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.
You can also view more information about Sunshine Health in our Member Handbook.
All services must be medically necessary. Your Primary Care Provider will work with you to make sure you get the services you need. These services must be given by your Primary Care Provider or by another provider that your Primary Care Provider refers you to.
Some services may:
- Have coverage limits.
- Need a doctor’s order.
- Need prior approval.
*Some Medicaid members may not have all the benefits listed.
| Service | Description | Coverage/ Limitations |
Prior Authorization |
|---|---|---|---|
Allergy Services |
Services to treat conditions such as sneezing or rashes that are not caused by an illness. |
We cover medically necessary blood or skin allergy testing and up to 156 doses per calendar year of allergy shots.
|
No |
Ambulance Transportation Services |
Ambulance services are for when you need emergency care while being transported to the hospital or special support when being transported between facilities. |
Covered as medically necessary.
|
No |
Ambulatory 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, as medically necessary. |
Yes |
Behavioral Health Assessment Services |
Services used to detect or diagnose mental illnesses and behavioral health disorders. |
We cover as medically necessary:
* Limitations do not apply to SMI Specialty Plan |
No |
| Behavioral Health Overlay Services | Behavioral health services provided in a group home setting for children ages 0 – 21 who have experienced trauma and are in the child welfare system. |
We cover 365/366 days of medically necessary services per calendar year. | Yes |
Cardiovascular Services |
Services that treat the heart and circulatory (blood vessels) system. |
We cover the following as prescribed by your doctor, when medically necessary:
|
Yes, for some services.
|
Child Health Services Targeted Case Management |
Services provided to children (ages 0 - 3) to help them get health care and other services. OR Services provided to children (ages 0 – 20) who use medical foster care services. |
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 |
Health care services provided in a county health department, federally qualified health center, or a rural health clinic. |
Services must be medically necessary and 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 three days of involuntary behavioral health inpatient admission. After the first three days, prior authorization required. Prior authorization is required for voluntary admissions. |
| Detoxification or Addictions Receiving Facility Services * | Emergency substance abuse services that are performed in a facility that is not a regular hospital. | All ages. Up to a total of 15 days per month.
|
No prior authorization required for the first three days of involuntary behavioral health inpatient admission. After the first three days, prior authorization required. Prior authorization is required for voluntary admissions. |
Dialysis Services |
Medical care, tests and other treatments for the kidneys. This service also includes dialysis supplies and other supplies that help treat the kidneys. |
We cover the following as prescribed by your treating doctor, when medically necessary:
|
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. | No |
Durable Medical Equipment and Medical Supplies Services |
Medical equipment is used to manage and treat a condition, illness, or injury. Durable medical equipment is used over and over again, and includes things like wheelchairs, braces, crutches and other items. Medical supplies are items meant for one-time use and then thrown away. |
As medically necessary, some service and age limits apply. Call 1-866-796-0530 (TTY: 1-800-955-8770) for more information. | 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, 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. |
We cover, as medically necessary:
|
No |
| Family Training and Counseling for Child Development * | Educational services for family members of children with severe emotional problems focused on child development and other family support. | Ages 0 to 21. Up to a total of nine hours per month.
|
No |
Gastrointestinal Services |
Services to treat conditions, illnesses, or diseases of the stomach or digestion system. |
Covered as medically necessary.
|
Yes, for some services.
|
Genitourinary Services |
Services to treat conditions, illnesses, or diseases of the genitals or urinary system.
|
Covered as medically necessary.
|
Yes, for some services.
|
Group Therapy Services |
Services for a group of people to have therapy sessions with a mental health professional. |
We cover, as medically necessary:
|
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:
|
Yes, for some services.
|
Home Health Services |
Nursing services and medical assistance provided in your home to help you manage or recover from a medical condition, illness or injury.
|
We cover, when medically necessary:
|
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, 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. | Ages 0-5 years only. 40 units per calendar year (1 unit = 15 minutes).
|
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:
|
Yes |
Integumentary Services |
Services to diagnose or treat skin conditions, illnesses or diseases. |
Covered as medically necessary.
|
Yes, for some services. |
Laboratory Services |
Services that test blood, urine, saliva or other items from the body for conditions, illnesses or diseases. |
Covered as medically necessary.
|
Yes, for some services. |
Medical Foster Care Services |
Services that help children with health problems who live in foster care homes. |
Must be in the custody of the Department of Children and Families. |
No |
Medication Management Services |
Services to help people understand and make the best choices for taking medication. |
Covered as medically necessary.
|
No |
Mental Health Targeted Case Management |
Services to help get medical and behavioral health care for people with mental illnesses. |
Covered as medically necessary. |
No |
| Mobile Crisis Assessment and Intervention Services * | 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.
|
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:
|
Yes, for any trip over 100 miles. |
| Nursing Facility Services | Medical care or nursing care that you get while living full-time in a nursing facility. This can be a short-term rehabilitation stay or long-term. | We cover 365/366 days of services in nursing facilities as medically necessary.
|
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, as medically necessary:
We cover for people of all ages, as medically necessary:
|
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. |
|
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, as medically necessary:
We cover for people of all ages, as medically necessary:
|
Yes, for some services. |
Podiatry Services |
Medical care and other treatments for the feet. |
We cover, as medically necessary:
|
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, as medically necessary:
|
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, as medically necessary. |
Yes |
Psychological Testing Services |
Tests used to detect or diagnose problems with memory, IQ or other areas. |
10 hours of psychological testing per calendar year, as medically necessary.
