care members receive Medicaid benefits and Long Term Care benefits.

These tables list the services covered by our Plan. Remember, services must be medically necessary in order for us to pay for them.

If there are changes in covered services or other changes that affect you, we will notify you in writing at least 30 days before the effective date of the change.

If you have any questions about any of the covered services, please call your care manager or Member Services at 1-866-796-0530.

NOTE: Services marked with an asterisk (*) are behavioral health in lieu of services. This means they are optional services you can choose over more traditional services based on your individual needs.

Your Plan Benefits: Managed Medical Assistance Services
Service	Description	Coverage/Limitations	Prior Authorization
Addictions Receiving Facility Services*	Services used to help people who are struggling with drug or alcohol addiction	As medically necessary and recommended by us	No prior authorization required for the first three days of involuntary behavioral health inpatient admission. After the first three days, prior authorization required. Prior authorization is required for voluntary admissions.
Allergy Services	Services to treat conditions such as sneezing or rashes that are not caused by an illness	We cover medically necessary blood or skin allergy testing and up to 156 doses per year of allergy shots.	No
Ambulance Transportation Services	Ambulance services are for when you need emergency care while being transported to the hospital or special support when being transported between facilities.	Covered as medically necessary.	No
Ambulatory Detoxification Services*	Services provided to people who are withdrawing from drugs or alcohol	As medically necessary and recommended by us	Yes
Ambulatory Surgical Center Services	Surgery and other procedures that are performed in a facility that is not the hospital (outpatient)	Covered as medically necessary.	Yes
Anesthesia Services	Services to keep you from feeling pain during surgery or other medical procedures	Covered as medically necessary.	Yes, for dental procedures not done in an office.
Assistive Care Services	Services provided to adults (ages 18 and older) to help with activities of daily living and taking medication	We cover 365/366 days of services per year, as medically necessary.	Yes
Behavior Analysis (BA)	Structured interventions, strategies, and approaches provided to decrease maladaptive behaviors and increase or reinforce appropriate behaviors	We cover recipients under the age of 21 years requiring medically necessary services.	No
Behavioral Health Assessment Services	Services used to detect or diagnose mental illnesses and behavioral health disorders	We cover, as medically necessary: One initial assessment per year One reassessment per year Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day)	No
Behavioral Health Overlay Services	Behavioral health services provided to children (ages 0–18 years) enrolled in a DCF program	We cover 365/366 days of medically necessary services per year, including therapy, support services and aftercare planning.	Yes
Cardiovascular Services	Services that treat the heart and circulatory (blood vessels) system	We cover the following as prescribed by your doctor, when medically necessary: Cardiac testing Cardiac surgical procedures Cardiac devices	Yes, for some services
Child Health Services Targeted Case Management	Services provided to children (ages 0-3 years) to help them get healthcare and other services OR Services provided to children (ages 0–20 years) who use medical foster care services	Your child must be enrolled in the DOH Early Steps program OR Your child must be receiving medical foster care services	No
Chiropractic Services	Diagnosis and manipulative treatment of misalignments of the joints, especially the spinal column, which may cause other disorders by affecting the nerves, muscles, and organs	We cover, as medically necessary: 24 patient visits per year, per member X-rays	No
Clinic Services	Healthcare services provided in a county health department, federally qualified health center, or a rural health clinic	Covered as medically necessary	No
Community-Based Wrap-Around Services*	Services provided by a mental health team to children who are at risk of going into a mental health treatment facility	As medically necessary and recommended by us	Yes
Crisis Stabilization Unit Services*	Emergency mental health services that are performed in a facility that is not a regular hospital	As medically necessary and recommended by us	No
Dialysis Services	Medical care, tests, and other treatments for the kidneys. This service also includes dialysis supplies and other supplies that help treat the kidneys.	We cover the following as prescribed by your treating doctor, when medically necessary: Hemodialysis treatments Peritoneal dialysis treatments	No
Drop-In Center Services*	Services provided in a center that helps people who are homeless get treatment or housing	As medically necessary and recommended by us	No
Durable Medical Equipment and Medical Supplies Services	Medical equipment is used to manage and treat a condition, illness or injury. Durable medical equipment is reused, and includes things like wheelchairs, braces, crutches and other items. Medical supplies are items meant for one-time use and then thrown away.	As medically necessary, some service and age limits apply. Call 1-866-796-0530 (TTY 1-800-955-8770) for more information.	Prior authorization may be required for some equipment or services.
Early Intervention Services	Services to children ages 0-3 years who have developmental delays and other conditions	Covered as medically necessary: One initial evaluation per lifetime, completed by a team Up to 3 screenings per year Up to 3 follow-up evaluations per year Up to 2 training or support sessions per week	No
Emergency Transportation Services	Transportation provided by ambulances or air ambulances (helicopter or airplane) to get you to a hospital because of an emergency	Covered as medically necessary.	No
