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Benefits Overview

Your Child Welfare Specialty Plan Benefits

This table lists the medical services that are covered by Sunshine Health. Remember, your child may need a referral from your child’s primary care provider (PCP) or approval from us before you go to an appointment or use a service. Services must be medically necessary (PDF) in order for us to pay for them.

There may be some services that we do not cover, but might still be covered by Medicaid. To find out about these benefits, call the Agency Medicaid Help Line at 1-877-254-1055. If you need a ride to any of these services, we can help you. You can call 1-877-659-8420 to schedule a ride.

If there are changes in covered services or other changes that will affect you, we will notify you in writing at least 30 days before the effective date of the change. If you have questions about any of the covered medical services, please call Member Services.

Except for emergency care, Sunshine Health must prior authorize any services to out-of-network providers and any elective inpatient admissions.

*Denotes services that 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.

Service Description Coverage/
Limitations
Prior
Authorization

Allergy Services

Services to treat conditions such as sneezing or rashes that are not caused by an illness.

We cover blood or skin allergy testing and up to 156 doses per calendar 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 *

Substance abuse detoxification services that are performed in a facility that is not a hospital.

For members under age 21: Up to 3 hours per day and no limit per calendar year.

 

For members over age 21: Up to 3 hours per day for up to 30 days per calendar year.  

 

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, for some procedures.

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 calendar year.

Yes

Behavioral Health Assessment Services

Services used to detect or diagnose mental illnesses and behavioral health disorders.

We cover:

  • One initial assessment per calendar year
  • One reassessment per calendar year
  • Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day)

 

Yes

Behavioral Health Overlay Services

Services provided in a group home setting for children ages 0 – 21 who have experienced trauma and are in the child welfare system.

We cover 365/366 days of services per calendar year.

 

Yes

 

Cardiovascular Services

Services that treat the heart and circulatory (blood vessels) system.

We cover the following as prescribed by your doctor:

  • Cardiac testing
  • Cardiac surgical procedures
  • Cardiac devices

Yes, for some services.

Child Health Services Targeted Case Management

Services provided to children ages 0 - 3 to help them get health care and other services.

Your child must be enrolled in the DOH Early Steps program.

Yes

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:

  • One new patient visit.
  • 24 established patient visits per calendar year.
  • X-rays.

 

No

Clinic Services

Health care services provided in a county health department, federally qualified health center, or a rural health clinic.

Services must be provided in a county health department, federally qualified health center, or a rural health clinic.

No

 

Community-Based Wrap-Around Services * Individualized care planning and care management service to support children with complex needs who are at risk of placement in a mental health treatment facility.

Children and youth up to age 21.

One per day with no limits per calendar year.

 

 

Yes
Crisis Stabilization Unit Services * Emergency mental health services that are performed in a facility that is not a regular hospital. All ages. One per day and no limit per calendar year.

 

No prior authorization required for the first day.After the first day, prior authorization required.
Detoxification or Addictions Receiving Facility Services * Emergency substance abuse services that are performed in a facility that is not a regular hospital. All ages. Up to a total of 15 days per month.

 

No prior authorization required for the first day. After the first day, prior authorization required.

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:

  • Hemodialysis treatments.
  • Peritoneal dialysis treatments.  

No

 

Drop-In Center Services * A social club offering peer support and a flexible schedule of activities.

Ages 18 and older.

Maximum of 20 days per calendar year.

Yes

Durable Medical Equipment and Medical Supplies Services

Medical equipment is used to manage and treat a condition, illness, or injury. Durable medical equipment is used over and over again, and includes things like wheelchairs, braces, crutches and other items. Medical supplies are items meant for one-time use and then thrown away.

Some service and age limits apply.

 

Yes, for some equipment or services.

 

 

Early Intervention Services

Services to children ages 0 - 3 who have developmental delays and other conditions.

We cover:

  • One initial evaluation per lifetime, completed by a team.
  • Up to three screenings per calendar year.
  • Up to three follow-up evaluations per calendar year.
  • Up to two 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:

  • One adult health screening (check-up) per calendar 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.

