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 medically necessary 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 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, as medically necessary.	Yes
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 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)	No
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, as medically necessary.	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 to help them get health care and other services. OR Services provided to children (ages 0–20) 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 calendar year, per member. X-rays.	No
Clinic Services	Health care services provided in a county health department, federally qualified health center, or a rural health clinic.	Medically necessary 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 three days of involuntary behavioral health inpatient admission. After the first three days, prior authorization required. Prior authorization is required for voluntary admissions.
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 three days of involuntary behavioral health inpatient admission. After the first three days, prior authorization required. Prior authorization is required for voluntary admissions.
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*	A social club offering peer support and a flexible schedule of activities.	Covered as medically necessary.	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 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.	As medically necessary, some service and age limits apply. Call 1-855-463-4100 (TTY: 1-800-955-8770) for more information.	Yes, for some equipment or services.
Early Intervention Services	Services to children ages 0 - 3 who have developmental delays and other conditions.	We cover medically necessary: One initial evaluation per lifetime, completed by a team Up to 3 screenings per calendar year Up to 3 follow-up evaluations per calendar year Up to 2 training or support sessions per week	No
Emergency Transportation Services	Transportation provided by ambulances or air ambulances (helicopters or airplanes) 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 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, as medically necessary	No
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. Covered as medically necessary.	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 as medically necessary: Unlimited units for group therapy and unlimited units for brief group medical therapy.	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 members and members ages 0 to 20 Up to 3 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, when medically necessary: Up to 26 hours per calendar year for adults ages 21 and over. For children up to 21 there are no limits if medically necessary	No
Infant Mental Health Pre and Post Testing Services*	Testing services by a mental health professional with special training in infants and young children.	Covered as medically necessary.	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 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.	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 Targeted Case Management	Services to help get medical and behavioral health care for people with mental illnesses.	Covered as medically necessary.	No
Mobile Crisis Assessment and Intervention Services*	A team of health care professionals who provide emergency mental health services in the home, community, or school.	Covered as medically necessary.	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 those 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 rehabilitation stay or long-term.	We cover 365/366 days of services in nursing facilities as medically necessary. See information on Patient Responsibility for room & board.	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 to 20 and for adults under the $1,500 outpatient services cap, as medically necessary: One initial evaluation per calendar 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 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 year for recipients 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 4-6 hours each day for 5 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, 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 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 healthcare provider.	We cover, as medically necessary: 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 0-20 who need constant care.	Up to 24 hours per day, as medically necessary.	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, as medically necessary.	Yes, for some services
Psychosocial Rehabilitation Services	Services to assist people to 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, as medically necessary.	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
Residential Outpatient Treatment	Short term residential treatment program for pregnant women with substance use disorder.	Ages 21 and older Up to 60 days/calendar year	Yes
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 members ages 0-20 to help you breathe better while being treated for a respiratory condition, illness or disease.	We cover medically necessary: One initial evaluation per calendar 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
Skilled Nursing	Medical care or skilled nursing care that you get while you are in a nursing facility. This can be a short- term or long-term rehabilitation stay.	All ages. Up to 60 days per calendar.	Yes
Specialized Therapeutic Services	Services provided to children ages 0-21 with mental illnesses or substance use disorders.	For children under the age of 21, we cover the following medically necessary services: 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 to talk or swallow better.	We cover the following medically necessary services for children ages 0 to 20: Communication devices and services Up to 210 minutes of treatment per week One initial evaluation per calendar 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 a secured facility.	Covered as medically necessary for ages 0 to 20.	Yes
Substance Abuse Intensive Outpatient Program*	Substance abuse treatment of detoxification services provided in an outpatient setting.	Covered as medically necessary.	Yes
Substance Abuse Short-term Residential Treatment Services/ Residential Outpatient Services*	Short-term substance abuse treatment in a residential program.	Covered as medically necessary. Maximum 60 days per calendar year.	Yes
Therapeutic Behavioral On- Site Services	Therapeutic services provided in the home or community to prevent children with mental illnesses from being placed in a hospital or other facility.	Covered as medically necessary for 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 medically necessary 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.

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
Biometric Equipment	Digital blood pressure cuff and weight scale	One (1) digital blood pressure cuff every three (3) years; One (1) weight scale every three (3) years	No
Care grant	Up to $150 per calendar year per child for services or supplies for educational use, social use or physical activities.	Ages 0 to 21. Up to $150 per calendar year.	Yes
Durable Medical Equipment/Supplies	Unlimited hypoallergenic bedding; one (1) HEPA filter vacuum cleaner.	Must be diagnosed with asthma.	Yes
Doula services	Pregnancy, postpartum and newborn care and assessment provided in your home by a doula.	Ages 13 and older. No limits.	Yes
Flu/Pandemic Prevention Kit	1 Flu/Pandemic Prevention kit; 3 ply face masks – 10 piece; oral digital thermometer; hand sanitizer	Ages 18 years and older. Eligible for the first 1,000 members who have received their flu vaccine.	No
Home Delivered Meals (Disaster Preparedness/ Relief)	Emergency meal kit	One (1) annually	Yes
Home delivered meals post inpatient discharge	Meals delivered to your home after discharge from hospital or nursing facility.	Ages 0 to 21. No limits.	Yes
Legal Guardianship	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 18.5.	Contact your care manager to determine eligibility.
Life Skills Development	For children or adolescents with development disabilities to provide life skills development that help the child or adolescent 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
Meal Stipend	Available for long distance medical appointment day-trips.	Up to $25/day for member and $25/day for escort for trips greater than 100 miles; max/fiscal year $250.	Yes
Medically Related Home Care Services/ Homemaker	Carpet cleanings	Up to two cleanings per year. Must be diagnosed with asthma.	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
Over-the-counter benefit	Coverage 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. Up to $25 per household, per month.	No
Prenatal/Postpartum	14 visits for low-risk pregnancy 18 visits for high-risk pregnancy Breast pump, hospital grade rental Breast pump	One per calendar year One every 2 calendar years	No No Yes No
Swimming Lessons (Drowning Prevention)	Children under 21 years old can receive swimming lessons.	Up to $200 per year.	Yes
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

Benefits Overview

Your Child Welfare Specialty Plan Benefits

Your Child Welfare Specialty Plan Benefits

Your Child Welfare Specialty Plan Expanded Benefits