Evaluation and Management Services	Services for doctor’s visits to stay healthy and prevent or treat illness	We cover medically necessary: One adult health screening (check-up) per year Well child visits are provided based on age and developmental needs One visit per month for people living in nursing facilities Up to two office visits per month for adults to treat illnesses or conditions	No
Family Therapy Services	Services for families to have therapy sessions with a mental health professional	We cover medically necessary: Up to 26 hours per year	No
Family Training and Counseling for Child Development*	Services to support a family during their child’s mental health treatment	As medically necessary and recommended by us	No
Gastrointestinal Services	Services to treat conditions, illnesses or diseases of the stomach or digestion system	Covered as medically necessary	Yes, for some services
Genitourinary Services	Services to treat conditions, illnesses or diseases of the genitals or urinary system	Covered as medically necessary	Yes, for some services
Group Therapy Services	Services for a group of people to have therapy sessions with a mental health professional	We cover medically necessary: Up to 39 hours per year	No
Hearing Services	Hearing tests, treatments and supplies that help diagnose or treat problems with your hearing. This includes hearing aids and repairs.	We cover hearing tests and the following as prescribed by your doctor, when medically necessary: Cochlear implants One new hearing aid per ear, once every 3 years Repairs	Yes, for some services
Home Health Services	Nursing services and medical assistance provided in your home to help you manage or recover from a medical condition, illness or injury	We cover, when medically necessary: Up to 4 visits per day for pregnant recipients and recipients ages 0-20 years Up to 3 visits per day for all other recipients	Yes
Hospice Services	Medical care, treatment and emotional support services for people with terminal illnesses or who are at the end of their lives to help keep them comfortable and pain free. Support services are also available for family members or caregivers.	Covered as medically necessary	Yes
Individual Therapy Services	Services for people to have one-to-one therapy sessions with a mental health professional	We cover medically necessary: Up to 26 hours per year	No
Infant Mental Health Pre and Post Testing Services*	Testing services by a mental health professional with special training in infants and young children	As medically necessary and recommended by us	No
Inpatient Hospital Services	Medical care that you get while you are in the hospital. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you	We cover the following inpatient hospital services based on age and situation, when medically necessary: Up to 365/366 days for recipients ages 0-20 years Up to 45 days for all other recipients (extra days are covered for emergencies)	Yes
Integumentary Services	Services to diagnose or treat skin conditions, illnesses or diseases	Covered as medically necessary	Yes, for some services
Laboratory Services	Services that test blood, urine, saliva or other items from the body for conditions, illnesses or diseases	Covered as medically necessary	Yes, for some services
Medical Foster Care Services	Services that help children with health problems who live in foster care homes	Must be in the custody of the Department of Children and Families	No
Medication Assisted Treatment Services	Services used to help people who are struggling with drug addiction	Covered as medically necessary	No
Medication Management Services	Services to help people understand and make the best choices for taking medication	Covered as medically necessary	No
Mental Health Partial Hospitalization Program Services*	Treatment provided for more than 3 hours per day, several days per week, for people recovering from mental illness	As medically necessary and recommended by us	Yes
Mental Health Targeted Case Management	Services to help get medical and behavioral healthcare for people with mental illnesses	Covered as medically necessary	No
Mobile Crisis Assessment and Intervention Services*	A team of healthcare professionals who provide emergency mental health services, usually in people’s homes	As medically necessary and recommended by us	No
Multisystemic Therapy Services*	An intensive service focused on the family for children at risk of residential mental health treatment	As medically necessary and recommended by us	No
Neurology Services	Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord or nervous system	Covered as medically necessary	Yes, for some services
Non-Emergency Transportation Services	Transportation to and from all of your medical appointments. This could be on the bus, a van that can transport disabled people, a taxi or other kinds of vehicles	We cover the following services for recipients who have no transportation: Out-of-state travel Transfers between hospitals or facilities Escorts when medically necessary	Yes, for trips over 100 miles
Nursing Facility Services	Medical care or nursing care that you get while living full-time in a nursing facility. This can be a short-term rehabilitation stay or long-term	We cover 365/366 days of services in nursing facilities, as medically necessary,	Yes
Occupational Therapy Services	Occupational therapy includes treatments that help you do things in your daily life, like writing, feeding yourself and using items around the house.	We cover for children ages 0-20 years and for adults under the $1,500 outpatient services cap, as medically necessary: One initial evaluation per year Up to 210 minutes of treatment per week One initial wheelchair evaluation per 5 years We cover for people of all ages, as medically necessary: Follow-up wheelchair evaluations, one at delivery and one 6-months later.	Yes, for some services
Oral Surgery Services	Services that provide teeth removals and to treat other conditions, illnesses or diseases of the mouth and oral cavity	Covered as medically necessary	Yes, for some services
Orthopedic Services	Services to diagnose or treat conditions, illnesses or diseases of the bones or joints	Covered as medically necessary	Yes, for some services