Up to 26 hours per calendar year

 

Yes, after
12 sessions.

Family Training and Counseling for Child Development * Educational services for family members of children with severe emotional problems focused on child development and other family support. Ages 0 to 21. Up to a total of nine hours per month.

 

Yes

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:

  • Up to 39 hours per calendar year for adults.
  • For children up to age 21 there are no limits if medically necessary.

 

Yes

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:

  • Cochlear implants.
  • One new hearing aid per ear, once every three 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:

  • Up to four visits per day for pregnant members and members ages 0-20.
  • Up to three visits per day for all other members.

 

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-on-one therapy sessions with a mental health professional.

We cover:

  • Up to 26 hours per calendar year for adults.
  • For children up to 21 there are no limits if medically necessary.

 

Yes, after 12 sessions.

Infant Mental Health Pre- and Post- Testing Services * Testing services by a mental health professional with special training in infants and young children.

For children ages 0 to 5 years only.

40 units per calendar year. 

(1 unit = 15 minutes)

 

 

Yes

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:

  • Up to 365/366 days for members ages 0-20.
  • Up to 45 days for all other members (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.

Yes

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 Targeted Case Management

Services to help get medical and behavioral health care for people with mental illnesses.

Covered as medically necessary.

Yes

Mobile Crisis Assessment and Intervention Services * A team of health care professionals who provide emergency mental health services in the home, community, or school. All ages. 96 units per calendar year.-       Maximum of 8 units per day
(1 unit = 15 minutes).

 

 

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 people with disabilities, a taxi, or other kinds of vehicles.

 

We cover the following services for members who have no transportation:

  • Out-of-state travel.
  • Transfers between hospitals or facilities.
  • Escorts when medically necessary.

 

Yes, for any trip 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 or long-term rehabilitation stay. All ages. Up to 60 days per calendar year.

 

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 and for adults under the $1,500 outpatient services cap:

  • One initial evaluation per calendar year.
  • Up to 210 minutes of treatment per week.
  • One initial wheelchair evaluation per five years.

We cover for people of all ages:

  • Follow-up wheelchair evaluations, one at delivery and one six months later.

Yes, for some services.

Oral Surgery Services

Services that provide teeth extractions (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 calendar year for members ages 21 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 * Structured mental health treatment services provided in a hospital four-six hours each day for five days per week. All ages. One per day and no limit per calendar year. 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 and for adults under the $1,500 outpatient services cap:

  • One initial evaluation per calendar year.
  • Up to 210 minutes of treatment per week.
  • One initial wheelchair evaluation per five years.

We cover for people of all ages:

  • Follow-up wheelchair evaluations, one at delivery and one six months later.

Yes, for some services.

Podiatry Services

Medical care and other treatments for the feet.

We cover:

  • Up to 24 office visits per calendar 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:

  • Up to a 34-day supply of drugs, per prescription.
  • Refills, as prescribed.

Yes, for some drugs.

Private Duty Nursing Services

Nursing services provided in the home to members ages 0 to 20 who need constant care.

Up to 24 hours per day.

Yes

Psychological Testing Services

Tests used to detect or diagnose problems with memory, IQ or other areas.

10 hours of psychological testing per calendar year.

 

Yes

Psychosocial Rehabilitation Services

Services to assist people re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores.

Up to 480 hours per calendar year.

 

Yes

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 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:

  • Respiratory testing.
  • Respiratory surgical procedures.
  • Respiratory device management.

 

Yes, for some services.

Respiratory Therapy Services

Services for members ages 0-20 to help you breathe better while being treated for a respiratory condition, illness or disease.

We cover:

  • One initial evaluation per calendar year.
  • One therapy re-evaluation per six months.
  • Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day).

