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Benefits Overview

Your Child’s Plan Benefits: Managed Medical Assistance Services

The table below lists the medical services that are covered by CMS Health Plan. Remember, you may need a referral from your child’s PCP or approval from us before your child goes to an appointment or uses a service. Services must be medically necessary in order for us to pay for them.

CMS Health Plan might not cover some services, but Medicaid might still cover them. To find out about these benefits, call the Agency Medicaid Help Line at 1-877-254-1055.

If your child needs a ride to any of these services, we can help. Please call MTM at 1-844-399-9469 to schedule a ride at no cost to you.

If there are changes in covered services or other changes that will affect your child, 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 your child’s care manager or Member Services at 1-866-799-5321 (TTY 1-800-955-8770).

Your Medicaid Benefits

Service

Description

Coverage/ Limitations

Prior Authorization

Addictions Receiving Facility Services

Services used to help people who are struggling with drug or alcohol addiction

Covered as medically necessary and recommended by us

Prior Authorization Required

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 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

Prior Authorization Required for Non Emergent Ambulance Transportation

Ambulatory Detoxification Services

Services provided to people who are withdrawing from drugs or alcohol

Covered as medically necessary and recommended by us

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

Prior Authorization required depending on services provided

Anesthesia Services

Services to keep you from feeling pain during surgery or other medical procedures

Covered as medically necessary

Prior Authorization may be Required

Assistive Care Services

Services provided to adults (ages 18 and older) help with activities of daily living and taking medication

We cover 365/366 days of services per year

Prior Authorization may be Required

Behavioral Health Assessment Services

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

We cover:

  • 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) enrolled in a DCF program

Covered as medically necessary

Prior Authorization Required

Behavioral Health Services – Child Welfare

A special mental health program to children enrolled in a DCF program

As medically necessary and recommended by us

Prior Authorization Required

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

Prior Authorization Required depending on services provided

Child Health Services Targeted Case Management

Services provided to children (ages 0–3) to help them get healthcare and other services

Your child must be enrolled in the DOH Early Steps program

Prior Authorization Required once member exceeds plan limits/units

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:

  • 24 established 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

 

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

Covered as medically necessary and recommended by us

Prior Authorization Required

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:

  • Hemodialysis treatments
  • Peritoneal dialysis treatments

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

Some service and age limits apply.

Call us toll-free at 1-866-799-5321 to learn more.

Prior Authorization is Required for custom and power wheelchairs, hospital beds, and scooters

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 3 screenings per year
  • Up to 3 follow-up evaluations per year
  • Up to 2 training or support sessions per week

Prior Authorization is Required depending on services provided

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 (checkup) per year
  • Well child visits (child health check­ ups) 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:

  • Up to 26 hours per year

Prior May be Authorization Required once member exceeds plan limits/units

Family Training and Counseling for Child Development

Services to support a family during their child’s mental health treatment

Covered as medically necessary and recommended by us

Prior Authorization Required

Gastrointestinal Services

Services to treat conditions, illnesses, or diseases of the stomach or digestion system

We cover:

  • Covered as medically necessary

Prior Authorization Required depending on services provided

Genitourinary Services

Services to treat conditions, illnesses, or diseases of the genitals or urinary system

We cover:

  • Covered as medically necessary

Prior Authorization required depending on services provided

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 year

Prior Authorization Required once member exceeds plan limits/units

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 3 years
  • Repairs

Prior Authorization is required for cochlear implants

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 4 visits per day for pregnant recipients Up to 3 visits per day for all other recipients

Prior Authorization Required

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

Prior Authorization Required depending on services provided

Individual Therapy Services

Services for people to have one-to-one therapy sessions with a mental health professional

We cover:

  • Up to 26 hours per year

Prior Authorization Required once member exceeds plan limits/units

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 and recommended by us

Prior Authorization Required

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 recipients

Prior Authorization Required

Integumentary Services

Services to diagnose or treat skin conditions, illnesses or diseases

Covered as medically necessary

Prior Authorization Required depending on services provided

Laboratory Services

Services that test blood, urine, saliva or other items from the body for conditions, illnesses or diseases

Covered as medically necessary

Prior Authorization Required

for Genetic Testing

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

Prior Authorization Required once member exceeds plan limits/units

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 who are recovering from mental illness

Covered as medically necessary and recommended by us

Prior Authorization Required

Mental Health Targeted Case Management

Services to help get medical and behavioral healthcare for people with mental illnesses

Covered as medically necessary

Prior Authorization may be Required once member exceeds plan limits/units

Mobile Crisis Assessment and Intervention Services

A team of healthcare professionals who provide emergency mental health services, usually in people’s homes

Covered 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

Covered as medically necessary and recommended by us

Prior Authorization Required

Neurology Services

Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord or nervous system

Covered as medically necessary

Prior Authorization Required depending on services provided

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

No

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

Prior Authorization Required

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:

  • One initial evaluation per year
  • Up to 210 minutes of treatment per week
  • One initial wheelchair evaluation every 5 years
  • Follow-up wheelchair evaluations, one at delivery and one 6 months later