Outpatient Hospital Services	Medical care that you get while you are in the hospital but are not staying overnight. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you	Emergency services are covered as medically necessary. Non-emergency services cannot cost more than $1,500 per year for recipients ages 21 years and over.	Yes, for some services
Pain Management Services	Treatments for long-lasting pain that does not get better after other services have been provided	Covered as medically necessary. Some service limits may apply.	Yes
Partial Hospitalization Services*	Services for people leaving a hospital for mental health treatment	As medically necessary and recommended by us	Yes
Physical Therapy Services	Physical therapy includes exercises, stretching and other treatments to help your body get stronger and feel better after an injury, illness or because of a medical condition.	We cover for children ages 0-20 years and for adults under the $1,500 outpatient services cap, as medically necessary: One initial evaluation per year Up to 210 minutes of treatment per week One initial wheelchair evaluation per 5 years We cover for people of all ages, as medically necessary: Follow-up wheelchair evaluations, one at delivery and one 6-months later.	Yes, for some services
Podiatry Services	Medical care and other treatments for the feet	We cover, as medically necessary: Up to 24 office visits per year Foot and nail care X-rays and other imaging for the foot, ankle and lower leg Surgery on the foot, ankle or lower leg	Yes, for some services
Prescribed Drug Services	This service is for drugs that are prescribed to you by a doctor or other health care provider.	We cover, as medically necessary: Up to a 34-day supply of drugs, per prescription Refills, as prescribed	Yes, for some services
Private Duty Nursing Services	Nursing services provided in the home to people ages 0-20 years who need constant care	We cover, as medically necessary: Up to 24 hours per day.	Yes
Psychiatric Specialty Hospital Services*	Emergency mental health services that are performed in a facility that is not a regular hospital	As medically necessary and recommended by us	No
Psychological Testing Services	Tests used to detect or diagnose problems with memory, IQ or other areas	We cover, as medically necessary: 10 hours of psychological testing per year.	No
Psychosocial Rehabilitation Services	Services to assist people reentering everyday life. They include help with basic activities such as cooking, managing money and performing household chores	We cover, as medically necessary: Up to 480 hours per year	No
Radiology and Nuclear Medicine Services	Services that include imaging such as x-rays, MRIs or CAT scans. They also include portable X-rays.	Covered as medically necessary	Yes, for some services
Regional Perinatal Intensive Care Center Services	Services provided to pregnant women and newborns in hospitals that have special care centers to handle serious conditions	Covered as medically necessary	Yes, for some services
Reproductive Services	Services for women who are pregnant or want to become pregnant. They also include family planning services that provide birth control drugs and supplies to help you plan the size of your family.	We cover medically necessary family planning services. You can get these services and supplies from any Medicaid provider; they do not have to be a part of our Plan. You do not need prior approval for these services. These services are free. These services are voluntary and confidential, even if you are under 18 years old.	No
Respiratory Services	Services that treat conditions, illnesses or diseases of the lungs or respiratory system	We cover medically necessary: Respiratory testing Respiratory surgical procedures Respiratory device management	Yes, for some services
Respiratory Therapy Services	Services for ages 0-20 years to help you breathe better while being treated for a respiratory condition, illness or disease	We cover medically necessary: One initial evaluation per year One therapy re-evaluation per 6 months Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day)	No
Self-Help/Peer Services*	Services to help people who are in recovery from an addiction or mental illness	As medically necessary and recommended by us	No
Specialized Therapeutic Services	Services for children ages 0-20 years with mental illnesses or substance use disorders	We cover the following medically necessary: Assessments Foster care services Group home services	Yes
Speech-Language Pathology Services	Services that include tests and treatments to help you talk or swallow better	We cover the following medically necessary services for children ages 0-20 years: Communication devices and services Up to 210 minutes of treatment per week One initial evaluation per year We cover the following medically necessary services for adults: One communication evaluation per 5 years.	Yes
Statewide Inpatient Psychiatric Program Services	Services for children with severe mental illnesses that need treatment in the hospital	Covered as medically necessary for children ages 0-20 years	Yes
Substance Abuse Intensive Outpatient Program Services*	Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from substance use disorders	As medically necessary and recommended by us	Yes
Substance Abuse Short-term Residential Treatment Services*	Treatment for people who are recovering from substance use disorders	As medically necessary and recommended by us	Yes
Therapeutic Behavioral On-Site Services	Services provided by a team to prevent children ages 0-20 years with mental illnesses or behavioral health issues from being placed in a hospital or other facility	We cover medically necessary services: Up to 9 hours per month.	No
Transplant Services	Services that include all surgery and pre and post-surgical care	Covered as medically necessary	Yes
Visual Aid Services	Visual Aids such as glasses, contact lenses and prosthetic (fake) eyes	We cover the following medically necessary services when prescribed by your doctor: Two pairs of eyeglasses for children ages 0-20 years One frame every two years and two lenses every 365 days for adults ages 21 years and older Contact lenses Prosthetic eyes	Yes, for some services
Visual Care Services	Services that test and treat conditions, illnesses and diseases of the eyes	Covered as medically necessary	Yes, for some services