No

Self-Help/
Peer Services *
Support services for people with mental health or substance use conditions provided by someone with similar experiences but who is in recovery. All ages.We cover: Up to 16 units per day
(1 unit = 15 minutes)

 

Yes

Specialized Therapeutic Services

Services provided to children ages 0-20 with mental illnesses or substance use disorders.

 

For children ages 0-21, we cover:

  • Comprehensive Behavioral Health Assessments.
  • Specialized Therapeutic Foster Care Services.
  • Therapeutic 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 services for children ages 0-20:

  • Communication devices and services.
  • Up to 210 minutes of treatment per week.
  • One initial evaluation per calendar year.

We cover the following services for adults:

  • One communication evaluation per five calendar years.

Yes

Statewide Inpatient Psychiatric Program Services

Services for children with severe mental illnesses that need treatment in a secured facility.

Covered as medically necessary for children ages 0-20.

Yes

Therapeutic Behavioral
On-Site Services

Therapeutic services provided in the home or community to prevent children ages 0-20 with mental illnesses from being placed in a hospital or other facility.

Ages 0 to 20.

Up to 9 hours per month.

 

Yes

Transplant Services

Services that include all surgery and pre- and post-surgical care. 

Covered as medically necessary.

Yes

Visual Aid Services

Visual aids are items such as glasses, contact lenses and prosthetic (fake) eyes.

We cover the following services when prescribed by your doctor:

  • Two pairs of eyeglasses for children ages 0-20.
  • 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.

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

Service Description Coverage/
Limitations
Prior
Authorization

Care grant

Up to $150 per calendar year per child for services or supplies for social use or physical activities.

Ages 0 to 21.

 

Up to $150 per calendar year.

 

Yes

CVS discount program

20% discount on certain over-the-counter items.

All ages.

No

Doula services

Pregnancy, postpartum and newborn care and assessment provided in your home by a Doula.

Ages 13 and older.

 

No limits.

Yes

Durable medical equipment – breast pump

 

 

 

  • Breast pump, hospital grade rental
  • Breast pump rental

1 per calendar year; ages 10 to 59.

 

 

1 per 2 calendar years; ages 10 to 59.

Yes

 

 

Home delivered meals post inpatient discharge

Meals delivered to your home after a hospitalization.

Ages 0 to 21.

 

No limits.

Yes

Life Skills Development

For children or adolescents with developmental disabilities to provide life skills help for the child or adolescent to keep, learn or improve skills and functioning for daily living. These services will be provided in the home or outpatient setting.

Ages 12 to 21.

 

Must have a diagnosed developmental disability.

 

Up to 160 hours per calendar year.

Yes

Newborn circumcision

Can be provided in a hospital, office or outpatient setting.

                 

Birth to 28 days old.

 

1 per lifetime if medically necessary.

No

Non-emergency transportation – non-medical purposes

Transportation provided for non-medical purposes such as social outings or family visits.

Ages 5 to 21.

 

Three round-trips per month.

 

 

Yes

Non-emergency transportation meals

Meals as part of a non-medical transportation trip.

Ages 0 to 21.

 

Up to $200 per day up to $1,000 per calendar year for trips over 100 miles.

Yes

Over-the-counter benefit

Up to $25 per household, per month, for cold, cough, allergy, vitamins, supplements, ophthalmic/otic preparations, pain relievers, gastrointestinal products, first aid care, hygiene products, insect repellant, oral hygiene products and skin care.

Ages 0 to 21.

 

No

Prenatal/perinatal visits

Prenatal/perinatal office visits for pregnant women.

Ages 10 to 59.

 

14 visits for low-risk pregnancy.

 

18 visits for high-risk pregnancy.

No

Postpartum visits

Doctor visits after delivery of your baby.

Ages 10 to 59.

 

Three visits within 90 days of delivery.

No

Transition Assistance

One-time payment of up to $500 per youth who is transitioning out of foster care at age 18 or out of extended foster care at age 21. Funds to support moving to a new home.

Ages 18 to 21.

 

Must be in out-of-home licensed foster care for a minimum of 6 months before transitioning out of foster care.

Yes