Prior Authorization Required

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

Prior Authorization Required depending on services provided

Orthopedic Services

Services to diagnose or treat conditions, illnesses or diseases of the bones or joints

Covered as medically necessary

Prior Authorization Required depending on services provided

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 and non-emergency services are covered as medically necessary

Prior Authorization Required depending on services provided

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

Prior Authorization Required

Partial Hospitalization Services

Services for people leaving a hospital for mental health treatment

Covered as medically necessary and recommended by us

Prior Authorization Required

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:

  • One initial evaluation per year
  • Up to 210 minutes of treatment per week
  • One initial wheelchair evaluation every 5 years
  • Follow-up wheelchair evaluations, one at delivery and one 6 months later

Prior Authorization Required

Podiatry Services

Medical care and other treatments for the feet

We cover:

  • 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

Prior Authorization Required depending on services provided

Prescribed Drug Services

This service is for drugs that are prescribed to you by a doctor or other healthcare provider

We cover:

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

Prior Authorization is required for select drugs

Private Duty Nursing Services

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

We cover:

  • Up to 24 hours per day

Prior Authorization Required

Program of All- inclusive Care for Children (PACC) program

Pediatric palliative care support services for a set number of children who have been diagnosed with potentially life-limiting conditions and have been referred for PACC services by their primary care provider or specialty physician. PACC services are currently available in most counties in Florida.

Please contact member services to see if services are available in your county.

Participation in PACC is voluntary. Children receiving PACC services can choose to enroll in another MMA plan; however, if they do so, they will relinquish their PACC services.

PACC services include:

  • Support Counseling;
  • Expressive Therapies;
  • Respite Support;
  • Hospice Nursing Services;
  • Personal Care;
  • Pain and Symptom Management;
  • Bereavement Services; and
  • Volunteer Services.

To participate in PACC, the enrollee must receive at least two (2) different PACC services during each three (3) month period.

 

Must be referred for PACC services by the child’s primary care physician or specialty physician as specified in s. 409.912(11), F.S.

Enrollees receiving PACC must be reauthorized annually as medically eligible for the PACC program.

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:

  • 10 hours of psychological testing per year

Prior Authorization Required once member exceeds plan limits/units

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 

We cover:

  • Up to 480 hours per year

Prior Authorization Required once member exceeds plan limits/units

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

Prior Authorization Required depending on services provided

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

No

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. 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 approval to get these services.

They are free. It is your choice 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

Prior Authorization Required depending on services provided

Respiratory Therapy Services

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

We cover:

  • One initial evaluation per year
  • One therapy re-evaluation every 6 months
  • Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day)

Prior Authorization Required depending on services provided

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

Prior Authorization Required

Specialized Therapeutic Services

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

We cover the following:

  • Assessments
  • Foster care services
  • Group home services

Prior Authorization Required

Speech- Language Pathology Services

Services that include tests and treatments help you talk or swallow better

We cover:

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

Prior Authorization Required

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

Prior Authorization Required

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

Covered as medically necessary and recommended by us

Prior Authorization Required

Substance Abuse Partial Hospitalization Program Services

Treatment provided for more than 3 hours per day, several days per week, for people who are recovering from substance abuse

Covered as medically necessary and recommended by us

Prior Authorization Required

Substance Abuse Short-term Residential Treatment Services

Treatment for people who are recovering from substance use disorders

Covered as medically necessary and recommended by us

Prior Authorization Required

Therapeutic Behavioral On-Site Services

Services provided by a team to prevent children ages 0–20 with mental illnesses or behavioral health issues from being placed in a hospital or other facility

We cover:

  • Up to 9 hours per month

Prior Authorization Required once member exceeds plan limits/units

Transplant Services

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

Covered as medically necessary

Prior Authorization Required

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

Prior Authorization Required for eyeglasses and contact lenses only

Visual Care Services

Services that test and treat conditions, illnesses and diseases of the eyes

Covered as medically necessary

Prior Authorization Required depending on services provided

American Indian members are not asked to pay copayments.

Your Plan Benefits: Expanded Benefits

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

Your Medicaid Expanded Benefits

Service

Description

Coverage/ Limitations

Prior Authorization

Caregiver Behavioral Health Services for Non- Medicaid Caregivers

This benefit covers caregiver counseling provided in an individual or group setting for non-Medicaid caregivers of members to help address any needs he or she may have (e.g. burnout, depression, high stress levels) to help caregivers to continue caring for the member(s)

Must be a non-Medicaid caregiver of a member

Prior Authorization Required

Cellphone Program

Members will receive free cellphone via Safelink/ TracFone. The phone includes 350 minutes for talk and unlimited text.

Phone includes 350 monthly minutes for talk and unlimited text messaging

No

Computerized Cognitive Behavioral Analysis for Non-Medicaid Caregivers

Including, but not limited to the following:

health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires, health and behavioral interviews (individual, group, family (with or without the patient)

Must be a non-Medicaid caregiver of a member; unlimited with prior authorization

Prior Authorization Required

CVS Discount Card

CVS ExtraCare Health Card saves members 20% on thousands of CVS/pharmacy brand health-related items for members and their family. The 20% discount applies to regularly priced items of $1   or more made at any CVS/ pharmacy locations or online at cvs.com.