Expanded benefits are extra goods or services we provide to you, free of charge. Call Member Services to ask about getting expanded benefits.

Your Plan Benefits: Expanded Benefits
Service	Description	Coverage/ Limitations	Prior Authorization
Acupuncture	Insertion of thin needles through skin to treat pain, stress and other conditions. Acupuncture is used to treat chronic pain, stress, and other physical and mental health conditions.	Ages 21 years and older Unlimited as deemed medically necessary	Yes
Art Therapy	Therapy for behavioral health treatments provided by a certified clinician	Ages 21 years and older. Unlimited as deemed medically necessary	Yes
Behavioral Health Integration/Collaborative Care	Unlimited visits with Collaborative Care teams for whole health. Unlimited visits for members with providers who manage both physical and mental health needs	Must have a behavioral health condition	No
Biometric Equipment	Digital blood pressure cuff and weight scale	Ages 13 years and older One (1) digital blood pressure cuff every three (3) years; One (1) weight scale every three (3) years	No
Camp Scholarship	$150 voucher to attend children’s camp. Must be enrolled in Care Management and have completed annual wellness exam	Ages 4-18 years	Contact your care manager to determine eligibility.
Care Grant	Up to $150 per year for tutoring, gym memberships, swimming lessons, sports equipment/supplies, or art supplies/workbooks	Ages up to 18 years	Contact your care manager to determine eligibility.
Caregiver Swimming Lessons	Voucher or reimbursement for caregivers to take group swimming lessons. Includes up to 8 lessons from a local YMCA, if available.	Ages 18 years and older. In areas where YMCA doesn’t exist, members may use a local swim vendor.	No
Cellular Services	Members can receive a free smartphone. The phone includes minutes, data and texts.	Ages 18 years and older.	No
Childcare	Voucher for childcare to help parents identified with childcare needs on Pathways to Prosperity screening.	$150 limit. Must be age 16 years and older.	Contact your care manager to determine eligibility.
Chiropractic Services	Services provided by chiropractors.	Ages 21 years and older	Yes
Circumcision (newborns only)	Male circumcision is a common procedure typically performed in the first month after birth. Can be provided in a hospital, office or outpatient setting	Birth to 28 days old One per lifetime if medically necessary	No
Computerized Cognitive Behavioral Therapy	Including health focused clinical interview, behavioral observations, and health and behavioral interviews for individual, group and family (with or without the patient)	Ages 21 years and older. Unlimited	Yes
Dental Kit	One dental hygiene kit per year for pregnant members who attend a Sunshine Health-sponsored event	Ages 13 years and older	No
Doula Services	Pregnancy, postpartum and newborn care and assessment provided in your home by a doula. Using a doula during pregnancy, birth, and postpartum has been shown to be an effective best practice that can enhance the birthing experience, reduce complications, and improve outcomes for women and infants.	Ages 13 years and older. No limits	No
Durable Medical Equipment (DME) services and supplies	Additional coverage for items not covered under standard benefits, such as wound supplies, hospital bed and mattresses, insulin pump and infusion pump	Ages 10 years and older	Yes, for some equipment and supplies
Durable Medical Equipment/Asthma Supplies	Unlimited hypoallergenic bedding and one (1) high-efficiency particulate air (HEPA) filter vacuum cleaner for members diagnosed with asthma	Must have asthma or COPD diagnosis	Contact your care manager to determine eligibility.
Educational Vouchers	$150 voucher after completion of Sunshine Health Works Launchpad Educational Modules	Ages 16 years and older	Contact your care manager to determine eligibility.
Equine Therapy	Provided to members with behavioral health conditions and involves activities with horses.	Ages 21 years and older. Up to 10 sessions per year.	Yes
Expanded Prenatal Services	14 visits for low-risk pregnancy 18 visits for high-risk pregnancy Breast pump, hospital grade rental Breast pump	Ages 13 years and up One per calendar year; Ages 13 years and up One every 2 calendar years; Ages 13 and up	No No Yes No
Expanded Primary Care Services	Visits to primary care provider. Visiting a primary care provider can help in maintaining everyday health.	Ages 21 years and older Unlimited	No
Flu Prevention Kit	1 Flu Prevention kit; 3 ply face masks – 10 piece; oral digital thermometer; hand sanitizer	Ages 18 years and older For the first 1,000 members who receive a flu vaccine.	Contact your care manager to determine eligibility.
Grocery Benefit	$50 food gift card per household per year for enrollees who identify as food insecure on Pathways to Prosperity screening	Ages 16 years and older	Contact your care manager to determine eligibility.