|
Yes, for some services |
Psychosocial Rehabilitation Services |
Services to assist people re-enter everyday life. They include help with basic activities such as cooking, managing money and performing household chores. |
Up to 480 hours per calendar year, as medically necessary.
|
No |
Radiology and Nuclear Medicine Services |
Services that include imaging such as x-rays, MRIs or CAT scans. They also include portable x-rays. |
Covered as medically necessary.
|
Yes, for some services. |
Regional Perinatal Intensive Care Center Services |
Services provided to pregnant women and newborns in hospitals that have special care centers to handle serious conditions. |
Covered as medically necessary. |
Yes, for some services. |
Reproductive Services |
Services for women who are pregnant or want to become pregnant. They also include family planning services that provide birth control drugs and supplies to help you plan the size of your family. |
We cover medically necessary family planning services. You can get these services and supplies from any Medicaid provider; they do not have to be a part of our Plan. You do not need prior approval for these services. These services are free. These services are voluntary and confidential, even if you are under 18 years old. |
No |
Residental Outpatient Treatment |
Short term residential treatment program for pregnant women with substance use disorder. |
Ages 21 and older. Up to 60 days/calendar year. |
Yes |
Respiratory Services |
Services that treat conditions, illnesses or diseases of the lungs or respiratory system. |
We cover medically necessary:
|
Yes, for some services. |
Respiratory Therapy Services |
Services for members ages 0-20 to help you breathe better while being treated for a respiratory condition, illness or disease. |
We cover medically necessary:
|
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:
|
No |
| Skilled Nursing | Medical care or skilled nursing care that you get while you are in a nursing facility. This can be a short-term or long-term rehabilitation stay. |
All ages. Up to 60 days per calendar.
|
Yes |
Specialized Therapeutic Services |
Services provided to children ages 0-20 with mental illnesses or substance use disorders.
|
For children under the age of 21, we cover medically necessary:
|
Yes |
Speech-Language Pathology Services |
Services that include tests and treatments to help you talk or swallow better. |
We cover the following medically necessary services for children ages 0-20:
We cover the following medically necessary services for adults:
|
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 |
Transplant Services |
Services that include all surgery and pre- and post-surgical care. |
Covered as medically necessary. |
Yes |
Visual Aid Services |
Visual aids are items such as glasses, contact lenses and prosthetic (fake) eyes. |
We cover the following medically necessary services when prescribed by your doctor:
|
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. Unlimited as deemed medically necessary |
Yes |
| Behavioral Health Day Services/Day Treatment | Day treatment and adult day care services | Per diem only | Yes |
| Behavioral Health Medical Services (Medication Management, Drug Screening) | Services to ensure members are properly taking their medicines | Unlimited units for verbal interaction, medication management and drug screening | No |
| Behavioral Health Psychosocial Rehabilitation | Services to help people re-enter everyday life (cooking, managing money and performing household chores) | No | |
| Computerized Cognitive Behavioral Analysis | Including health focused clinical interview, behavioral observations, and health and behavioral interviews for individual, group and family (with or without the patient) |
Yes | |
| Homemaker Services (Carpet Cleaning) | Must be diagnosed with asthma to qualify | Up to two cleanings per year | |
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. Unlimited as deemed medically necessary |
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 |
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
|
Members diagnosed with asthma can receive 1) Unlimited Hypoallergenic Bedding 2) One (1) HEPA Filter Vacuum Cleaner
|
|
|
| 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.
|
Ages 21 and older.
|
Yes, for some equipment and supplies.
|
| Equine Therapy | For eligible members with cerebral palsy and autism | Up to 10 sessions per year | 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 (General) | For nutritional support | Up to 10 meals per event | Yes |
Home delivered meals post inpatient discharge |
Meals delivered to your home after a hospitalization. |
No age limit. Unlimited as deemed medically necessary |
Yes |
| Home Delivered Meals - Disaster Preparedness/ Relief | 1 emergency meal kit annually | Per hour and per diem | Yes |
| Home Health Nursing/Aid Services | Services to help with daily living | 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. Unlimited as deemed medically necessary |
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 |
| Medication Assisted Treatment Services | Services used to help people who are struggling with drug addiction. | Covered as medically necessary. | Yes |
Newborn circumcision |
Can be provided in a hospital, office or outpatient setting. * SMI Specialty Plan members are not eligible
|
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.
|
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. SMI Specialty Plan members are eligible to receive $35 per household worth of OTC items each 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/ |
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. |
| Swimming Lessons (Drowning Prevention) | Children under age 21 can receive swimming lessons | (Space is limited) | Up to $200 per year |
| Therapeutic Behavioral On-Site Services | Therapy services, behavior management, and therapeutic support are coordinated through individualized treatment teams to help members with complex needs from requiring placement in a more intensive, restrictive behavioral health setting | Up to nine hours per month, as medically necessary. | No |
Vaccines:
|
Vaccines to prevent disease.
|
Ages 21 and older.
|
|
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. Unlimited as deemed medically necessary |
No |
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. Unlimited as deemed medically necessary |
No
|
Therapy (group) |
Mental health therapy in a group setting. |
Ages 21 and older. Unlimited as deemed medically necessary |
No |
| Pet Therapy | Provided to members with autism, behavioral health conditions, cancer treatment, cerebral palsy, emotional abuse or other chronic conditions as medically necessary | Yes | |
| Targeted case management for members with a substance use disorder | A service to help those with substance use disorders get needed care and coordinate other needed services | Ages 21 and older.
Must have a substance use disorder. Unlimited as deemed medically necessary |
No |