Benefits Overview

Your Plan Benefits: Managed Medical Assistance Services

The table below lists the medical services that are covered by Sunshine Health. Remember, you may need a referral from your 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 state 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.

NOTE: Services marked with an asterisk (*) 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.

Except for emergency care, Sunshine Health must prior authorize any services provided by an out-of-network provider and any elective inpatient admissions.

Service	Description	Coverage/ Limitations	Prior Authorization
Allergy Services	Services to treat conditions such as sneezing or rashes that are not caused by an illness.	We cover blood or skin allergy testing and up to 156 doses per calendar year of allergy shots.	No
Ambulance Transportation Services	Ambulance services are for when you need emergency care while being transported to the hospital or special support when being transported between facilities.	Covered as medically necessary.	No
Ambulatory Detoxification Services *	Substance abuse treatment of detoxification services provided in an outpatient setting.	For members under age 21: Up to three hours per day and no limit per calendar year. For members over age 21: Up to three hours per day for up to 30 days per calendar year.	Yes
Ambulatory Surgical Center Services	Surgery and other procedures that are performed in a facility that is not the hospital (outpatient).	Covered as medically necessary.	Yes
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) that help with activities of daily living and taking medication.	We cover 365/366 days of services per calendar year.	Yes
Behavioral Health Assessment Services	Services used to detect or diagnose mental illnesses and behavioral health disorders.	We cover: One initial assessment per calendar year. One reassessment per calendar year. Up to 150 minutes of brief behavioral health status assessments (no more than 30 minutes in a single day).	Yes
Cardiovascular Services	Services that treat the heart and circulatory (blood vessels) system.	We cover the following as prescribed by your doctor: Cardiac testing. Cardiac surgical procedures. Cardiac devices.	Yes, for some services.
Child Health Services Targeted Case Management	Services provided to children (ages 0 - 3) to help them get health care and other services.	Child must be enrolled in the DOH Early Steps program.	Yes
Chiropractic Services	Diagnosis and manipulative treatment of misalignments of the joints, especially the spinal column, which may cause other disorders by affecting the nerves, muscles and organs.	We cover: One new patient visit. 24 established patient visits per calendar year. X-rays.	No
Clinic Services	Health care services provided in a county health department, federally qualified health center, or a rural health clinic.	Services must be provided in a county health department, federally qualified health center, or a rural health clinic.	No
Community-Based Wrap-Around Services *	Individualized care planning and care management service to support children with complex needs who are at risk of placement in a mental health treatment facility.	Ages 0 to 21. One per day with no limits per calendar year.	Yes
Crisis Stabilization Unit Services *	Emergency mental health services that are performed in a facility that is not a regular hospital.	All ages. One per day and no limit per calendar year.	No prior authorization required for the first day.After the first day, prior authorization required.
Detoxification or Addictions Receiving Facility Services *	Emergency substance abuse services that are performed in a facility that is not a regular hospital.	All ages. Up to a total of 15 days per month.	No prior authorization required for the first day.After the first day, prior authorization required.
Dialysis Services	Medical care, tests and other treatments for the kidneys. This service also includes dialysis supplies and other supplies that help treat the kidneys.	We cover the following as prescribed by your treating doctor: Hemodialysis treatments. Peritoneal dialysis treatments.	No
Drop-In Center Services *	A social club offering peer support and a flexible schedule of activities.	18 years of age and older. Maximum of 20 days per calendar year.	Yes