Healthy Living Benefit	Assistive devices and adaptive aids to help enrollees maintain independence in their homes. Enrollees can select two from the following items: digital scale, home blood pressure cuff, peak flow meter, reachers/grabbers, lumbar pillow, personal fan, clip on lamp, walker bag, or an assistive technology device such as a smart home device (i.e. Amazon Echo).	Ages 21 years and older	No
Hearing Services	Hearing services include: assessment, hearing evaluation, hearing aid fitting, hearing aid monaural in ear, behind ear hearing aid, hearing aid dispensing fee, in ear binaural hearing aid, behind ear binaural hearing aid, behind ear cors hearing aid and behind ear bicros hearing aid.	Ages 21 years and older All services limited to one every two calendar years, except for hearing aid monaural in ear, which is one per calendar year.	No
Housing Assistance	A maximum of $250 per community-based enrollee per year to assist with housing related expenses (rent, utilities, etc.)	Must be 16 years or older. Funds are paid directly to the utility company or place where assistance is needed.	Contact your care manager to determine eligibility.
Home Delivered Meals – Disaster Preparedness	Healthy food delivered to your home during an emergency, such as a natural disaster.	1 emergency meal kit annually	Yes
Home Delivered Meals - General	Healthy food delivered to your home for nutritional support.	Up to 10 meals per event	Yes
Home Delivered Meals - Post Transition Meals	Meals delivered to your home after discharge from hospital or nursing facility	No age limit	Yes
Home Delivered Meals for Enrollees who are Pregnant	266 meals to enrollees who are at least 20 weeks pregnant and have a qualifying medical condition	Up to four months postpartum	Contact your care manager to determine eligibility.
Home Health Nursing/Aide Services	Home health care provides individuals with greater independence to remain in their homes and be as self-sufficient as possible. Services to help with daily living	Ages 21 years and older Unlimited as deemed medically necessary	Yes
Home Visits by a Social Worker	Home visits by a clinical social worker to assess your needs and provide available options and education to address those needs. Home visits also reduce the need for transportation.	Ages 18 years and older 48 visits per calendar year	Yes
Homemaker Services (e.g. hypoallergenic carpet cleanings)	Preventing allergen buildup in home carpets is a vital measure to help alleviate symptoms.	Up to two cleanings per year Must be diagnosed with asthma to qualify	Contact your care manager to determine eligibility.
Legal Guardianship	Legal guardianship can help protect an individual who is no longer able to make decisions for themselves that are in the best interest of their health and well-being. Maximum of five hundred dollars ($500) per eligible enrollee per lifetime	This is available to members who are in a SNF or PDN setting and parent is obtaining guardianship to protect those who are unable to care for their own well-being. Available for members aged 17 through 21 years	Contact your care manager to determine eligibility.
Massage Therapy	Massage of soft body tissues to help injuries and reduce pain. Massage of soft tissues can improve circulation, decrease pain and muscle tightness, improve work of the immune system, and improve sleep.	Ages 21 years and older Unlimited as deemed medically necessary	Yes
Meal Stipend (available for long distance medical appointment day trips)	To support enrollees of all ages who need to travel long distance for medical appointments, available for long distance medical appointment day trips	Up to twenty dollars ($20) per meal up to 3 meals per day; up to two hundred dollars ($200) per day; up to one thousand dollars ($1,000) per year for trips greater than one hundred (100) miles	Yes
Nursing Facility Transition Assistance	To help families of children living in a nursing facility to bring their child home. The benefit will provide assistance to the children and their families to help overcome barriers preventing the child from living at home with their family.	For individuals currently residing in a nursing facility and are either under 21 years old or under 30 years of age and have been living in a nursing facility before turning 21 years old. Lifetime limit: $65,000	Yes
Nutritional Counseling	A healthy diet can promote weight loss, lower blood pressure and cholesterol and has additional health benefits such as reducing depression and improving sleep. Outpatient visits with a dietician for members	Ages 21 years and older	No
Occupational Therapy	Treatments that help you do things in your daily life, like writing, feeding yourself and using items around the house. Occupational therapy can help individuals develop, recover, or maintain meaningful activities of daily living allowing them to be more self-sufficient.	Ages 21 years and older One evaluation per calendar year One re-evaluation per calendar year Up to seven therapy visits per week	Yes, except initial evaluation