One card per member

No

Doula Services

Doula services for members with a goal of improved birth outcomes, reduced pre-term births, and improved prenatal care

For members ages 13 to 20

Prior Authorization Required

Home Delivered Meals (General)

Members may be eligible to receive 10 meals for nutritional support

10 meals per authorized request

Prior Authorization Required

Home Delivered Meals - Disaster Preparedness/ Relief

One (1) emergency meal kit annually

1 kit per member annually

Prior Authorization Required

Home Delivered Meals

- Post-Facility Discharge (Hospital or Nursing Facility)

Members discharged within two weeks from an inpatient facility (Hospital, Skilled Nursing Facility or inpatient Rehabilitation) may be eligible to receive 10 meals per authorized request

10 meals per authorized request

Prior Authorization Required

Housing Assistance

Members can receive up to $250 per year for housing assistance and $75 limit per quarter to purchase healthy food items $250 per year plus $75 per quarter for health food items

Prior Authorization Required

Individual Therapy Sessions for Caregivers

Provide individual therapy sessions to address behavioral health needs for caregivers of members

For caregivers of a member; unlimited visits with prior authorization

Prior Authorization Required

Meals - Non- emergency Transportation Day-Trips

Qualified members can receive up to $200 per day, up to $1,000 per year for trips greater than 100 miles from the member’s residence.

Up to $200 per day, up to $1,000 per year for trips greater than 100 miles from member’s residence.

Restrictions may apply for additional passengers.

Prior Authorization Required

Newborn Circumcisions

Provide circumcision coverage for children with prescribed limits

For members age 0 through 28 days

Limit of 1 per lifetime

Non-medical Transportation

Provide transportation services for non-medical appointments. Limited to trips within the member’s home county/local area.

Not for member in a SNF/nursing home setting; up to 2 trips per month

No

Over-the- Counter (OTC)

Each head of household is eligible to receive $25 worth of OTC items each month that are mailed to their home

Monthly household limits do not carry over from month to month. Limited to items listed in the OTC catalog

No

Swimming Lessons (Drowning Prevention)

Members under age 21 can receive $150 per year for swimming lessons

Space is limited

Prior Authorization Required

Transition From SNF/Statewide Inpatient Psychiatric Program Services to Private Home Setting

This benefit provides up to $2,500, per lifetime for the child’s private home setting if they are in a skilled nursing facility or statewide inpatient psychiatric program and transitioning to a private home setting within the community

Up to $2,500 per member per lifetime.

The benefit is available up to 90 days post transition

Prior Authorization Required

Your Medicaid Special Programs

Service

Description

Coverage/ Limitations

Prior Authorization

Adaptive Devices

Receive items to help members move around the home

1 item per plan year.

No

Benefit Counseling

Receive benefit counseling services

Three (3) sessions per plan year.

No

Carpet Cleaning

Provide carpet-cleaning service for qualified members with asthma. Benefit allowed by household and based on diagnosis.

For qualified members with asthma

2 carpet cleanings per year

Prior Authorization Required

Community Connections Help Line

FREE Community Connections Help Line to connect you to community services such as utility assistance, food banks and transportation in your community

None

No

Education/ Supports for Wellness

Help members access wellness education/supports in their community

Up to $200 per member per year

No

Financial Counseling

Receive financial counseling services

Six (6) sessions per plan year

No

Health/Wellness Coaches

Access to a health/wellness coach to receive education and guidance to caregivers and members to make healthy choices

None

No

Healthy Behaviors Program

Members receive rewards who complete specific preventive health, wellness, and engagement milestones

None, Additional information can be found on page 33

No

HEPA Filter Vacuum Cleaner

Provide qualified members with asthma with a vacuum cleaner with HEPA filter. Using HEPA filters can trap these pollutants and may help bring allergy relief. HEPA stands for high-efficiency particulate air.

For qualified members with asthma

Limit of 1 per lifetime

Prior Authorization Required

Hypoallergenic Bedding

Eligible members with asthma can get an allowance to buy hypoallergenic bedding

For qualified members with asthma

Prior Authorization Required

Nutritional Counseling

Assessment, hands-on care, education, and guidance to caregivers and members about nutrition

None

No

Pest Control

Receive pest control services

Up to $500 annual per member's household

Prior Authorization Required

Steps2Success

Reading Scholarships: FREE reading scholarships for qualified members who are in Pre-Kindergarten to 12th grade who want to improve their reading skills

General Educational Development® (GED®) Exam: You can take the GED® test for FREE if you’re age 16 or older and don’t have your high school diploma

Reading Scholarship: Space is limited

GED: 1 voucher per year per member (covers 4 tests)

No

Tutoring Services

Receive 12 tutoring sessions to aid in removing educational barriers

Up to 2 hours of tutoring time per session; maximum of 12 tutoring sessions annually

No