Durable Medical Equipment and Medical Supplies Services	Medical equipment is used to manage and treat a condition, illness, or injury. Durable medical equipment is used over and over again, and includes things like wheelchairs, braces, crutches and other items. Medical supplies are items meant for one-time use and then thrown away.	Some service and age limits apply.	Prior authorization may be required for some equipment or services.
Early Intervention Services	Services to children ages 0 - 3 who have developmental delays and other conditions.	We cover: One initial evaluation per lifetime, completed by a team. Up to three screenings per calendar year. Up to three follow-up evaluations per calendar year. Up to two training or support sessions per week.	No
Emergency Transportation Services	Transportation provided by ambulances or air ambulances (helicopter or airplane) to get you to a hospital because of an emergency.	Covered as medically necessary.	No
Evaluation and Management Services	Services for doctor’s visits to stay healthy and prevent or treat illness.	We cover: One adult health screening (check-up) per calendar year. Well Child Visits are provided based on age and developmental needs. One visit per month for people living in nursing facilities. Up to two office visits per month for adults to treat illnesses or conditions.	No
Family Therapy Services	Services for families to have therapy sessions with a mental health professional.	We cover: Up to 26 hours per calendar year.	Yes, after 12 sessions.
Family Training and Counseling for Child Development *	Educational services for family members of children with severe emotional problems focused on child development and other family support.	Ages 0 to 21. Up to a total of nine hours per month.	Yes
Gastrointestinal Services	Services to treat conditions, illnesses, or diseases of the stomach or digestion system.	Covered as medically necessary.	Yes, for some services.
Genitourinary Services	Services to treat conditions, illnesses, or diseases of the genitals or urinary system.	Covered as medically necessary.	Yes, for some services.
Group Therapy Services	Services for a group of people to have therapy sessions with a mental health professional.	We cover: Up to 39 hours per calendar year for adults. For children up to age 21 there are no limits if medically necessary.	Yes
Hearing Services	Hearing tests, treatments and supplies that help diagnose or treat problems with your hearing. This includes hearing aids and repairs.	We cover hearing tests and the following as prescribed by your doctor: Cochlear implants. One new hearing aid per ear, once every three years. Repairs.	Yes, for some services.
Home Health Services	Nursing services and medical assistance provided in your home to help you manage or recover from a medical condition, illness or injury.	We cover: Up to four visits per day for pregnant members and members ages 0-20. Up to three visits per day for all other members.	Yes
Hospice Services	Medical care, treatment and emotional support services for people with terminal illnesses or who are at the end of their lives to help keep them comfortable and pain free. Support services are also available for family members or caregivers.	Covered as medically necessary.	Yes
Individual Therapy Services	Services for people to have one-on-one therapy sessions with a mental health professional.	We cover: Up to 26 hours per calendar year for adults. For children up to 21 there are no limits if medically necessary.	Yes, after 12 sessions.
Infant Mental Health Pre- and Post- Testing Services *	Testing services by a mental health professional with special training in infants and young children.	Ages 0-5 years only. 40 units per calendar year (1 unit = 15 minutes).	Yes
Inpatient Hospital Services	Medical care that you get while you are in the hospital. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you.	We cover the following inpatient hospital services based on age and situation: Up to 365/366 days for members ages 0-20. Up to 45 days for all other members (extra days are covered for emergencies).	Yes
Integumentary Services	Services to diagnose or treat skin conditions, illnesses or diseases.	Covered as medically necessary.	Yes, for some services.
Laboratory Services	Services that test blood, urine, saliva or other items from the body for conditions, illnesses or diseases.	Covered as medically necessary.	Yes, for some services.