Over-the-Counter Benefit	Coverage for cold, cough, allergy, vitamins, supplements, ophthalmic/otic preparations, pain relievers, gastrointestinal products, first aid care, hygiene products, insect repellent, oral hygiene products and skin care.	All ages Up to $50 per household, per month	No
Palliative Care	Up to 20 days per year of palliative care for enrollees living with chronic illness. Includes personal care assistance	Ages 5 to 75 years	Yes
Peer Support Certification	Up to $600 voucher to become a Peer Support Specialist for members who identify as needing job support on a Pathways to Prosperity screening	Ages 16 years and older	Contact your care manager to determine eligibility.
Pet Therapy	Provided to members with behavioral health conditions and involves activities with trained animals	Ages 21 years and older Sessions as needed per provider recommendation	Yes
Physical Therapy	Physical therapy aids in pain relief to help individuals function, move, and maintain a better quality of living. Physical therapy in an office setting.	Ages 21 years and older One evaluation per calendar year One re-evaluation per calendar year Up to seven treatment units per week	Yes, except initial evaluation.
Respiratory Therapy	Respiratory illnesses such as chronic obstructive pulmonary disease (COPD) and asthma can have a severe impact on activities of daily living.	Ages 21 years and older One initial evaluation and re-evaluation per calendar year One visit per day	Yes
Respite Care	Short-term relief for caregivers of enrollees members with special healthcare needs.	Up to 200 hours in-home and up to 10 days out-of-home per year	Yes
Speech Therapy	Speech Therapy increases self-esteem by allowing individuals to better communicate their thoughts and feelings and gain more confidence in social situations, decreasing social isolation, loneliness, anxiety, and depression. Speech and language therapy services in the office setting	Ages 21 years and older One evaluation/re- evaluation per calendar year One AAC re-evaluation per calendar year One evaluation of oral pharyngeal swallowing per calendar year Up to seven therapy treatment units per week AAC fitting, adjustment and training; up to four 3-minute sessions per calendar year	Yes, except initial evaluation
Swimming Lessons (children only)	Children under 21 years can receive group swim sessions which include up to 8 lessons from a local YMCA.	One group session, up to 8 lessons from local YMCA. In areas where a YMCA does not exist, members may use a local swim vendor.	No
Tattoo Removal	Voucher for members who have completed Sunshine Health Works Launchpad Educational modules who provide proof of workforce need.	One per lifetime; $500 limit, Age 18-26 years	Contact your Care Manager to determine eligibility.
Tutoring	Voucher to assist in learning	Twelve (12) tutoring sessions to aid in removing educational barriers; up to 2 hours of tutoring time per session; maximum of 12 sessions annually. Ages 16 years and up	Contact your Care Manager to determine eligibility.
Transportation Services to Non-Medical Appointments/Activities	Up to three trips a month for non-medical purposes such as shopping or social events.	Ages 18 years and older. Must not have another means of transportation to qualify	No
Vaccine: Influenza	Vaccines to prevent disease	Unlimited	No
Vaccine: Pneumonia	Vaccines to prevent disease.	Ages 21-65 years. Unlimited as deemed medically necessary	No
Vaccine: Shingles	Vaccines to prevent disease	Ages 21-65 years. One per lifetime, 2 doses.	No
Vaccine: TDaP	Vaccines to prevent disease	One per pregnancy	No
Vision Services	One routine eye exam per year, prescription eyeglasses (one pair of frames per year), and multiple types of contact lenses (six months’ supply)	Ages 21 years and older	No
Vital Records Support	$50 reimbursement for copies of personal documentation, such as driver’s license or birth certificate	Ages 16 years and older	No
Waived Copayments	Waiving copayments reduces financial burden on individuals. All services, including behavioral health	Ages 21 years and older	No
Welcome Baby! Bundle	One gift package for pregnant members. Choose one option per pregnancy: 1) Safe Sleep Survival Kit with Cribette, 2) Car Seat with safe sleep educational materials, 3) Highchair with safe sleep educational materials, 4) Baby Shower in a Box, or 5) Stroller with safe sleep educational materials.	Must complete three prenatal visits, and attend a Sunshine Health event	Contact your Care Manager to determine eligibility.
YMCA Membership	For individuals or family of four. Includes access to free standing YMCA facilities and Y360 virtual platform	Ages 18 years and older. Caregiver, parent or guardian must be present for ages 17 years and under.	Contact your Care Manager to determine eligibility.

