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).

Medical Necessity definition (PDF)

Your KidCare 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
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 for services (No prior authorization is required for initial assessments or reassessments)
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
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
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	One oral exam every six months Two cleanings per year One full mouth X-ray (Includes parts of teeth and mouth) every three years Bitewing, every 6 months Not covered: Bridge work	Prior Authorization Required for orthodontic care
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 0–36 months 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 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 Authorization May be 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
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
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	We cover: 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 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 0–18 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 0–18 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 0–18	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 0–18 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 0–18 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 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.

Your KidCare 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	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
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 18	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 (Must be requested by CM)
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
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. Maximum of five hundred dollars ($500) per eligible enrollee per lifetime.	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 swimming lessons	Up to $200 per year	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 KidCare 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 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 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 26	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 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	No

Benefits Overview (KidCare)

Your Child’s Plan Benefits

Your KidCare Benefits

Your Plan Benefits: Expanded Benefits

Your KidCare Expanded Benefits

Your KidCare Special Programs