Medical Foster Care Services	Services that help children with health problems who live in foster care homes.	Must be in the custody of the Department of Children and Families.	Yes
Medication Assisted Treatment Services	Services used to help people who are struggling with drug addiction.	Covered as medically necessary.	No
Medication Management Services	Services to help people understand and make the best choices for taking medication.	Covered as medically necessary.	No
Mental Health Targeted Case Management	Services to help get medical and behavioral health care for people with mental illnesses.	Covered as medically necessary.	Yes
Mobile Crisis Assessment and Intervention Services *	Emergency mental health services provided in the home, community or school by a team of health care professionals.	All ages. 96 units per calendar year.- Maximum of 8 units per day (1 unit = 15 minutes).	No
Neurology Services	Services to diagnose or treat conditions, illnesses or diseases of the brain, spinal cord or nervous system.	Covered as medically necessary.	Yes, for some services.
Non-Emergency Transportation Services	Transportation to and from all of your medical appointments. This could be on the bus, a van that can transport people with disabilities, a taxi, or other kinds of vehicles.	We cover the following services for members who have no transportation: Out-of-state travel. Transfers between hospitals or facilities. Escorts when medically necessary.	Yes, for any trip over 100 miles.
Nursing Facility Services *	Medical care or nursing care that you get while living full time in a nursing facility. This can be a short-term or long-term rehabilitation stay.	All ages. Up to 60 days per calendar year.	Yes
Occupational Therapy Services	Occupational therapy includes treatments that help you do things in your daily life, like writing, feeding yourself and using items around the house.	We cover for children ages 0-20 and for adults under the $1,500 outpatient services cap: One initial evaluation per calendar year. Up to 210 minutes of treatment per week. One initial wheelchair evaluation per five years. We cover for people of all ages: Follow-up wheelchair evaluations, one at delivery and one six months later.	Yes, for some services.
Oral Surgery Services	Services that provide teeth extractions (removals) and to treat other conditions, illnesses or diseases of the mouth and oral cavity.	Covered as medically necessary.	Yes, for some services.
Orthopedic Services	Services to diagnose or treat conditions, illnesses or diseases of the bones or joints.	Covered as medically necessary.	Yes, for some services.
Outpatient Hospital Services	Medical care that you get while you are in the hospital but are not staying overnight. This can include any tests, medicines, therapies and treatments, visits from doctors and equipment that is used to treat you.	Emergency services are covered as medically necessary. Non-emergency services cannot cost more than $1,500 per calendar year for members ages 21 and over.	Yes, for some services.
Pain Management Services	Treatments for long-lasting pain that does not get better after other services have been provided.	Covered as medically necessary. Some service limits may apply.	Yes
Partial Hospitalization Services *	Structured mental health treatment services provided in a hospital four-six hours each day for five days per week.	All ages.One per day and no limit per calendar year.	Yes
Physical Therapy Services	Physical therapy includes exercises, stretching and other treatments to help your body get stronger and feel better after an injury, illness or because of a medical condition.	We cover for children ages 0-20 and for adults under the $1,500 outpatient services cap: One initial evaluation per calendar year. Up to 210 minutes of treatment per week. One initial wheelchair evaluation per five years. We cover for people of all ages: Follow-up wheelchair evaluations, one at delivery and one six months later.	Yes, for some services.
Podiatry Services	Medical care and other treatments for the feet.	We cover: Up to 24 office visits per calendar year. Foot and nail care. X-rays and other imaging for the foot, ankle and lower leg. Surgery on the foot, ankle or lower leg.	Yes, for some services.