Your Long Term Care Plan Benefits
Service	Description	Prior Authorization
Adult Companion Care	This service helps you fix meals, do laundry and light housekeeping.	Yes
Adult Day Health Care	Supervision, social programs, and activities provided at an adult day care center during the day. If you are there during meal times, you can eat there.	Yes
Assistive Care Services	These are 24-hour services if you live in an adult family care home.	Yes
Assisted Living	These are services that are usually provided in an assisted living facility. Services can include housekeeping, help bathing, dressing, and eating, medication assistance, and social programs.	No
Attendant Nursing Care	Nursing services and medical assistance provided in your home to help you manage or recover from a medical condition, illness, or injury	Yes
Behavioral Management	Services for mental health or substance abuse needs	No
Care Coordination/ Case Management	Services that help you get the services and support you need to live safely and independently. This includes having a case manager and making a plan of care that lists all the services you need and receive.	No
Home Accessibility/ Adaptation Services	This service makes changes to your home to help you live and move in your home safely and more easily. It can include changes like installing grab bars in your bathroom or a special toilet seat. It does not include major changes like new carpeting, roof repairs, plumbing systems, etc.	Yes
Home Delivered Meals	This service delivers healthy meals to your home.	Yes
Homemaker Services	This service helps you with general household activities, like meal preparation and routine chores.	Yes
Hospice	Medical care, treatment, and emotional support services for people with terminal illnesses or who are at the end of their lives to help keep them comfortable and pain free. Support services are also available for family members or caregivers.	No
Intermittent and Skilled Nursing	Extra nursing help if you do not need nursing supervision all the time or need it at a regular time	Yes
Medical Equipment and Supplies	Medical equipment is used to help manage and treat a condition, illness, or injury. Medical equipment is reused and includes things like wheelchairs, braces, walkers, and other items. Medical supplies are used to treat and manage conditions, illnesses, or injury. Medical supplies include things that are used and then thrown away, like bandages, gloves, and other items.	Yes
Medication Administration	Help taking medications if you can’t take medication by yourself	Yes
Medication Management	A review of all the prescription and over-the-counter medications you are taking	Yes
Nutritional Assessment/Risk Reduction Services	Education and support for you and your family or caregiver about your diet and the foods you need to eat to stay healthy	Yes
Nursing Facility Services	Nursing facility services include medical supervision, 24-hour nursing care, help with day-to-day activities, physical therapy, occupational therapy, and speech-language pathology	Yes
Personal Care	These are in-home services to help you with: Bathing Dressing Eating Personal Hygiene	Yes
Personal Emergency Response Systems (PERS)	An electronic device that you can wear or keep near you that lets you call for emergency help anytime	Yes
Respite Care	This service lets your caregivers take a short break. You can use this service in your home, an Assisted Living Facility or a Nursing Facility.	Yes
Occupational Therapy	Occupational therapy includes treatments that help you do things in your daily life, like writing, feeding yourself, and using items around the house.	Yes
Physical Therapy	Physical therapy includes exercises, stretching, and other treatments to help your body get stronger and feel better after an injury, illness, or because of a medical condition.	Yes
Respiratory Therapy	Respiratory therapy includes treatments that help you breathe better.	Yes
Speech Therapy	Speech therapy includes tests and treatments that help you talk or swallow.	Yes
Structured Family Caregiving*	Services provided in your home to help you live at home instead of in a nursing facility	We may offer the choice to use this service instead of nursing facility services.
Transportation	Transportation to and from all of your LTC program services. This could be on the bus, a van that can transport disabled people, a taxi, or other kinds of vehicles.	Yes, if over 100 miles

