Benefits Overview (KidCare)
Your Child’s Plan Benefits
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.
There may be some services that we do not cover. If you need a ride to any of these services, we can help you. 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 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 your child’s care manager or Member Services at 1-866-799-5321 (TTY 1-800-955-8770).
If you are looking for information on your child's dental benefits, visit Dental Care.
NOTE: Services marked with an asterisk (*) are behavioral 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 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 |
Behavior Analysis (BA) | Behavior analysis (BA) services are structured approaches to increase or reinforce appropriate behaviors. They are used to help children with Autism Spectrum Disorders. | CMS Title XXI recipients under the age of 19 years requiring medically necessary BA Services. | Prior Authorization Required |
Behavioral Health Assessment Services | Services used to detect or diagnose mental illnesses and behavioral health disorders | We cover, as medically necessary:
| No |
Behavioral Health Overlay Services | Behavioral health services provided to children (ages 0–18 years old) enrolled in a DCF program | Covered as medically necessary | Prior Authorization Required |
Cardiovascular Services | Services that treat the heart and circulatory (blood vessels) system | We cover the following as prescribed by your doctor, when medically necessary:
| Prior Authorization Required depending on services provided |
Child Health Services Targeted Case Management | Services provided to children (ages 0–3 years old) to help them get healthcare and other services OR Services provided to children (ages 0-20 years old) 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:
| No |
Clinic Services | Healthcare 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 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 prior authorization required for the first three days of involuntary behavioral health inpatient admission. After the first three days, prior authorization is 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 is required. Prior authorization is required for voluntary admissions. |
| Dental Services | Services include oral exams, cleanings, crowns X-rays, endodontic care (soft tissue and nerves within the teeth), fillings, fluoride treatments, full and partial dentures, oral surgery, orthodontic treatment with prior authorization, periodontal care, preventive care, restorations and sealants |
| |
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:
| 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 | 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 0–36 months who have developmental delays and other conditions | We cover, as medically necessary:
| 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, as medically necessary:
| No |
Family Therapy Services | Services for families to have therapy sessions with a mental health professional | Up to 26 hours per year, as medically necessary | No |
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 | No |
Gastrointestinal Services | Services to treat conditions, illnesses, or diseases of the stomach or digestion system | 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 | 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 | Up to 39 hours per year, as medically necessary | 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:
| 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, when medically necessary:
| 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 | Up to 26 hours per year, as 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 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 | 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 |
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 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 | No |
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:
| 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, as medically necessary:
| 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, as medically necessary:
| Prior Authorization Required |
Podiatry Services | Medical care and other treatments for the feet | We cover, as medically necessary:
| 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, as medically necessary:
| Prior Authorization is required for select drugs |
Prescribed Pediatric Extended Care (PPEC) | This service provides skilled nursing supervision and therapeutic interventions in a non-residential setting to medically dependent or technologically dependent recipients | A maximum of 12 hours a day while receiving nursing services, personal care, developmental therapies, and caregiver training | Prior Authorization Required |
Private Duty Nursing Services | Nursing services provided in the home to people ages 0 to 18 years old who need constant care | Up to 24 hours per day, as medically necessary | 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:
| 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 | All ages. Up to a total of 15 days per month. (IMD facilities) | No prior authorization is required for the first three days of involuntary behavioral health inpatient admission. After the first three days, prior authorization is required. Prior authorization is required for voluntary |
Psychological Testing Services | Tests used to detect or diagnose problems with memory, IQ or other areas | 10 hours of psychological testing per year, as medically necessary | Prior Authorization Required except for H2019. |
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 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 | 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:
| Prior Authorization Required depending on services provided |
Respiratory Therapy Services | Services for recipients ages 0–18 years old to help you breathe better while being treated for a respiratory condition, illness or disease | We cover, as medically necessary:
| 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 | No |
Specialized Therapeutic Services | Services provided to children ages 0–18 years old with mental illnesses or substance use disorders | We cover the following medically necessary services:
| Prior Authorization Required |
Speech- Language Pathology Services | Services that include tests and treatments help you talk or swallow better | We cover the following medically necessary services:
| 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 0–18 years old | Prior Authorization Required |
Substance Abuse Intensive Outpatient Program Services | Substance abuse treatment of detoxification services provided in an outpatient setting.
| 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 0–18 years old with mental illnesses or behavioral health issues from being placed in a hospital or other facility | Up to 9 hours per month, as medically necessary | No |
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 medically necessary services when prescribed by your doctor:
| 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 co-payments.
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.
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 |
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 | 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 | Contact your care manager to determine eligibility. |
Cellphone Program | Members can receive a free smartphone. | The phone includes minutes, data and texts. | 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 |
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 years old | Prior Authorization Required |
Flu/Pandemic Prevention Kit | 1 Flu/Pandemic Prevention kit; 3 ply face masks – 10 piece; oral digital thermometer; hand sanitizer | Eligible for the first 1,000 members who have received their flu vaccine | 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 1 per lifetime. | Contact your care manager to determine eligibility. |
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 | Contact your care manager to determine eligibility. |
| Hypoallergenic Bedding | Eligible members with asthma can get an allowance to buy hypoallergenic bedding | For qualified members with asthma | Contact your care manager to determine eligibility. |
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 | No |
| Legal Guardianship | This is available for members who are in a SNF or PDN setting and parent is obtaining guardianship to protect individuals who are unable to care for their own well-being. | For members 17 through 18.5 years old. Maximum of five hundred dollars ($500) per eligible enrollee per lifetime. | Contact your care manager to determine eligibility. |
Meals - Non- emergency Transportation Day-Trips | Meal stipend (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 100 miles. | Prior Authorization Required. |
Newborn Circumcisions | Provide circumcision coverage for children with prescribed limits | For members age 0 through 28 days. Limit 1 per lifetime | No |
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 |
| Nutritional Counseling | Assessment, hands-on care, education and guidance to caregivers and members about nutrition | None | 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 can receive group swim lessons from the YMCA. In areas where a YMCA does not exist, members may be able to use a local swimming lesson vendor. | Up to 8 lessons. Contact your child's Care Manager for details. | No |
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 | Contact your care manager to determine eligibility. |
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 sessions per plan year. | No |
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 sessions per plan year | No |
Health/Wellness Coaches | Access to a health/wellness coach to provide 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 | No |
Pest Control | Receive pest control services | Up to $500 annual per member's household | Contact your care manager to determine eligibility. |
| Respite Care | Provides caregivers a temporary rest from caregiving | 200 hours of in-home respite care, 10 days of out of home respite care. Must not receive respite services through Model and/or Developmental Disability Waiver. | Contact your child's Care Manager to determine eligibility. |
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 Application (PDF): 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 | Contact your care manager to determine eligibility. |