Prescribed Drug Services	This service is for drugs that are prescribed to you by a doctor or other health care provider.	We cover: Up to a 34-day supply of drugs, per prescription. Refills, as prescribed.	Yes, for some drugs.
Private Duty Nursing Services	Nursing services provided in the home to members ages 0 to 20 who need constant care.	Up to 24 hours per day.	Yes
Psychological Testing Services	Tests used to detect or diagnose problems with memory, IQ or other areas.	10 hours of psychological testing per calendar year.	Yes
Psychosocial Rehabilitation Services	Services to assist people re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores.	Up to 480 hours per calendar year.	Yes
Radiology and Nuclear Medicine Services	Services that include imaging such as x-rays, MRIs or CAT scans. They also include portable x-rays.	Covered as medically necessary.	Yes, for some services.
Regional Perinatal Intensive Care Center Services	Services provided to pregnant women and newborns in hospitals that have special care centers to handle serious conditions.	Covered as medically necessary.	Yes, for some services.
Reproductive Services	Services for women who are pregnant or want to become pregnant. They also include family planning services that provide birth control drugs and supplies to help you plan the size of your family.	We cover family planning services. You can get these services and supplies from any Medicaid provider; they do not have to be a part of our Plan. You do not need prior approval for these services. These services are free. These services are voluntary and confidential, even if you are under 18 years old.	No
Respiratory Services	Services that treat conditions, illnesses or diseases of the lungs or respiratory system.	We cover: Respiratory testing. Respiratory surgical procedures. Respiratory device management.	Yes, for some services.
Respiratory Therapy Services	Services for members ages 0-20 to help you breathe better while being treated for a respiratory condition, illness or disease.	We cover: One initial evaluation per calendar year. One therapy re-evaluation per six months. Up to 210 minutes of therapy treatments per week (maximum of 60 minutes per day).	No
Self-Help/ Peer Services *	Support services for people with mental health or substance use conditions provided by someone with similar experiences but who is in recovery.	All ages.We cover: Up to 16 units per day (1 unit = 15 minutes)	Yes
Specialized Therapeutic Services	Services provided to children ages 0-20 with mental illnesses or substance use disorders.	For children ages 0-21, we cover: Comprehensive Behavioral Health Assessments. Specialized Therapeutic Foster Care Services. Therapeutic Group Home Services.	Yes
Speech-Language Pathology Services	Services that include tests and treatments to help you talk or swallow better.	We cover the following services for children ages 0-20: Communication devices and services. Up to 210 minutes of treatment per week. One initial evaluation per calendar year. We cover the following services for adults: One communication evaluation per five calendar years.	Yes
Statewide Inpatient Psychiatric Program Services	Services for children with severe mental illnesses that need treatment in a secured facility.	Covered as medically necessary for children ages 0-20.	Yes
Substance Abuse Short-term Residential Treatment Services/ Residential Outpatient Services *	Short-term substance abuse treatment in a residential program for pregnant adults.	Pregnant women ages 21 and over with a substance use disorder. Up to 60 days per calendar year.	Yes
Therapeutic Behavioral On-Site Services	Therapeutic services provided in the home or community to prevent children ages 0-20 with mental illnesses from being placed in a hospital or other facility.	Up to nine hours per month.	Yes
Transplant Services	Services that include all surgery and pre- and post-surgical care.	Covered as medically necessary.	Yes
Visual Aid Services	Visual aids are items such as glasses, contact lenses and prosthetic (fake) eyes.	We cover the following services when prescribed by your doctor: Two pairs of eyeglasses for children ages 0-20. Contact lenses. Prosthetic eyes.	Yes, for some services.
Visual Care Services	Services that test and treat conditions, illnesses and diseases of the eyes.	Covered as medically necessary.	Yes, for some services.