Expanded benefits are extra services we provide to you at no cost. Talk to your care manager about getting expanded benefits.

Your Long Term Care Plan Extra Benefits
Service	Description	Coverage/ Limitations	Prior Authorization
Assisted Living Facility/Adult Family Care Home - Bed Hold Days	Services such as personal care, housekeeping, medication oversight and social programs to assist the member in an assisted living facility	Ages 18 years and older. Beds can be held for 30 days if the member has been in the facility for a minimum of 30 days between episodes.	No
Healthy Living Benefit	Assistive devices and adaptive aids to help enrollees maintain independence in their homes. Enrollees can select two from the following items: digital scale, home blood pressure cuff, peak flow meter, reachers/grabbers, lumbar pillow, personal fan, clip on lamp, walker bag, or an assistive technology device such as a smart home device (ie. Amazon Echo).	Ages 21 years and older	No
Home Allowance	Up to $250 annually for Home and Community-Based (HCBS) LTC members needing financial assistance to maintain residency in a community setting	Ages 16 years and older	Contact your Care Manager to determine eligibility.
Home Delivered Meals – General	Up to 10 meals per event for nutritional support	Ages 18 years and older	Yes
Home Delivered Meals – Disaster Preparedness	Healthy food delivered to your home during an emergency, such as a natural disaster	1 emergency meal kit annually	Yes
Individual Therapy Sessions for Caregivers	Therapeutic counseling to support primary caregivers who reside with LTC enrollees in a private home	Ages 18 years and older	Yes
Joy for All Battery Operated Plus Companion Pet	Designed to bring comfort, companionship, and fun to individuals experiencing social isolation, loneliness, or any type of cognitive decline	One pet per member.	Contact your Care Manager to determine eligibility.
Nursing Facility to Community Setting Transition Assistance	Up to $5,000 to transition safely to independent living situations	Ages 18 years and older, must reside in nursing facility	Contact your Care Manager to determine eligibility.
Sensory Kit	Sensory support kit tailored to the developmental and diagnosis needs of enrollees	Must be enrolled in Long Term Care. Ages 3 years and older	Contact your Care Manager to determine eligibility.
Transportation Services to Non-Medical Appointments/Activities	Up to three trips a month for non-medical purposes such as shopping or social events	Ages 18 years and older. Must not have another means of transportation to qualify.	No
Welcome Home! Basket	A gift basket with up to $50 worth of items to help them get transitioning LTC members in their new home	Ages 21 years and older. Must be an LTC member.	No

Your Long Term Care Participant Direction Option

You may be offered the Participant Direction Option (PDO). You can use PDO if you use any of these services and live in your home:

Attendant care services
Homemaker services
Personal care services
Adult companion care services
Intermittent and skilled nursing care services

PDO lets you self-direct your services. This means you get to choose your service provider and how and when you get your service. You have to hire, train and supervise the people who work for you (your direct service workers).

You can hire family members, neighbors or friends. You will work with a case manager who can help you with PDO.

If you are interested in PDO, ask your case manager for more details. You can also ask for a copy of the PDO Guidelines to read and help you decide if this option is right for you.

Benefits Overview

Your Medicaid Benefits

Your Medicaid Expanded Benefits

Your Long Term Care Plan Benefits

Your Long Term Care Plan Extra Benefits

Your Long Term Care Participant Direction Option