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
Acupuncture	Insertion of thin needles through skin to treat pain, stress and other conditions.	Members 21 years and older. Up to 40 units per calendar year (1 unit = 15 minutes).	Yes
Cellular phone service	Additional minutes for Safelink phone or Connections Plus plan.	Members 18 years and older.	No
Chiropractic	Services provided by chiropractors.	Members 21 years and older. Up to 12 additional visits per calendar year (total of 36 visits).	No
Contact lenses	Contact lens types: spherical, PMMA, toric or prism ballast, gas permeable, extended wear, hydrophilic, spherical, toric or prism ballast; and hydrophilic extended wear, other types.	Members ages 21 and older. Six-month supply.	No
CVS discount program	20 percent discount on certain over-the-counter items.	No age limit.	No
Doula services	Pregnancy, postpartum and newborn care and assessment provided in your home by a Doula.	Ages 13 and older. No limits.	Yes
Durable medical equipment and supplies Breast pump	Additional coverage for items not covered for members age 21 and older, such as wound supplies, hospital bed and mattresses, insulin pump and infusion pump. Breast pump, hospital grade rental Breast pump rental	Ages 21 and older. One per calendar year; ages 10 to 59. One every 2 calendar years; ages 10 to 59.	Yes, for some equipment and supplies. Yes Yes
Eye exam	Routine eye exam.	Ages 21 and older. One per year based on date of service.	No
Eye glasses	Prescription eyeglasses.	Ages 21 and older. One per year based on date of service.	No
Hearing services	Hearing services include: assessment, hearing evaluation, hearing aid fitting, hearing aid monaural in ear, behind ear hearing aid, hearing aid dispensing fee, in ear binaural hearing aid, behind ear binaural hearing aid, behind ear cors hearing aid and behind ear bicros hearing aid.	Ages 21 and older. All services limited to one every two calendar years, except for hearing aid monaural in ear, which is one per calendar year.	No
Home delivered meals post inpatient discharge	Meals delivered to your home after a hospitalization.	No age limit. Up to 10 meals for members in case management.	Yes
Home visit by a social worker	Home visit by a clinical social worker to assess your needs and provide available options and education to address those needs.	Ages 21 and older. 48 visits per calendar year.	Yes
Massage therapy	Massage of soft body tissues to help injuries and reduce pain.	Ages 21 and older. Up to 40 units per calendar year (1 unit=15 minutes).	Yes
Meals – non-emergency transportation day trips	Meals during non-emergency transportation services.	No age limit. $200 per day up to $1,000 per calendar year for trips over 100 miles.	Yes
Newborn circumcision	Can be provided in a hospital, office or outpatient setting.	Birth to 28 days old. One per lifetime if medically necessary.	No
Nutritional counseling	Outpatient visits with a dietician for members.	Ages 21 and older. Unlimited.	Yes
Occupational therapy	Treatments that help you do things in your daily life, like writing, feeding yourself and using items around the house.	Ages 21 and older. One evaluation per calendar year. One re-evaluation per calendar year. Up to seven therapy visits per week.	Yes, except initial evaluation.
Outpatient hospital service	Service provided in a hospital setting on an outpatient basis.	Ages 21 and older. Unlimited.	Yes, for some services.
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.	All ages. Up to $25 per household, per month.	No
Physical therapy	Physical therapy in an office setting.	Ages 21 and older. One evaluation per calendar year. One re-evaluation per calendar year. Up to seven treatment units per week.	Yes, except initial evaluation.
Prenatal/ perinatal visits	Prenatal/perinatal office visits.	Ages 10 to 59. 14 visits for low-risk pregnancy. 18 visits for high-risk pregnancy.	No
Primary care visits	Visits to primary care provider.	Ages 21 and older. Unlimited.	No
Postpartum visits	Doctor visits after delivery of your baby.	Ages 10-59. Three visits within 90 days of delivery.	No
Respiratory therapy	Respiratory therapy in an office setting.	One initial evaluation or re-evaluation per calendar year. One visit per calendar year in office.	No
Speech language therapy	Speech and language therapy services in the office setting.	Ages 21 and older. One evaluation/re-evaluation per calendar year. One AAC re-evaluation per calendar year. One evaluation of oral pharyngeal swallowing per calendar year. Up to seven therapy treatment units per week. AAC fitting, adjustment and training; up to four 30-minute sessions per calendar year.	Yes, except initial evaluation.
Vaccines: TDaP Influenza Shingles Pneumonia	Vaccines to prevent disease.	Ages 21 and older. One per pregnancy. One per calendar year. As medically needed. As medically needed.	No No Yes, for ages 21-65. Yes, for ages 21-65.
Waived copayments	All services, including behavioral health.	Ages 21 and older.	No

Service	Description	Coverage/ Limitations	Prior Authorization
Assessment services – limited functional mental health assessment	Standard assessment of mental health needs and progress.	Ages 21 and older. Two additional assessments per calendar year for a total of three.	Yes
Intensive outpatient treatment	Intensive outpatient treatment for alcohol or drug services and behavioral health treatment or services.	Ages 21 and older. Unlimited.	Yes
Therapy – Art	Art therapy delivered in an outpatient setting. Must be delivered by a behavioral health clinician with art therapy certification.	Ages 21 and older. Unlimited.	Yes
Therapy (individual or family)	One-on-one individual mental health therapy.	Ages 21 and older. 56 additional units for a total of 160 units per calendar year (one unit = 15 minutes).	Yes
Therapy (group)	Mental health therapy in a group setting.	Ages 21 and older. 60 additional units for a total of 216 units per calendar year (one unit = 1 minute).	Yes

Benefits Overview

Your Plan Benefits: Managed Medical Assistance Services

Your Medicaid Benefits

Your Medicaid Expanded Benefits

Your Behavioral Health Enhanced Benefits